Community-Based Learning in Dental Education

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Community-BasedDental Education and Service Learning

Margot B. Stein, Ph.D.UNC School of Dentistry

CCPH Consultancy NetworkJune 20, 2005-San Juan, Puerto Rico

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Many thanks to:

Community-Campus Partnerships for Health

Robert Wood Johnson Dental Pipeline Project

Dental School of the University of Puerto Rico

ADEA

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Workshop Agenda

Welcome and Overview of Objectives Introduction to Service-Learning (SL) Models of SL in Dental Education Preparing Dental Students for Service

in the Community Case Study Exercise: Puerto Rico Resources and Wrap-up

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Workshop Objectives

1. Define service-learning (SL) and explain how it differs from and complements traditional clinical experiences in dental education;

2. Identify the key components of SL: curriculum development; community partnerships, community service, and reflection;

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Workshop Objectives

3. Describe how SL fosters student leadership, cultural competency, lifelong learning, and a commitment to caring for the underserved; and

4. Explore ways to develop a plan for incorporating SL into the dental education curriculum at the predoctoral or postdoctoral level

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Trends Shaping Education and Practice in Health Professions

Advances in diagnosis and treatment

Changing role of health care and education consumer

Demographic changes Disparities in health access and

outcomes Broadened definition of health

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Competences for the Dentist of the 21st Century (ADEA)

Participate in improving oral health

Provide empathic care for all patients

Evaluate social and economic trends

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Assess patient goals, values, and concerns

Provide patient education

Obtain psychosocial and behavioral histories

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Recognize signs of abuse or neglect and report and refer as necessary

Apply ethical principles

Evaluated career options, practice location, and reimbursement mechanisms

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Recognize predisposing and etiologic factors

Manage dental care for disabled and special care patients

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Dental School Accreditation Standards (excerpts)

Graduates must be competent in:

Application of behavioral sciences

Patient-centered oral health promotion

Managing a diverse patient population

Skills for a multicultural work environment

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Dental School Accreditation Standards (excerpts)

Evaluating models of oral health

Ethical reasoning, critical thinking, problem solving, life-long learning, self-assessment

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Calls for Change in the Education of Health Professions, 1990-2005

Advocating greater emphasis on community-based learning:

Pew Health Professions Commission Council on Graduate Medical Education IOM Report: Dentistry at the Crossroads IOM Report: Future of Public Health Surgeon General’s Report on Oral Health New Initiatives Emphasizing Community-

Based Dental Education

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Trends Shaping Education and Practice in Health Professions

Expectations of accountability, involvement, relevance

Continued pressure on costs Increasingly managed and

integrated care New technologies

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CCPH Mission

To foster partnerships between communities and educational institutions that build on each

other’s strengths and develop their roles as change agents for

improving education of health professionals, civic responsibility

and the overall health of communities.

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“Service”

English Definitions:-to help, a helpful act

-to benefit-a contribution to the welfare of others-disposal for use of the entire system- use of labor that does not produce a tangible commodity-work that gives good

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Service-Learning Focuses On:

1. The context in which the service is provided;

2. The connection between the service and their academic course work; and

3. Their roles as professionals and citizens.

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SL is a Type of Experiential Education (A. Furco, 1996)

SERVICE-LEARNINGCOMMUNITY-SERVICE FIELD EDUCATION VOLUNTEERISM PRACTICUM CLINICAL ROTATION

InternshipClerkship

Recipient BENEFICIARY Provider Service FOCUS Learning

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Theoretical Underpinning of SL:Experiential Learning Theory –D. Kolb, 1984

Reflective Observation

Active Experimentation

Concrete Experiences

Abstract Conceptualization

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Service-Learning is NOT the same thing as doing clinical

work in a community setting.

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Clinical Work in Community Settings

Focuses almost exclusively on the delivery of dental services (technical competence) to patients in the community

Is not holistic Emphasis on treatment, less on

prevention Tends to be a “top down”,

hierarchical model

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Points of Departure: SL and Clinical Education

Balance between service and learning

Emphasis on addressing community-identified concerns and broad determinants of health

Integral involvement of community partners

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Points of Departure: SL and Clinical Education

Emphasis of SL is on:

- Reciprocal learning- Reflective practice- Developing citizenship skills- Achieving social change

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SL Involves Partnerships Partnerships:

Common missions, values, outcomes Share mutual trust, respect and

commitment Acknowleges assets and needs Balances power & shares resources Have clear, open communication Agree on roles, norms & processes Do continuous quality improvement Share credit for success Develop/ripen over time

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Benefits of SL for Students

Personal/interpersonal skill development

Communication skills

“The personal becomes the political”

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Reflection in Service Learning

Reflection is a bridge between experience and theory

John Dewey described reflection as “turning a subject over in the mind and giving it serious and consecutive considerations.”

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Reflection in Service Learning(Bringle & Hatcher. Educational Horizons. 1999)

Is a learning strategy designed torespond to limitations of traditionalstudent learning:

how to generalize prior learning to new circumstances or situations

promotes personal understanding of students’ lives and the world outside the Classroom.

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Types of reflection for SL: Journals are easy to assign and provide a

way for students to express their thoughts of feelings about the service experience Students need to know, at beginning of

course, what is expected in a journal and how it is going to be used

If intended as personal document, not submitted for a grade

May be shared with other students or community agency personnel

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Reflection in Service LearningCritical incident journal:

Students focus on a specific event that occurred at the service cite in which a decision was made, a conflict occurred, or a problem was resolved. They are asked to describe the event, how it was handled, alternative ways in which they could have resolved the situation, and how they might act in a similar situation in the future (e.g., their thoughts, reaction, and future action). They may include information from the course that might be relevant to the incident.* -Why was it such a confusing event? -How did you/others around the event feel

about it? -What did you do or 1st consider doing?

-List 3 actions that you might have taken and evaluate each one.

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An Example of Critical Incident Essay Applied to Dentistry: (Mofidi, et. al., 2003)

Excerpts from student essays: -”We truly have to imagine ourselves in the shoes of the

person we are treating in order to best help them.”-”I realize now that everyone deserves your compassion

and no one deserves your judgment”-”Are those who acquired this disease (AIDS) through risky

behavior of their own doing not so worthy of my support [as unsuspecting victims]? I am not sure, but I will continue to examine my feelings.”

-”I learned that there is a greater need out there than I anticipated. And no matter how small a difference I make, it is still a difference. . . It is enough to make me try to make the difference.”

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Ethical Case Study. Write a case study of an ethical dilemma confronted at the service site, with a description of the context, the individuals, involved, and the controversy/dilemma observed-May be used for structured group

discussion, provide basis for formal papers or class presentation

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Directed Readings Class Presentations

Students share experiences, service accomplishments, products created during their service, using videos, PowerPoint, bulletin boards, panel discussions. Community present.

Provide opportunities for student to organize experiences, develop creative displays, share information.

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Electronic ReflectionWeb-based mode of communication (i.e., class home pages, chat rooms, on-line survey forms), e-mail, and class listservs to present material, structure discussions, submit reflective journal entries, and deal with issues at the service site

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SL Findingsbased on literature reviews and findings from the Health Professions Schools in Service to the Nation project HPSISN 1996-1998

Student Outcomes-transformational learning experiences-clarifications of values, sense of self-awareness of determinants of health-sensitivity to diversity-knowledge of health policy issues-leadership development

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SL Findings: Student Outcomes

Following a SL experience students in the health sciences reported better knowledge of:

Community resources Health care needs of the community Barriers to receiving care Impact of socioeconomic status on

health These findings were statistically significant

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Following a SL experience studentsWere more likely to report awillingness to:

Work on a multiprofessional team Work in a rural setting Volunteer their time

These findings were statistically significant

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Following a SL experience students reported: Feeling better prepared to work in

community settings Feeling more comfortable working with

diverse patient populations Greater commitment to work in HPSA’s

and with diverse patient populations

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SL Findings: Faculty Outcomes

-Enhanced relationship between students and community

-Linkage of personal/professional lives-Better understanding of community issues-New career and scholarship directions-New directions and confidence in teaching

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SL Findings- Community Gains:

-Service, economic and social benefits (access to experts for research, data analysis, program

evaluation, extended service delivery)-Increased awareness of institutional assets/limitations-high value placed on relationship with faculty-Value in being seen as teachers and experts

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SL Findings: Academic Institutions

Gain: Affirmation of mission and strategic

goals Better university-community

relationships Recruiting tool for students and

faculty

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SL Protocol for Health Professions Schools

1. Include more community sites2. Build long term relationships3. Develop a Service Learning

Experience4. Develop an orientation component5. Develop of reflection component6. Promote the professional ethic of

service

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Risk Management and SL

Responsibilities of”-Community Agencies-Faculty-The Institution-The students

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Lessons Learned(HPSISN* 1996-1998)

Service-learning is a powerful pedagogy SL can contribute to key competencies SL van benefit all stakeholders Community can be effective educators Community assets are often overlooked

and underestimated

*Health Professions Schools in Service to the Nation, a national demonstration program funded by Pew Charitable Trusts and the Corporation for National Service

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ChallengesSL is a process…

Financial constraints of institutions Rigid and over-loaded curriculum Disciplinary boundaries Lack of roles and rewards for

innovation Accepting the implications of true

partnerships Culture of needs-based and expert

approaches

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Strategies for SL

Review mission and strategic plan How can service-learning further both?

Review accreditation requirements How can service-learning enable you to

meet them?

Review curriculum Where can SL enhance?

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Strategies for SL

Examine faculty roles and rewards policies

What constitutes scholarship? Invest in faculty development

Engage your community partners in a dialogue

Develop and promote principle-centered partnerships (CCPH Principles of Partnership)

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Strategies for SL

Assess and build on your strengths and assets

Create/enhance existing support structures

Collaborate across disciplines and campus

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One example of SL: The UNC Chapel Hill SOD Experience in DISC

Dentists in Service to Communities Objective: to increase available oral health services to underserved peoples and communitiesFunded by grant from KBR Charitable Trust initially for dental and dental hygiene students

140 publicly owned, underserved sites in diverse communities (prisons, nursing homes, psychiatric hospitals, health centers, etc)

Rising sophomores, rising juniors, seniors

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DISC at UNC-CH At present, all UNC graduating dental

students will have spent 47 days in extramural rotations. By 2006-07, this will become 60 days total with support of RWJ Dental Pipeline. Some students take summer externships for several additional months

All seniors spend 4 (soon 5) weeks each in a hospital rotation and a community rotation. In addition,

Rising sophomores and juniors are eligible for summer extramural elective rotations

Other extramural elective rotations are available to seniors when other requirements completed

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Tangible Results of DISC

Accomplishments in year 3: Students treated 2,320 patients 55% (1097) of these patients were children Students produced $196,237 worth of dental

services Students evaluated all externships & sites and

were evaluated by their preceptors on site All students wrote reflective essays and

participated in discussions

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DISC at UNC-CH

Issues: Dense curriculum/curriculum change Timing and scheduling of courses Elective vs. compulsory participation and how to maintain enthusiasm Finding willing/qualified preceptors in

student-selected sites (sometimes Faculty “buy-in” around quality of

education issues

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DISC at UNC-CH

Rewards: Increase opportunities for students to

experience clinical dentistry in underserved populations in their community context

Early exposure to ways to expand careers to broader and more diverse patients

Students further define career and ethical responsibilities to include service to the traditionally underserved and experience related rewards of public service

And many other personal rewards in self awareness and spiritual terms

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DISC Program at UNC-CH

Activities: Reflection—photo scrap books, critical

incident essays, post-rotation discussions SL exercise Reading elective: all students read an

assigned book related to social science theme. Past year was Nickled and Dimed by B. Ehrenreich) and write a reflective essay about it and meet together for discussion over dinner.

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Preparation for Working in the Community

Need for new curricular themes in addition to emphasis on technical competence Communication skills to communicate

effectively and comfortably with patients A comprehensive (holistic) approach

to understanding the social, economic and cultural context of the patient

Patient-centered care Cultural sensitivity/competence

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Preparation…Role of social and behavioral sciences in the

pre-clinical dental school curriculum1. Teach students how to relate scientific principles

and technical expertise with patient’s life history and clinical presentation

2. Teach concepts of culture, ethnicity and other key social variables

3. Be able to apply these concepts to the delivery of oral health care

4. Teach collaboration and group problem-solving

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Preparation…Need for new teaching strategies:Traditional: Passive

Didactic/lecture

Innovative: Active/Interactive/Discussion Collaborative/Team Problem-based learning Critical thinking/problem solving Essays

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Preparation…

New Instructional Methodologies Scrap books/photos Observation-Reflection: Writing

(journals, critical incidents reports and essays)

Role Plays Video Collaboration: team-based projects

and presentations Readings humanities/social science

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Preparation…

Clear expectations-Communicated orally and in writing-1 month before departure course director holds

mandatory meeting (“send-off”) for students-All necessary paperwork (critical incident log

books, instructions, descriptions of all requirements and due dates, contact information for UNC personnel, needle-stick protocol on cards, etc)

For students, this structure provides certainty and boosts confidence in ability to function effectively away from the “mother ship”.

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Re-entry…

Post-rotation reflection seminars: structured reflective experience Revolve around feelings and issues associated

with community-based experience Discuss critical incidents with peers Compare commonalities and differences Groups of 8-10 2 hours Guided by trained dental faculty facilitator

chosen by course director

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Resources

Community-Campus Partnerships for Healthwww.ccph.infohttp://depts.washington.edu/ccph/ servicelearningres.html For training and technical assistance CCPH Consultancy Network Electronic and printed resources Collaboration between CCPH and ADEA

http://www.ccph.info/

http://depts.washington.edu/ccph/

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Resources

Robert Wood Johnson Dental Pipeline Projectwww.dentalpipeline.org

National Service-Learning Clearinghouse

www.servicelearning.org

http://www.dentalpipeline.org/

http://www.servicelearning.org/

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Closing Reflection

“I cannot know what your destiny will be, but one thing I do know is that the truly happy among you will be those who have learned to serve.”

Albert Schweitzer

Documents

Community-Based Learning in Dental Education