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Using a Multifaceted Approach Including Community-Based Service-Learning to Enrich Formal Ethics Instruction in a Dental School Setting

Key words: ethics, curriculum, community-based service-learning, dental students, dental hygiene students

Submitted for publication 04/01/05; accepted 02/19/06

	Abstract

Top Abstract Methodology Results Discussion Conclusion References

 
The purpose of this investigation was to examine the degree to which a multifaceted approach to formal ethics instruction including community-based service-learning can enrich the learning environment and how it influences students’ attitudes and perceptions about their role as oral health care providers, access to care, disparity, and working in a diverse community. Students’ attitudes were evaluated prior to and following the seven-week course to determine if community-based service-learning had any impact on their perceptions. Factor analysis was conducted; and based on the identified factor structure, subscales were computed and used for subsequent analyses of change in attitude over time (pre- and post-test results) and to compare assessment of experience between discipline groups (dental and dental hygiene) as well as gender. There was a statistically significant difference in student attitudes from the beginning of the course to the end about volunteering in the community (p=.036). Additionally, there was a statistically significant difference (p<.01) between male and female students related to course impact on career choice and personal ability. Female students reported the course had a greater impact on their career choice and personal ability than did males. Students were required to complete a reflection paper on their service-learning experience. Reflective papers were analyzed using the qualitative constant comparative method. Reflective papers served as a rich source of information for understanding student perceptions related to their role as oral health care providers, access to oral health care, disparity, and cultural competence. Both dental and dental hygiene students indicated a desire for additional opportunities to participate in community-based service-learning activities and a desire for addressing the current access to care issues in their curricula. We found that a multifaceted approach to ethics instruction incorporating a community-based service-learning component provided an enriched environment for the discussion of several ethical issues facing oral health care providers today.

With so little time dedicated to ethics instruction, the burden often falls on ethics instructors to develop effective strategies that will have the greatest impact in a limited timeframe. Many methodologies have been suggested in the literature. For example, case-based learning is promoted as a method for teaching ethics in professional school settings, as is small group discussion for enhancing student-faculty dialogue.^6–7 This article will describe the short-term impact of a multifaceted approach used at the University of Missouri-Kansas City (UMKC) School of Dentistry for formal ethics instruction. This approach used a variety of strategies including case-based and team-based learning, with the addition of a community-based service-learning component to enrich the students’ learning experience. Students’ attitudes were evaluated prior to and following the seven-week course to determine if community-based service-learning had any impact on students’ perceptions related to learning, service, working in a diverse community, and disparity of care. Additionally, the students’ reflection papers were qualitatively analyzed to assess aspects not measured by the pencil and paper survey.

The ethics course, taught to a combined class of first-year dental and senior dental hygiene students (n=103 dental students, n=27 dental hygiene students), has followed a case-based learning approach for the past five years. Two years ago the course was modified to use a team-based approach as outlined by Michaelsen et al.⁸ Students were placed in teams of six to seven students, with both dental and dental hygiene students represented in each team; case-based and service projects were conducted within teams. With this learning strategy, the responsibility for preparing for class in advance and being active participants during class time is much greater for the student. Students are quizzed at the onset of the class period on the material being covered for that day. This is followed by a short (twenty- to thirty-minute) faculty presentation on the most pertinent information, followed by case analysis within teams. Teams work through an ethical decision making schema, and then the class as a whole is brought back together to discuss team findings. Teams present their findings, and the students engage in a full classroom discussion. A team-based approach for the ethics course was implemented to achieve three objectives. First, a major objective was to divide a large class of 130 students into small group learning environments within the context of a large classroom, thus fostering a more personalized and cohesive approach to learning. Second, the approach was designed to create an egalitarian opportunity for dental and dental hygiene students to become more familiar with one another as oral health care providers. The final objective was to create a classroom environment where team members would feel a responsibility to one another as they developed team-based assignments and, as a consequence, would come to understand and appreciate the value of working together as a team.

Grant moneys were procured to implement an additional experiential strategy of community-based service-learning during the fall 2004 semester. The grant was obtained from the Center for the City at the University of Missouri-Kansas City (UMKC). The center supports community-engaged scholarship by providing seed grants to help faculty redesign their courses to incorporate service-learning. The community-based service-learning project was developed around the themes of cultural competency and disparity of oral health care. Service-learning has been described as a form of experiential education that combines community service with classroom instruction and focuses on critical reflective thinking as well as on personal and civic responsibility.⁹ Ottenritter also emphasizes that service-learning can open the eyes of advantaged, healthy students to the health disparities in our communities. In a recent report of the Commission on Community-Engaged Scholarship in the Health Professions, the authors report that service-learning engages students in activities that address local needs while developing their academic skills and commitment to their communities.¹⁰ Service-learning is distinguishable from community service by the integration of study within a classroom environment with hands-on activity outside the classroom, typically through a collaborative effort to address a community problem.¹¹

Ottenritter outlines specific stages for carrying out a service-learning project, proceeding from preparation to action, reflection, and celebration.⁹ This community-based service-learning project was designed to integrate classroom instruction with service-learning to enrich the students’ learning of course materials. Through a combination of assigned readings, mini-lectures, and case-based assignments that provided both qualitative and quantitative data about health disparities and cultural diversity, the students were prepared in-house for the community-based service-learning project.

Because of the limited curricular commitment to formal ethics instruction during the semester (one semester credit hour), students were notified during the summer prior to the course and were required to read a book in advance (The Spirit Catches You and You Fall Down by Anne Fadiman¹²). The book details the collision between a Hmong family and Western medicine and the misconceptions and miscommunications that often take place between health care providers and patients. The first day of class the primary author (CGA) presented information related to disparity and cultural competency using the surgeon general’s report on oral health, Healthy People 2010, the Anne Fadiman book, and other literature on cultural competency. Issues common to the surgeon general’s report and Healthy People 2010 were discussed.^13–14 These included disparity and access as a function of gender, race, ethnicity, income, education, disability, and geographic boundaries. A series of questions related to cultural competency were developed around the Fadiman book.¹² By having students come prepared to the first session, they were immediately engaged in the course. Students worked within their assigned teams to collectively discuss and debate the questions. A full classroom discussion followed. These activities all contributed to the "preparation" stage of our service-learning project as outlined by Ottenritter.⁹

In collaboration with the Boys and Girls Club of Kansas City, the service-learning project was arranged in which each team of dental and dental hygiene students went out with faculty supervision to provide oral screenings, oral hygiene instructions, and fluoride varnish applications. All student groups were rotated through the Boys and Girls Club over the course of four weeks. Because the dental hygiene students were seniors and had provided dental hygiene care to patients for two semesters while the dental students had not yet engaged in clinical patient care, dental students initially assisted. However, after a brief orientation they switched roles, and the dental students were given the opportunity for hands-on experience. This concluded the "action" stage of our service-learning project. Following the students’ group rotation at the Boys and Girls Club, each student was required to write a reflection paper, which allowed students to participate in another important component of service-learning: introspective reflection on lessons learned from the community-based experience. The goal of this component is for students to concretely connect the experience to the learning associated with it, in this case the issues of disparity and cultural competence.^9,15 This concluded the "reflection" stage of our service-learning project. The final day of class involved a pizza party with four peer-selected teams providing presentations on an ethical dilemma that they identified along with the ethical decision making that the team proceeded through to arrive at a solution. This concluded the fourth and final stage of service-learning: celebration!

The purpose of this study was to examine the degree to which a multifaceted approach to formal ethics instruction within a limited curricular timeframe can enrich the learning environment and how it influences students’ attitudes and perceptions about service-learning, working in a diverse community, and disparity of care.

	Methodology

Top Abstract Methodology Results Discussion Conclusion References

 
Participants were first-year dental (Class of 2008; n=103) and senior dental hygiene (Class of 2005; n=27) students at the University of Missouri-Kansas City (UMKC) School of Dentistry. A nine-item pre-test survey was developed by the UMKC Center for the City to assess students’ pre-existing attitudes regarding service to the community. The survey items appear in the left-hand column of Table 1. The UMKC Center for the City’s mission statement reads: "The Center for the City leverages the intellectual and human resources of Kansas City’s major urban university with the issues and challenges of the urban core."¹⁶ As part of its mission, the center collects data from several disciplines on campus using a standardized survey instrument to better understand the impact that community-based learning has on students. This instrument served as the pre-test for the project. Demographic information was also collected on the survey instrument. The survey was administered on the first day of class as part of the orientation session. The post-test evaluation instrument included the identical nine items from the pre-test and twenty-six additional items to assess students’ actual experiences during the community-based service-learning project. The response format was a five-point Likert-type scale that ranged from strongly disagree (1) to strongly agree (5). The post-test was administered the last day of class, which was seven weeks from the administration of the initial pre-test. Questionnaires were coded to allow for matching of the nine items on attitudes toward community-based service-learning in the pre- and post-test results while maintaining student anonymity. Participation was completely voluntary.

Descriptive data summarized demographic characteristics of the sample. Using SPSS 12.1, we took the nine items on both the pre- and post-tests (assessing attitudes toward community-based service-learning) and the additional twenty-six items on the post-test (assessing the impact that community-based learning had on the students) and subjected them separately to principal components analysis and varimax rotation to examine the underlying factor structure. Factors were identified using the Scree plot and eigenvalues that contributed a significant proportion of variance. To identify the domains represented by the factors, we considered items to be related to the underlying factor structure if factor loadings were >0.4. Based on the identified factor structure, subscales were computed and used for subsequent analyses of change in attitude over time (pre-and post-test results) and to compare assessment of experience between discipline groups (dental and dental hygiene) and gender. Qualitative data in the form of student reflections on the service-learning project were analyzed using the constant comparative method as outlined by Lincoln and Guba.¹⁷ Three faculty separately analyzed and unitized the data, ultimately reaching consensus on category topics.

	Results

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Of the 130 dental and dental hygiene students enrolled in the course, 118 (91 percent) participated in the pre-test survey, which included demographic information. Descriptive statistics are displayed in Table 2. In several instances students left demographic information blank on the pre-test survey. Actual numbers of dental and dental hygiene respondents for each demographic variable are also reported in Table 2. Dental student respondents were predominantly under twenty-five years of age (72.5 percent) and Caucasian (82.4 percent). Of those reporting gender, forty-six (50.5 percent) were male, and thirty-one (34.1 percent) female. Dental hygiene participants were all females, a majority under twenty-five years of age (51.9 percent) and predominantly Caucasian (77.8 percent).

"As I talked with many of these children, I began to realize how I take for granted that I am able to go to the dentist on a regular basis and receive any necessary treatments. Many of the kids I talked to were not able to go to the dentist regularly, mainly due to the lack of financial funds. ... I realize how privileged I am, and also see how great this is to be doing this for these children.... What a way to throw us directly into the mix."

Another student wrote:

"As I have visited the Boys and Girls Club ... I have had a chance to reflect on the issue of access to oral health care. The people who don’t have the money lack access to commodities just as in cars, housing, etc. Also, why is it that more dentists don’t go to the underserved communities? I am assuming they need to make a profit and underserved areas are usually lower income. I wonder if I will help these people when I graduate? I would like to say yes, but considering the seemingly huge debt I am incurring at UMKC to pay for this educational experience, I may not be able to do as much as I would like. I don’t like the idea of socialized medicine, but are there any reasonable answers?"

And another wrote:

"Since I had grown up in suburbia my entire life, I have had very little experience interacting with lower-income inner-city individuals. I wasn’t quite sure what to expect. Once I arrived ... and met our group’s first patient my concerns quickly vanished.... I refocused my attention from my concerns to trying to provide a helpful service to some needy children."

Reflection upon their role as professionals (Category 2) within the oral health care system elicited comments such as:

"I often take for granted my oral health care, such as cleanings, dental treatment, and orthodontic manipulation. I was under the impression, before I began Introduction to Ethics, that everyone who needs care can get it. I believed that poor oral health care was a crisis in other countries and was not a problem in the United States. I have realized, though, that there is a serious problem in the United States. All oral health care professionals are absolutely necessary to help lessen this predicament."

And even at an early stage of professional education, one dental student wrote:

"The country with the ‘best dentistry in the world’ should be instilled with a compass to outreach."

Despite all the prior planning, there was a single session in which no community participants came for care. The following are some of the reflections of students who were assigned for that day:

"My experience at the Boys and Girls Club was not what I had originally expected.... Not one child presented for this wonderful program that had been implemented, organized, and sponsored so it was no charge to the participants. Looking at this situation, it is not too far off from reality in a community dentistry setting.... One of the reasons we might have not had any children show up is because their parents did not have to make any investments in this program. It was free, it was convenient, and it was readily available to them. All they had to do was sign on a dotted line and their kid was signed up."

Another student wrote:

"We donated our time to the club, but not one child showed up. Because of this, my paper examines noncooperative patients associated with community service.... The most obvious form of noncooperation is failure to appear.... The easy thing for the doctor to do would be to quit doing community service due to the lack of appreciation."

And a third student wrote:

"My experience at the Boys and Girls Club was quite common when dealing with the underprivileged population.... Dental and hygiene students, a dentist, and several faculty members volunteered their time and resources to provide for these children, but the underserved population wasted that donation."

For many students, the actual delivery of oral care for the first time (Category 3) was very exciting while at the same time nerve-racking as illustrated by the following reflections:

"My career as an oral health care provider seemed to officially begin on.... That, of course, was the day that I went to the Boys and Girls Club and, for the first time, actually, physically treated a patient."

"I was a little nervous about the situation for two reasons. First of all, although I have shadowed countless hours in dental offices, I had never actually performed any kind of procedure inside of the mouth."

Data was collected on the children participants at the Boys and Girls Club using the Basic Screening Survey (BSS) distributed by the Association of State and Territorial Dental Directors (ASTDD).¹⁸ Students were given background information and calibration on the BSS. They were also provided the opportunity to participate in a cursory oral health screening, review of basic oral hygiene, and fluoride varnish application on one another. This hands-on activity prepared students prior to their assigned rotation. In total, 156 children were seen as a result of the service-learning project. All 156 received oral hygiene instructions and were provided with a basic screening, of which the results were communicated to the center and parents or guardians. Of the 156 children, 36 percent presented with untreated decay. Two of the children (5 percent) with untreated decay were identified as having urgent treatment needs. All 156 children had fluoride varnish applied and were sent home with a home care kit including a toothbrush, floss, and post-varnish instructions.

	Discussion

Top Abstract Methodology Results Discussion Conclusion References

 
Previous surveys have demonstrated that the curricular time devoted to formal ethics instruction in dental schools is limited, with the average ethics course comprising a one-hour, sixteen-week semester. Ethics instructors must develop effective teaching strategies that can have the greatest impact within this very limited timeframe. Through the incorporation of case-based and team-based teaching methodologies and now a community-based service-learning component, we believe we are maximizing the time allotted to make ethics instruction meaningful. An evaluation of service-learning by twenty institutions that participated in the Health Professions Schools in Service to the Nation project found that students reported service-learning was both professionally and personally enriching and had a substantial effect on their sense of themselves as providers of health services and as community participants.¹⁹ Similarly, our students reported that the "hands-on" experience was enriching, and many indicated that they hoped to have additional opportunities to participate in community-based service-learning activities. Likewise, many of them indicated a desire to actively engage in addressing our current access to oral health care dilemma. The combined classroom information with the community-based service-learning component appeared at least to begin the dialog needed for these future oral health care providers to meaningfully consider ethical issues and potential solutions within the oral health care delivery system. Qualitative analysis of our students’ reflection papers suggests that the community-based service-learning project achieved the goal for service learning proposed by Ottenritter, which is "to open the eyes of advantaged and healthy students to the health disparities in our community."

A 1999 UCLA study of service-learning in higher education reported a strong correlation between students enrolled in a service-learning course and their intention to continue volunteer work, actively address social problems, and develop civic responsibility.²⁰ It was exciting to see that, in a short seven-week course in ethics, we were able to show a statistically significant attitude change related to willingness to volunteer. These results also give preliminary credence to the idea that the continuity of ethics instruction across the curriculum is important in producing clinicians sensitive to community needs. As students gain additional experiences and become increasingly professionalized, it is important to continue the discussion of ethical dilemmas and ethical decision making.

First-year dental students with limited dental experience provided thoughtful insights in their reflections on the service-learning project as it related to their roles as oral health care providers, access to care, and cultural competency. Exercises and experiences involving reflection on oral health care issues need to continue across the curriculum as the students gain experience in grappling with ethical issues.

While there were no statistical differences in dental and dental hygiene students’ ratings of the service-learning project, gender emerged as a significant factor in relation to course impact and personal ability. Although there was a trend for female students to respond more positively to the service-learning project, there was a statistically significant difference in rating of course impact related to career and willingness to volunteer between female and male students for both disciplines. This finding merits continued study to determine if this initial gender difference remains across time.

Bertolami, in his article on ethics curricula, stated that "ethics courses are inadequate in content and form to the extent that they do not cultivate an introspective orientation to professional life."²¹ We believe that the redesign of our ethics course over the past few years has allowed us to increase the scope and impact of formal ethics instruction by exploring relevant and timely issues related to access to care, disparity, and cultural competency. The added service-learning component that allows for immersion in these topics appears to provide a valuable firsthand experience.

While course faculty believe that community-based service-learning enriched the ethics instruction, there were several issues encountered along the way. First, it took a significant amount of time to prepare and carry out a project of this magnitude. The increased time commitment for service-learning has been addressed in previous literature.²² Course faculty spent the summer coordinating with the Boys and Girls Club, collecting appropriate forms, ordering supplies, etc. In addition, portable clinical equipment had to be transported to the site prior to the project. Despite all the prior planning, there was a single session in which no community participants came for care. The students assigned to this session were very disappointed since they had heard positive comments from their peers who had previously participated in the project. As a result, an additional site was identified during the project where both the students at the dental school and the children at the Boys and Girls Club could benefit from the project. In spite of all the minor problems encountered in planning and implementing this project, we are currently in the process of planning for continuation of the program in the upcoming fall semester. A primary advantage to this project was the collaboration among several course faculty. The team effort exerted by the course faculty ensured that the project did not fall upon the shoulders of a single individual. In addition, several additional dental and dental hygiene faculty volunteered to staff the project site during the four rotations. The willingness of community agencies and participants to actively engage and support the project was encouraging to the faculty and deemed a successful measure. We are grateful for the collaboration and cooperation of all participants.

Limitations of this study should be considered in the interpretation of the results. This article reports on a single curricular experience from one dental school. The short period of time between pre-test and post-test administration of the instrument may have been insufficient to adequately capture sustained attitude change, and certainly future studies need to evaluate the longitudinal impact of such a program. Further study is needed in the area of community-based service-learning to determine the impact of various educational interventions on students over time, particularly considering the tremendous amount of time needed for this type of instruction.

	Conclusion

Top Abstract Methodology Results Discussion Conclusion References

 
A multifaceted approach to formal ethics instruction using a variety of strategies including case-based and team-based learning and a community-based service-learning component appeared to enrich the students’ learning experience. There was a statistically significant change in a positive direction in student attitudes about volunteering in the community from the beginning of the course to the end. Female students reported the course had a greater impact on their career choice and personal ability than did males. Our analysis of student reflections indicated that the students gained insight and experience in three areas: exposure to and awareness of community oral health; professional roles in the oral health care system; and first-time experience with delivery of care.

	Acknowledgments

 
The primary investigator wishes to thank the dental school faculty who helped with this project by giving their time to provide faculty supervision at the Boys and Girls Club. They are Drs. Harvey Eplee, Greg Johnson, Joy Matthews, Pam Overman, Tressa Parkinson, Kim Skaggs, Tim Taylor, Kirk Weber, and Professor Kim Bray.

	Footnotes

 
Dr. Gadbury-Amyot is Professor and Director, Division of Dental Hygiene; Prof. Simmer-Beck is Assistant Professor, Division of Dental Hygiene; Dr. McCunniff is Associate Professor, Department of Dental Public Health and Behavioral Sciences; and Dr. Williams is Professor, Department of Dental Public Health and Behavioral Sciences—all at the University of Missouri-Kansas City. Direct correspondence and requests for reprints to Dr. Cynthia C. Gadbury-Amyot, Professor and Director, Division of Dental Hygiene, School of Dentistry, University of Missouri-Kansas City, 650 E. 25^th Street, Kansas City, MO 64108; 816-235-2050 phone; 816-235-2157 fax; amyotc{at}umkc.edu.

	REFERENCES

Top Abstract Methodology Results Discussion Conclusion References

 

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