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Practicum to socialize DH students in LTC settings

ABsTRAcTintroduction: as the population ages, educational health

care programs must increase efforts to provide geriatric healthknowledge to students and to socialize them into settings such aslong term care (Lt C). methods: a new practicum was developedin which dental hygiene (DH) students were scheduled onsitein Lt C facilities. a guiding objective for the practicum was tosocialize students into this environment by providing them withpractical knowledge and experience that could give them theconfidence, attitudes, and desire to work with this population

upon graduation. t his study provides a qualitative analysis of dataacquired from focus groups with the students and from individualinterviews with the registered dental hygienist (rDH) instructorswho guided them. r esults: six main themes were identifiedfrom the student focus group data: 1) communication challengesbetween students and Lt C staff; 2) communication challengesbetween students and Lt C residents; 3) uncertainty about followup for oral health recommendations; 4) barriers to provision ofdaily mouthcare; 5) uneasiness of students in Lt C environment;and 6) appreciation for the practicum experience. t ranscriptsfrom the r DH interviews revealed two themes: 1) challenges inthe facility context; and 2) challenges and enhancements forstudent learning. discussion: f rom these results, we determinedthat changes need to be made to the practicum, including:providing more classroom preparation before the practicum;

beginning the practicum earlier in the year to provide studentswith more experience; arranging onsite visits to correspond tothe schedules of the residents and staff; improving and increasinginteractions between students and Lt C staff; and developing andestablishing clear protocols for what students should do underspecific conditions, and how their recommendations for residentscan be implemented. Conclusion: we believe that the practicumsuccessfully contributed to the socialization of DH studentsinto the LtC environment by building their awareness of thecomplexities of working in this context with this population.

RsuMintroduction : avec le vieillissement de la population, les programmes

denseignement des soins de sant doivent accrotre leurs efforts pourinstruire les tudiantes et tudiants concernant les soins griatriques et lesamener se joindre des cadres comme celui des soins de longue dure(sLD). mthodes : Lon a donc a mis au point une nouvelle pratiqueamenant les tudiantes en hygine dentaire (HD) faire des stages dansdes services de sLD. Lun des objectifs de cette pratique a pour objet defamiliariser les tudiantes avec cet environnement, en leur procurant desconnaissances pratiques et des expriences susceptibles daffermir leur

confiance, dvelopper leurs attitudes et les inciter travailler chez cettepopulation aprs la rception de leur diplme. Cette tude prsente uneanalyse qualitative des rsultats obtenus de groupes cibles dtudianteset des entrevues personnelles avec des hygines dentaires agres (HDa)instructrices qui les ont guides. r sultats : Les tudiantes du groupecibl ont soulign six thmes principaux : 1) les dfis de la communicationentre les tudiantes et le personnel des sLD; 2) les dfis de communicationentre les tudiantes et les rsidents des sLD; 3) lincertitude du suivi desrecommandations en sant buccodentaire; 4) les obstacles de la prestationdes soins buccodentaires quotidiens; 5) les malaises des tudiantes danslenvironnement des sLD; 6) lapprciation de lexprience pratique. Latranscription des entrevues en HDa a rvl deux thmes : 1) les dfis dansun contexte de facilit et 2) les dfis et lamlioration de lapprentissagedes tudiantes. discussion : De ces rsultats, nous avons conclu quilfallait apporter des modifications la pratique, notamment : offrir plus de

prparation en classe avant dentreprendre la pratique; entreprendre lapratique plus tt dans lanne pour accrotre lexprience des tudiantes;organiser des visites sur place correspondant aux calendriers des tudianteset du personnel; amliorer et accrotre linteraction entre les tudiantes etle personnel des sLD; laborer et tablir des protocoles clairs pour ce queles tudiantes doivent faire dans des conditions particulires et mettre enpratique leurs recommandations pour les rsidentes. Conclusion : nousestimons que la pratique a contribu efficacement lintgration destudiantes en HD dans le cadre des sLD en les sensibilisant la complexitdu travail chez le type de population.

Practicum experience to socialize dental hygienestudents into long term care settingssharon m. Compton*, DipDH, Bsc, ma (Ed), phD;sandra J. Cobban, DipDH, mDE, phD;l isa a . Kline*, phD

Key words: older adults, older seniors, geriatrics, dental hygiene student practicum, long term care, socialization

BAcKGROunDDeveloped countries worldwide have steadily increasingnumbers of older persons as the population ages: in 2000,20 per cent of the population in these regions was aged60 and older, and this is expected to increase to 33.3 percent by 2050.1 In Canada, individuals aged 65 and oldercurrently comprise 14.4 per cent of the total population,

and it is estimated that these numbers will increase to24.5 per cent by 2036.2,3 There is some question as towhether the inevitably increasing need for health care inthe growing older adult population can be met or if thehealth professions are severely underprepared in trainingand attitude.4 Oral health care, in particular, is an area ofgreat concern, particularly for older adults living in long

tH is is a p EEr r EviEw ED arti CLE. submitted 11 mar. 2013. r evised 1 apr. 2013. accepted 3 apr. 2013.

* university of a lberta, Edmonton.

Correspondence to: Dr. sharon Compton; [email protected], professor and director, dental hygiene program t his work is dedicated in memory of Dr. s andy Cobban who passed away on January 11, 2013.

E v i D E n C E f o r p r a C t i C E
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term care (LTC): a review of the literature reveals that thecurrent provision of oral care in LTC facilities worldwideis inadequate, with frail dependent elderly people oftenreceiving little or no oral care.523

One of the steps that can be taken to address thegrowing numbers of older adults and the care they willrequire is to focus on the education of future healthprofessionals. There are two key areas of focus for thiseducational initiative: curricula must ensure that studentsfrom all health disciplines learn how to maintain andimprove oral health, and that students be socialized intoworking with older adults, particularly in the long termcare environment.

The reason all health professions must be involved inoral health maintenance and promotion is because poororal health, a potentially serious condition in itself, is alsolinked to or associated with other health complicationsto which older persons, such as the frail elderly in LTC orassisted living, are particularly susceptible.24 For example,evidence indicates that poor oral health may lead to an

increased risk of developing or worsening illnesses orconditions, including pneumonia,2532 influenza,3335 heartdisease,3638 stroke,39,40 diabetes,41 and malnutrition.42,43Poor oral health may also affect ones quality of life byimpacting chewing, eating, swallowing, and speaking,as well as poor facial aestheticssuch as decayed teeth,breath malodourall or many of which may result in selfconsciousness and isolation due to reduced inclination tointeract socially with others.4456

While many studies have provided considerableevidence of oralsystemic relationships, health curriculamay not be adequately addressing this issue. For instance,a comprehensive study was conducted to explorethe amount of information related to oralsystemic

science currently being taught in the predoctoral orundergraduate professional curricula of nursing, medical,and pharmacy schools in universities across Canada, theUnited States, Europe, Asia, Australia, and New Zealand.57This study, which involved circulating an online surveyto associate or academic deans at these schools, foundsubstantial deficiencies in the provision of oral healtheducation and oralsystemic health education to theirstudents.57 In a different survey of baccalaureate nursingstudents, it was revealed that, although students believedthat oral health is important to nursing practice andknew that there was an association between oral healthand other health issues, most of them lacked sufficientknowledge and understanding of the components of anoral health examination to be able to conduct a properoral health screening.58 Researchers concluded that theoral health content of nursing courses was inadequate,and that improvements would have to be made so thatstudents awareness of the importance of oral health tooverall health can be translated to practice in a way thatwill benefit the health outcomes of patients.58

One way to improve the oral health knowledgeand practice of nursing students can be found in aninterprofessional educational initiative at George BrownCollege in Ontario, Canada.59 Recognizing the associationbetween oral health and overall health, this program

initiative combines students from the Bachelor of Sciencein Nursing program with students from DH.59 Thisprogram enables the students to learn from one anotherand to develop an understanding of how they can combinetheir skills and knowledge and thus work collaborativelyto provide better oral care as well as better overall healthcare.59 However, there is a lack of information concerningoral health education in the non dental health sciences,which may reflect the fact that much progress has yet tobe made.

Improving the quality and quantity of oral healtheducation, while extremely important and in needof growth, is in itself insufficient to ensure that therewill be a health care workforce prepared to manage theincreasing number of older adults. It is also essentialto focus on the socialization of students in the area ofgeriatric health care, and there have been many calls toimprove geriatric education in the health professions.6068Some of the obstacles that must be overcome concernthe attitudes and perceptions of health care students

towards working with the older adult population. Inthree different studies of medical,69 dental,70 and nursing71students, it was revealed that many students, prior toany experience working with this population, exhibitednegative attitudes and perceptions towards working witholder persons and had minimal or no inclination to wantto work with them. However, it was also found that, afterhaving some experience working with this population,the same students developed more positive attitudes andperceptions. Researchers concluded that it is essential forthere to be increased practicums in which students caninteract with older adults, and that the positive attitudesand perceptions that arise from these experiences mustbe fostered and supported during their education, which

may result in a desire to work with older adults upongraduation.6971

There have been reports of positive developmentsin which some educational health care programs offertraining and practicums in LTC so that students canacquire first hand experience working with this complexpopulation. The aforementioned educational initiativewith the collaboration between nursing and DH takesplace in the LTC environment.59 One nursing school hasdeveloped a program of academic and service partnershipsin which faculty and students conduct clinical practice infour LTC homestwo large urban residences and two smallrural residences.68 The objectives of this program are toincrease communication, share resources, allow interactivelearning, and use nursing expertise to develop thecompetence of nursing students, resulting in new nursinggraduates considering a career in LTC.67 Although it is tooearly to determine if the student objectives have been met,the preliminary report on this program revealed positiveoutcomes for the other objectives.68 Other educationalprograms are targeted directly for students by providingthem with LTC experience so they can learn to apply theirknowledge in a practical setting as well as acquire a betterunderstanding of the challenges and rewards of workingwith the frail older adult population. For example, therehave been reports from nursing,72,73 medicine,74,75 and

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speech-language pathology72,76 programs in the USA, fromnursing schools in New Zealand77 and Australia,78 andfrom dentistry schools in Canada,79,80 all demonstratingthat educational curricula are beginning to address theneed to prepare future health professionals for the growingolder adult population, particularly in LTC. In addition toproviding students with practical knowledge of geriatrichealth care, these programs also aim to socialize studentsinto geriatric health care environments so that they mayseriously consider choosing to work with that populationwhen they graduate.

The success of these programs with regards to studentsocialization has been mixed.In one study, undergraduatenursing students and graduate speech-language pathologystudents participated in a service learning project withresidents with dementia at an LTC facility.72 Aims of thisprogram included encouraging students to:

1. Acknowledge that the person, rather than thedisorder, comes first.

2. Consider the impact of the relationship between a

person and other people in the persons life, such asfamily, caregivers, and community members.

3. Become well rounded professionals with experienceand insight beyond their fields.

4. Participate in qualitative analysis of their ownlearning processes through journalling.

Students were prepared for the project by classroominstruction and self study assignments. The speech-language pathology students, or the experimentalgroup, received more instruction about dementia andcommunicating with individuals with the conditionthan the nursing students, or the control group; theexperimental group also had to create a personalizedconnection kit for each resident, whereas the nursing

students did not.72 Results of this project, based onquestionnaires, indicated that students from both groupsobtained benefit in terms of taking more responsibility fortheir own learning, enhancing their personal growth, andgaining a broader understanding of community needsand service; therefore, in these respects, the project wasdeemed successful.72 Speech-language pathology studentsfound the experience, regarding the socialization aspectsof the project, to be very beneficial to their professionaldevelopment and said that they were inclined to continueto volunteer or work or do both in the LTC community.72Nursing students, however, felt more classroom time spentcovering dementia would have been more beneficial to theirprofessional development than community time, and theysaid they were unlikely to want to continue to volunteeror work in the LTC community after the completion ofthe course.72 The speech-language pathology students hadmore extensive training and knowledge to prepare themto work with the LTC population and dementia patientsin particular, which contributed to their more positiveattitudes.72

In another study of baccalaureate nursing students,senior students spent four days of their clinical rotationin an LTC setting where they completed basic assessmentsof residents using the MDS (minimum data set), andparticipated with the care planning team at the LTC facility

to learn how the MDS contributes to care planning.73The main goal of the practicum was to improve studentsattitudes about older adults and to create increasedinterest in geriatric nursing. While attitudes may haveimproved, based on focus group results a week afterwardsin which most students rated their experience positively,none of the students said that they planned to work inLTC immediately after graduation, prompting researchersto suggest that their program is not as effective as it couldbe.73

A common theme that emerges in most of the studieson student experiences in LTC concerns the emotionalimpact upon the students. In two different studies, onewith medical students74 and the other with nursingstudents,78 it was revealed that many students weresomewhat overwhelmed by the range and intensity ofemotions they experienced while working with the LTCresidents. In both reports, it was concluded that greatersupport must be provided to help students not onlyprepare for the emotions they will feel, but to teach them

how to deal with those emotions in a way that will bebeneficial. However, other studies of student experiencesin LTC demonstrate more positive results arising fromstudents emotional experiences. For example, in variousstudies with dental students,79,80 medical students,75 andspeech-language pathology students,76 many studentsexpressed that the emotional learning they experiencedhelped them grow as professionals and as individuals,increasing their understanding and appreciation forthe lives and situations of the older adults in their care.The many positive experiences revealed in these variousstudies may encourage students, upon graduation, to workwith older adults and in the LTC environment.

If the health professions are going to be adequately

prepared to manage the increasing numbers of older adults,it is important to increase and improve efforts to provideoral health and general geriatric health knowledge tohealth care students. Perhaps most importantly, however,would be to socialize them into the LTC environment, sothey will have the knowledge, experience, confidence,attitude, and desire to return upon graduation or later intheir careers.

eldersmil es: a dental hygiene program practicumElderSMILES (Strengthening Mouthcare In Long-

term Eldercare Settings) is a practicum that was initiatedin the dental hygiene program at the University ofAlberta in January 2011. The primary objectives for thepracticum were to socialize DH students to the long termcare environment, to assess residents oral health and toprovide daily mouthcare for residents. The purpose of thispaper is to report the qualitative data based on the firstobjective which was the socialization of DH students tothe long term care setting.

Two long term care facilities were chosen and werelocated within reasonable proximity to the universitywhich facilitated student access to each facility. The twofacilities differed in their structural organization andin some services offered, so each had the potential ofproviding a range of experiences for the students.

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Senior level DH diploma students were at each site oneday per week over a 13-week period. A registered dentalhygienist (RDH) who was also a clinical instructor in theDH program guided the students at each site. Studentsworked in pairs to complete an intra oral assessmentfor residents using a modified Oral Health AssessmentTool (OHAT)81 and, when appropriate, provided dailymouthcare and oral hygiene instructions to the resident.The chosen modification of the OHAT was selectedbecause the Edmonton Zone of Alberta Health Servicesmodified the OHAT developed by Chalmers82 andsubsequently, has recommended incorporating it into theresidents assessment for long term care facilities. Studentsalso assessed and recorded the amount of plaque andhard debris on the teeth using a disposable dental mouthmirror and a visual inspection. When possible, studentsalso provided demonstrations for health care aides on howto effectively complete daily mouthcare for a resident.

There were 48 participating DH students, all of whomwere in the final year of a 3-year diploma program. None

of the students had any prior experience with longterm care (LTC) facilities other than a few students withpersonal experience with family members. Each studentwas scheduled for the ElderSMILES practicum for twodays and a few students were scheduled for three days.Prior to the start of the practicum, students and the RDHclinical instructors attended a workshop that includeda presentation from one of the facilities and a detailedorientation to the processes to be followed during the LTCpracticum experience. Students and the registered dentalhygienist (RDH) clinical instructors were provided with aresource manual.

Onsite at each facility, the RDH instructor would begineach day with a briefing session and, after seeing each

resident, the group would debrief and determine nextsteps. Oral assessment details and recommendations wererecorded in the residents care plan and when possible,discussed with the registered nurse who develops andmonitors the residents care plan.

MeTHODsFollowing the 13-week period, two focus groups wereconducted with DH students. Each focus group includedthree students who had volunteered to participate. Focusgroups were chosen for gathering data from the studentsbecause this research method provides the opportunity tocapture interaction with the group that can better reflectthe collectivity of student experiences in the practicum.83Focus groups also allow for the expansion of ideas bystimulating the thinking of the individuals as they reflecton and respond to what other members of the group say,providing potentially rich and detailed perspectives fromparticipants.84 In addition, individual interviews wereconducted with the two RDH instructors. The questionsfor both focus groups and individual interviews weredeveloped by the authors, and approval for the evaluationof the practicum was granted by the Health ResearchEthics Board at the University of Alberta as well as theCovenant Health Research Centre. Focus group andinterview questions are outlined in Table 1.

focus group questions

f rom your practicum in Lt C, describe the learning

experience that stands out most for you. (Note to facilitator

try to have each student respond to this question)

Describe any challenges you experienced. Describe how communication and directions transpired

from the time you entered the facility to completion of the

days experience. f or example, were you met upon arrival

and directed to your area as planned?

Describe any challenges you had with performing the oral

assessments.

Describe any challenges you had with mouthcareinstruction with residents.

Describe any challenges you had with mouthcare

instruction with HCas? o thers? (If others, who were they?

RNs? Other caregiver?)

How do you feel you were able to communicate with

residents? HCas? o thers? (If others, who were they?)

Did you feel part of an interdisciplinary team? if so, how?

if not, why not? (Provide an example)

How would you describe the receptiveness of the facility

staff to the Eldersmi LEs program, and having dental

hygiene students on site?

please share any suggestions for the future of this

practicum

Interview questions

Overall,whatstoodoutforyouwhenyoureflec onthe

practicum experience?

Describeanyoverallchallengesyouexperienced.

Describehowcommunicationanddirectionstranspired

from the time you entered the facility to completion of thedays experience. f or example, were you met upon arrival

and directed to your area as planned?

Howwereresidentsidentifie foryouandthestudentsto

see each week?

Describeanychallengesyouorstudentshadwith

performing the oral assessments.


mouthcare instruction with residents.


mouthcare instruction with HCas? o thers? (If others, whowere they? RNs? Other caregiver?)

Howdoyoufeelyouorstudentswereableto

communicate with residents? HCas? o thers? (If others,who were they?)

Didyoufeelpartofaninterdisciplinaryteam?Ifso,how?

if not, why not? (Provide an example)

Howwouldyoudescribethereceptivenessofthefacility

staff to the Eldersmi LEs program, and having dentalhygiene students on site?

Pleasecommentonhowtheassessmenttoolsworkedfor

you and the students? Easy to follow? Difficult to follow?suggestions?

Pleaseshareanysuggestionsforthefutureofthis

practicum.

t able 1: f ocus group and interview questions.

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The focus groups with students were conducted bythe second author, who was not involved in the onsitepracticum experience. She was assisted by a masters levelgraduate student who was not involved in the practicumbut is a registered dental hygienist. The assistantrecorded notes. The interviews with the RDH clinicalinstructors were conducted by the first author. Both thefocus groups and the interviews were audio taped andtranscribed verbatim. The full transcriptions were firstreviewed by the second author who read each transcriptand identified thematic categorization. The first authorreviewed them independently and the two authors latermet to compare themes. Any discrepancies that occurredin the categorization of data into a particular theme werediscussed by the authors until consensus was reached.

ResuLTs

Qualitative analysis of the transcripts revealed six mainthemes from the focus groups conducted with the students:

1. Communication challenges between students and

LTC staff2. Communication challenges between students and

LTC residents3. Uncertainty about follow up for oral health

recommendations4. Barriers to provision of daily mouthcare5. Uneasiness of students in LTC environment6. Appreciation for the practicum experience

1. Communication challenges between students andLTC staff

The predominant concern was that the health careaides (HCAs) were not present when the student wasvisiting the resident in LTC. This made it impossible for

the student to demonstrate or to explain the importanceof proper mouthcare to the HCAs, which was to have beenpart of the practicum experience. If the HCAs had beenpresent, students believed that it would have improvedtheir ability to work with the residents. Students alsofound that the HCAs were so busy with their many dutiesthat it was not feasible to interact with them: We couldnot really communicate with them, just due to time factor.Students also experienced communication challengeswith the RNs: You kind of feel uncomfortable because youfeel the nurses are kind of saying, What are you doing here?You are wasting our time.

2. Communication challenges between students andLTC residents

Communication challenges between the students andthe residents were due to many factors, including residentsnot knowing or understanding what the student wasdoing, students minimal understanding of the residentscognitive and physical capacities, and the physicalchallenges of working with frail seniors. Some residentswere great. Others, not so much. Learning how to approachthe residents in their rooms was a new and challengingexperience for the students. In one student experience, shenoted, She [the resident] thought we were there to do somethingto her and she didnt know us and she seemed afraid and thats

why she was defensive. I guess what I am trying to say is if youcan find a way to communicate with them, they may be willingto cooperate but if they do not understand what we are there for,they are not going to be receptive. Obtaining a meaningfullevel of rapport with residents in order to perform oralassessments and to provide some daily mouthcare for theresidents in their rooms was challenging, but studentsappreciated the complexity of the rapport building processafter their interactions with residents.

3. Uncertainty about follow up for oral healthrecommendations

Students expressed uncertainty and frustration aboutfollow ups to their recommendations for oral care forresidents: I feel after we leave, what happens next? All thereferrals we recorded does that ever get looked at by anybody?Students had the impression that what they were doingwould not have any lasting impact: It almost seemeddefeating. You know, you are writing these notes down and youknow that no one is going to see that. Thats what I felt. It

seemed to most of the students that, as soon as they weregone, mouthcare would again be minimally performedand their recommendations for oral care would be ignored.

4. Barriers to provision of daily mouthcareSome of the barriers to provision of daily mouthcare

that were encountered by the students included residentsnot being in their rooms when the students arrived: [Wehad problems] fitting into their busy schedules. They [residents]were not where they were supposed to be or they had somethingelse planned. They also faced uncooperative residents whocreated physical challenges for the students, by making itdifficult to perform mouthcare: Basically, it took four peopleto brush her [the residents] teeth and it was 20 minutes to get

the whole mouth done. Other physical challenges includedthe fact that many residents are in wheelchairs, whichmade it difficult for the students: Youre bending down, it isdark in their room and the flashlight is bothering them. And Ihad one lady who would keep pushing herself in the wheelchair,moving around a lot. Many students suggested that some ofthe greatest barriers to provision of daily mouthcare weredue to the situations and inherent limitations at the LTCfacilities. The fact that students were unable to interactwith the HCAs during the practicum led to the comment:

I think the biggest challenge was the people that actually wouldbe providing the daily mouthcare were not the ones we wereteaching it to. As well, it was noted that: They [the staff]are really busy. Like they are overworked for sure. So to throwanother task on top of everything else, well, it just seems almostimpossible for them to do it.

5. Uneasiness of students in LTC environmentStudents experienced considerable emotional challenges

working in the LTC environment. Many of them hadnever had experiences with older adults and had neverbeen to a long term care facility: Some people [students];including me, the initial reaction was a little overwhelming justbecause it is the first time we are dealing with this population.

Like, I love old people but being in the facility where they aresick, they are in a wheelchair and slouched down it was just

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overwhelming. So sad. And I was initially like, oh my gosh! Idont know how to deal with this. Many students expressedthat they felt overwhelmed and did not know how toadequately deal with the people and situations that theyfaced: It was really challenging emotionally. We went in oneresidents room and she had her shirt bunched up and in hermouth and she was chewing on her shirt. My instructor helpedremove it but she [the resident] just looked like she was in a lotof pain and maybe that was why she was chewing on her shirt.In another situation, it was noted that: We [DH students]were approached by one older man and he was saying, Can youguys get me out of here? and we were like, uhm, now what?

6. Appreciation for the practicum experienceEven with many challenges and frustrations experienced

by the students, they still expressed appreciation forhow much they learned during the practicum, with theonsite experience enriching their classroom, theory basedlearning. As one student noted, I think it was a great ideaand Im so glad [the practicum] was started. Just the exposure

for us as some students would have no idea about the cognitivechanges and the combative ways. We would not ever have seenthat and no matter what, its just a great experience and itis good to have it. It also helped students become moreaware of the need to improve the standards of oral careprovided to LTC residents, for as another student said, Ilearned a lot. We hear in our class that this population haspoor oral health and are under served but to actually see howbad it is, that gets your mind going. What is being done? Whatcan be done? Students therefore recognized the value forhaving the practicum, and supported further developingand continuing the practicum: Hopefully, [the practicum]can grow and improve in some areas and, maybe thisfirst year was somewhat unorganized and we lacked some

communication, but now it gives us hope that improvementwill be made.

From the interviews that we conducted with theregistered dental hygienists who were clinical instructors,qualitative analysis of the transcripts identified thefollowing two themes: challenges in the facility context,and challenges and enhancements for student learning.

1. Challenges in the facility contextThe RDH instructors identified numerous challenges

that arose from the situations they encountered at theLTC facilities, frequently echoing sentiments expressedby the students. They noted that it was difficult to workwithin the daily routine and activities of the residents.The scheduled time of the practicum being from 9 a.m. to3 p.m., did not coincide with when morning mouthcarewas provided, leading to the suggestion that a start time of7 a.m. would be better, to be onsite when the mouthcarewas provided by HCAs. Differences were found in staffattitudes towards the DH group at the two facilities, forit was noted that staff in facility #1 were accommodatingand generally helpful, although the DH group did not feelas though they were a part of the health care team. Staffin facility #2 were not welcoming to the DH group, and itwas noted that: I think if we didnt show up, I do not think

anyone would miss us. It was also expressed that: Thereneeds to be a better system to incorporate us into the dailyflow. RDH instructors also commented that HCAs wereextremely busy, and so there was minimal interactionwith them, preventing the HCAs from being involved inmouthcare instruction by the students. And finally, theRDHs expressed uncertainty regarding follow up on therecommendations for oral care for residents: We madecomments in the chart but I am not sure what happened afterthat.

2. Challenges and enhancements for student learningThe RDHs were able to provide important feedback

as instructors as to their perceptions on the studentexperience. One practical concern that was noted was thatfacility #1 was very crowded, with no place to have a pre andpost case discussion in private, which hampered learningopportunities. RDHs were aware that the students wereoften overwhelmed with emotion from their interactionand observation of residents: I would ask if this was their

first time in a nursing home and I was surprised at how manysaid yes. As a result, students needed a lot of coachingand encouragement. Recognizing that there was muchvariability in comfort level of students and their ability tocommunicate with residents, one RDH noted that: I triedto partner a weaker communicator with a stronger one.

RDHs also felt that students should have had moredidactic preparation prior to having the practicumexperience, although some did extremely well. Theinstructors noted that students recognized the challengesof doing oral assessments in the residents room, suchas the lack of light and difficulty using a head lamp or aflash light. They also acknowledged some of the physicalchallenges facing students when they tried to complete

oral assessments with some residents, noting: There were afew residents [for whom] we used six handed Tai Chi in order toprovide effective care. Tai Chi is a form of Chinese martialart emphasizing gentle force and a sensitive response tothe movements of others with whom one is in contact. Itwas also noted by the RDHs that it was challenging forstudents to decipher the complex resident chart, but thatit was good experience for students to review the chartsand thus to learn about the complexity of the residentsand about the different assessments.

DIscus sIOn

Many lessons were learned from insights we obtainedfrom the DH students and the RDH instructors in ourstudy of the ElderSMILES practicum. It highlighted manyof the challenges of working in the LTC environment withits complex population. One of the main issues that aroseconcerns the emotional challenges students face workingwith LTC residents for the first time. Similar challengeshave been reported in other studies of student practicumsin LTC, which often highlight inadequate preparationcausing students to feel emotionally overwhelmed, andthus, to be potentially discouraged from returning to LTCupon graduation. For example, as reported in one study,after second year Bachelor of Nursing students completeda 3-week clinical placement in LTC facilities working

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specifically with dementia patients, results indicated thatstudents were, on the whole, completely unprepared fordealing with residents with dementia, having little or noknowledge and experience from which to draw.78 Studentsmainly reported experiencing fear, confusion, shock, andsadness.78 It was also revealed that the students did notreceive adequate support from nurse mentors, the latterof whom underestimated how apprehensive and navethe students were.78 It was concluded that, unless nursingstudents receive a far more comprehensive education aboutdementia, it is likely that their unpleasant experiencesin LTC during clinical placements will undermine theirinterest in working in such settings upon graduation.78

Increased preparedness before a practicum appears tobe a key element in the effective socialization of studentsinto an LTC environment. In two studies of dentalstudents who participated in LTC practicums, it wasfound that there was a significant gap between what theylearned in the classroom and what they found to be thecase in practice, particularly concerning the complexity

of the LTC environment and residents.79,80

Similar to theresults of our study, students suggested their knowledgeand training was not sufficient to adequately preparethem for the practical challenges of working with the LTCpopulation.79,80 However, despite this knowledge gap, thestudents did report overall positive experiences and anincreased sense of professional responsibility towards theolder adult population,79,80 and this is also what we foundto be the case in our study.

Most of the previous studies done on student practicumsin LTC, while highlighting similar challenges to thosewe encountered, did not involve DH students, but onlystudents in other health disciplines.59,68,7280 However, theoral health care provided to LTC residents has been shown

to be severely inadequate523 making it imperative thatDH curricula address this issue and develop practicumslike ours, to increase the future likelihood of having aregular DH presence in LTC. One study which involved acollaboration of nursing and dental hygieneconsistingof clinicians and students from both disciplineswas ableto address one of the main challenges that we encounteredin our practicum, namely the difficulty DH students hadworking with the LTC residents.85 In this collaborativestudy, nursing members of the team were able to use theirspecific training to interact with the residents in such away that minimized disruptive or resistive behaviours,enabling the DH members of the team to use their specifictraining to conduct oral health assessments, scoring oralhygiene and DMFT (decayed, missing, and filled teeth).85Perhaps if the students in our practicum had been able tointeract more effectively with the LTC staff, it may havehad a similar result, reducing some of the physical andemotional challenges faced by our students when theywere working with the LTC residents.

In addition to identifying challenges, numerousrecommendations were made by the students and RDHinstructors who took part in our study, which will enableus to modify the practicum in ways that will addresssome of the problems encountered in its first year ofimplementation. The recommendations include:

Increasing classroom theory content prior to thepracticum to better prepare students to manage andwork with complex residents who have cognitive andphysical impairments.

Developing clear protocols for various scenarios thatstudents may face.

Increasing awareness with staff at the facilities asto what students are doing, in order to lead to morestudentstaff communication and interaction.

Trying to ensure that LTC staff is present when thestudents are onsite.

Providing oral care in service training sessions forLTC staff.

Developing and establishing protocols for follow upin regards to referrals and recommendations madefor residents.

Starting the practicum earlier in the academic year toprovide the students with more experience.

Scheduling of the daily practicum hours to coincidebetter with the daily schedules of the residents.

Since the implementation and evaluation of theElderSMILES practicum, many of these changes have beenmade and the practicum continues to be developed andoffered. More theory has been added to the didactic coursethat accompanies this practicum, and case scenarios arebeing developed to facilitate small group discussions inclass. Some detailed protocols have been developed toguide clinical instructors and students when onsite at thepracticum and more mock scenarios are being created thatwill be used for learning activities in class time.

The practicum is in its third term onsite; it has beennoted by the clinical instructors that dental hygiene hasestablished a known presence at the facilities and that ittook more than the initial 13 week term for this relationship

to be developed. Additionally, at one facility early in2013, students were able to provide numerous in serviceeducation sessions for the staff and the sessions were verywell attended. The clinical instructors have also been ableto discuss follow up referrals and recommendations withthe registered nurse on the units who are responsible forensuring any recommendations made in a residents careplan are attended to. As we complete our third term onsitein the same LTC facilities, relationships are developingwith facility staff and we have an increased presence andinvolvement in the oral care for residents.

The scheduling of the practicum has remained the sameboth in terms of when it is held during the academic year(winter term) and in terms of hours of the day, 09001530hours. Consideration has been given to increasing thelength of time students spend onsite for the LTC practicum.However, other commitments in the DH program wouldhave to shift to accommodate the change and these arebeing considered. The students were onsite from 0900to 1530 hours, and these hours were set to accommodatethe facility schedules around mealtimes and otheractivities. For the most part, the hours were appropriatefor the practicum except for the fact that health care aidesperform any daily mouthcare for residents when they aregetting the residents up in the morning and ready for theday. Therefore, this created a challenge for the students

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to interact with the HCAs to offer any guidance for theirdaily mouthcare techniques or to demonstrate any oralhealth issues for them to be aware of and possibly report.The staff in service sessions were increased this year at onefacility in an attempt to provide further education for staffon oral health issues and daily mouthcare techniques.

We believe that the changes we have made to thepracticum, arising from what we learned from the resultsof this study, will diminish some of the challenges thatstudents face. We intend to conduct additional qualitativestudies in order to assess whether or not these changeslead to a more positive experience for the students thatmay ultimately contribute to their socialization into theLTC environment.

cOncLusIOn

Student feedback from our study suggests that theElderSMILES practicum was a huge awareness buildingexperience for them. Comments concerning theirappreciation of the practicum confirm our premise that

it will serve the dental hygiene profession well if studentsare exposed to the long term care environment prior tograduating. As has been found in similar studies of LTCpracticums in other health professional programs,58,67,7179we were able to provide students with essential practicalknowledge and experience working with older adults aswell as build within them a desire and perhaps even asense of obligation to work in LTC upon graduation.

This study clarified elements of our practicum thatrequired further assessment and development in orderto address the challenges encountered by the students.We are optimistic that future implementations of thispracticum, incorporating lessons learned from this study,will produce a more positive educational experience for

students, emphasizing the rewards of working with thispopulation. Follow up studies of graduates who havecompleted this and other LTC practicums will be essentialto determine how many choose careers working with thegrowing older adult population, and thus if socializationefforts within educational programs have been successful.

Acknowledgements

The authors would like to acknowledge funding from the

Canadian Foundation for Dental Hygiene Research and

Education as well as funding from the Fund for Dentistry,

School of Dentistry, Faculty of Medicine and Dentistry,

University of Alberta.

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