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Community-Based Dental Education and Service Learning Margot B. Stein, Ph. D. UNC School of Community-Based Dental Education and Service Learning Margot B. Stein, Ph. D. UNC School of Dentistry CCPH Consultancy Network June 20, 2005 -San Juan, Puerto Rico 1

Many thanks to: Community-Campus Partnerships for Health ¡ Robert Wood Johnson Dental Pipeline Project Many thanks to: Community-Campus Partnerships for Health ¡ Robert Wood Johnson Dental Pipeline Project ¡ Dental School of the University of Puerto Rico ¡ ADEA ¡ 2

Workshop Agenda Welcome and Overview of Objectives ¡ Introduction to Service-Learning (SL) ¡ Models 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 ¡ 3

Workshop Objectives 1. Define service-learning (SL) and explain how it differs from and complements 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; 4

Workshop Objectives 3. Describe how SL fosters student leadership, cultural competency, lifelong learning, and 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 5

Trends Shaping Education and Practice in Health Professions Advances in diagnosis and treatment ¡ 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 ¡ 6

Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Participate Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Participate in improving oral health Provide empathic care for all patients Evaluate social and economic trends 7

Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Assess Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Assess patient goals, values, and concerns Provide patient education Obtain psychosocial and behavioral histories 8

Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Recognize Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ ¡ Recognize signs of abuse or neglect and report and refer as necessary Apply ethical principles Evaluated career options, practice location, and reimbursement mechanisms 9

Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ Recognize predisposing Competences for the Dentist of the 21 st Century (ADEA) ¡ ¡ Recognize predisposing and etiologic factors Manage dental care for disabled and special care patients 10

Dental School Accreditation Standards (excerpts) Graduates must be competent in: l Application of behavioral Dental School Accreditation Standards (excerpts) Graduates must be competent in: l Application of behavioral sciences l Patient-centered oral health promotion l Managing a diverse patient population l Skills for a multicultural work environment 11

Dental School Accreditation Standards (excerpts) l Evaluating models of oral health l Ethical reasoning, Dental School Accreditation Standards (excerpts) l Evaluating models of oral health l Ethical reasoning, critical thinking, problem solving, life-long learning, selfassessment 12

Calls for Change in the Education of Health Professions, 1990 -2005 Advocating greater emphasis 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 13

Trends Shaping Education and Practice in Health Professions Expectations of accountability, involvement, relevance ¡ Trends Shaping Education and Practice in Health Professions Expectations of accountability, involvement, relevance ¡ Continued pressure on costs ¡ Increasingly managed and integrated care ¡ New technologies ¡ 14

CCPH Mission To foster partnerships between communities and educational institutions that build on each 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. 15

“Service” English Definitions: -to help, a helpful act -to benefit -a contribution to the “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 16

Service-Learning Focuses On: 1. The context in which the service is provided; 2. The 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. 17

SL is a Type of Experiential Education (A. Furco, 1996) SERVICE-LEARNING COMMUNITY-SERVICE VOLUNTEERISM FIELD SL is a Type of Experiential Education (A. Furco, 1996) SERVICE-LEARNING COMMUNITY-SERVICE VOLUNTEERISM FIELD EDUCATION PRACTICUM CLINICAL ROTATION Internship Clerkship Recipient Service BENEFICIARY Provider FOCUS Learning 18

Theoretical Underpinning of SL: Experiential Learning Theory –D. Kolb, 1984 Concrete Experiences Reflective Observation Theoretical Underpinning of SL: Experiential Learning Theory –D. Kolb, 1984 Concrete Experiences Reflective Observation Active Experimentation Abstract Conceptualization 19

Service-Learning is NOT the same thing as doing clinical work in a community setting. Service-Learning is NOT the same thing as doing clinical work in a community setting. 20

Clinical Work in Community Settings Focuses almost exclusively on the delivery of dental services 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 ¡ 21

Points of Departure: SL and Clinical Education ¡ ¡ ¡ Balance between service and 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 22

Points of Departure: SL and Clinical Education ¡ Emphasis of SL is on: - Points of Departure: SL and Clinical Education ¡ Emphasis of SL is on: - Reciprocal learning Reflective practice Developing citizenship skills Achieving social change 23

SL Involves Partnerships ¡ Partnerships: l l l l l Common missions, values, outcomes SL Involves Partnerships ¡ Partnerships: l l l l l 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 24

Benefits of SL for Students ¡ Personal/interpersonal skill development ¡ Communication skills ¡ “The Benefits of SL for Students ¡ Personal/interpersonal skill development ¡ Communication skills ¡ “The personal becomes the political” 25

Reflection in Service Learning ¡ ¡ Reflection is a bridge between experience and theory 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. ” 26

Reflection in Service Learning (Bringle & Hatcher. Educational Horizons. 1999) Is a learning strategy Reflection in Service Learning (Bringle & Hatcher. Educational Horizons. 1999) Is a learning strategy designed to respond to limitations of traditional student learning: l l how to generalize prior learning to new circumstances or situations promotes personal understanding of students’ lives and the world outside the Classroom. 27

Reflection in Service Learning Types of reflection for SL: ¡ Journals are easy to Reflection in Service Learning 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 l Students need to know, at beginning of course, what is expected in a journal and how it is going to be used l If intended as personal document, not submitted for a grade l May be shared with other students or community agency personnel 28

Reflection in Service Learning Critical incident journal: Students focus on a specific event that Reflection in Service Learning Critical 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 1 st consider doing? -List 3 actions that you might have taken and evaluate each one. 29

An Example of Critical Incident Essay Applied to Dentistry: (Mofidi, et. al. , 2003) 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. ” 30

Reflection in Service Learning ¡ Ethical Case Study. Write a case study of an Reflection in Service Learning ¡ 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 formal papers or class presentation 31

Reflection in Service Learning Directed Readings ¡ Class Presentations ¡ l l Students share Reflection in Service Learning Directed Readings ¡ Class Presentations ¡ l l Students share experiences, service accomplishments, products created during their service, using videos, Power. Point, bulletin boards, panel discussions. Community present. Provide opportunities for student to organize experiences, develop creative displays, share information. 32

Reflection in Service Learning ¡ Electronic Reflection Web-based mode of communication (i. e. , Reflection in Service Learning ¡ Electronic Reflection Web-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 33

SL Findings based on literature reviews and findings from the Health Professions Schools in SL Findings based 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 34

SL Findings: Student Outcomes Following a SL experience students in the health sciences reported 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 35

SL Findings: Student Outcomes Following a SL experience students Were more likely to report SL Findings: Student Outcomes Following a SL experience students Were more likely to report a willingness to: l l l Work on a multiprofessional team Work in a rural setting Volunteer their time These findings were statistically significant 36

SL Findings: Student Outcomes Following a SL experience students reported: l l l Feeling SL Findings: Student Outcomes Following a SL experience students reported: l l l 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 37

SL Findings: Faculty Outcomes -Enhanced relationship between students and community -Linkage of personal/professional lives 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 38

SL Findings- Community Gains: -Service, economic and social benefits (access to experts for research, 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 39

SL Findings: Academic Institutions Gain: ¡ Affirmation of mission and strategic goals ¡ Better SL Findings: Academic Institutions Gain: ¡ Affirmation of mission and strategic goals ¡ Better university-community relationships ¡ Recruiting tool for students and faculty 40

SL Protocol for Health Professions Schools 1. 2. 3. 4. 5. 6. Include more SL Protocol for Health Professions Schools 1. 2. 3. 4. 5. 6. Include more community sites Build long term relationships Develop a Service Learning Experience Develop an orientation component Develop of reflection component Promote the professional ethic of service 41

Risk Management and SL Responsibilities of” -Community Agencies -Faculty -The Institution -The students 42 Risk Management and SL Responsibilities of” -Community Agencies -Faculty -The Institution -The students 42

Lessons Learned (HPSISN* 1996 -1998) ¡ ¡ ¡ Service-learning is a powerful pedagogy SL 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 43

Challenges SL is a process… Financial constraints of institutions ¡ Rigid and over-loaded curriculum Challenges SL 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 ¡ 44

Strategies for SL ¡ Review mission and strategic plan How can service-learning further both? 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? 45

Strategies for SL ¡ Examine faculty roles and rewards policies What constitutes scholarship? ¡ 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) 46

Strategies for SL ¡ ¡ ¡ Assess and build on your strengths and assets Strategies for SL ¡ ¡ ¡ Assess and build on your strengths and assets Create/enhance existing support structures Collaborate across disciplines and campus 47

One example of SL: The UNC Chapel Hill SOD Experience in DISC Dentists in 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 communities Funded by grant from KBR Charitable Trust initially for dental and dental hygiene students l l 140 publicly owned, underserved sites in diverse communities (prisons, nursing homes, psychiatric hospitals, health centers, etc) Rising sophomores, rising juniors, seniors 48

DISC at UNC-CH l l At present, all UNC graduating dental students will have DISC at UNC-CH l l 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 49

Tangible Results of DISC l Accomplishments in year 3: ¡ ¡ ¡ Students treated Tangible Results of DISC l 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 50

DISC at UNC-CH Issues: l Dense curriculum/curriculum change l Timing and scheduling of courses DISC at UNC-CH Issues: l Dense curriculum/curriculum change l Timing and scheduling of courses l Elective vs. compulsory participation and how to maintain enthusiasm l Finding willing/qualified preceptors in student-selected sites (sometimes l Faculty “buy-in” around quality of education issues 51

DISC at UNC-CH Rewards: Increase opportunities for students to experience clinical dentistry in underserved DISC at UNC-CH Rewards: Increase opportunities for students to experience clinical dentistry in underserved populations in their community context l Early exposure to ways to expand careers to broader and more diverse patients l 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 l 52

DISC Program at UNC-CH Activities: ¡ Reflection—photo scrap books, critical incident essays, post-rotation discussions 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. 53

Preparation for Working in the Community Need for new curricular themes in addition to Preparation for Working in the Community Need for new curricular themes in addition to emphasis on technical competence l Communication skills to communicate effectively and comfortably with patients l A comprehensive (holistic) approach to understanding the social, economic and cultural context of the patient l Patient-centered care l Cultural sensitivity/competence 54

Preparation… Role of social and behavioral sciences in the pre-clinical dental school curriculum 1. Preparation… Role of social and behavioral sciences in the pre-clinical dental school curriculum 1. 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 55

Preparation… Need for new teaching strategies: Traditional: Passive Didactic/lecture Innovative: Active/Interactive/Discussion Collaborative/Team Problem-based learning Preparation… Need for new teaching strategies: Traditional: Passive Didactic/lecture Innovative: Active/Interactive/Discussion Collaborative/Team Problem-based learning Critical thinking/problem solving Essays 56

Preparation… New Instructional Methodologies ¡ Scrap books/photos ¡ Observation-Reflection: Writing (journals, critical incidents reports 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 57

Preparation… Clear expectations -Communicated orally and in writing -1 month before departure course director 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”. 58

Re-entry… Post-rotation reflection seminars: structured reflective experience l l l Revolve around feelings and Re-entry… Post-rotation reflection seminars: structured reflective experience l l l 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 59

Resources ¡ Community-Campus Partnerships for Health www. ccph. info http: //depts. washington. edu/ccph/ servicelearningres. Resources ¡ Community-Campus Partnerships for Health www. ccph. info http: //depts. washington. edu/ccph/ servicelearningres. html l For training and technical assistance l CCPH Consultancy Network l Electronic and printed resources l Collaboration between CCPH and ADEA 60

Resources Robert Wood Johnson Dental Pipeline Project www. dentalpipeline. org ¡ National Service-Learning Clearinghouse Resources Robert Wood Johnson Dental Pipeline Project www. dentalpipeline. org ¡ National Service-Learning Clearinghouse www. servicelearning. org ¡ 61

Closing Reflection “I cannot know what your destiny will be, but one thing I 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 62