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Educational Methodologies |
Key words: service-learning, curriculum, dental hygienists, dental care for disabled, community dentistry, dental hygiene education, mental processes, awareness, professional role, qualitative research
Submitted for publication 08/03/06; accepted 11/04/06
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Abstract |
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Casamassimo et al. found that dentists who had no experience or hands-on training about children with special health care needs were less likely to care for these patients after graduation.4 Conversely, they found that dentists who received education in children with special health care needs perceived fewer barriers to providing care to special needs patients. Results showed that only one in four practitioners reported having educational experience with special needs patients, which led to the conclusion that students must be exposed to this population with meaningful educational experiences to address their needs. Surveys of dental students and practicing general dentists alike found that respondents did not think their undergraduate dental education had prepared them well to treat patients with special needs.5,6 Respondents who said their education had prepared them well were more likely to treat various types of special needs patients, feeling more positive and confident than those who responded neutrally or negatively to the dental education statement.6 Johnson found that all responding dental hygienists reported seeing patients with disabilities, while 53 percent reported never having formal training. Over half of the open-ended comments from the dental hygienists surveyed expressed a need for more educational opportunities in caring for patients with disabilities.7
Service-learning has become increasingly recognized in the literature as an important pedagogy in higher education.8–10 Waldman et al. describe specific examples of how some dental hygiene programs have incorporated activities to prepare students to care for patients with special needs.11 For example, dental educators traditionally integrate experiential learning through clinical rotations in community health centers, hospitals, and private practices located in health care provider shortage areas. In addition to clinical rotations, dental education typically sends students to community sites to provide oral health education presentations. However, not all community service is considered "service-learning." The nature of the "service" in service-learning is distinctly different from "community service" in that the service is constructed as mutually beneficial to both the served population and the students providing the service. Service-learning is an instructional method that combines community service with classroom instruction, focusing on critical, reflective thinking as well as personal and civic responsibility.12 Furco places the various forms of experiential education on a continuum.13 Internships and practica, with their primary focus on the students’ career development, are at one end of the continuum. Volunteer activities, in which the emphasis is on civic involvement and the services provided to recipients, are on the other. Furco locates service-learning in the middle of the continuum and states that it is unique in its "intention to equally benefit the provider and the recipient of the service as well as to ensure equal focus on both the service being provided and the learning that is occurring."13,14
The connection to formal educational objectives further distinguishes service-learning from community service. Service-learning is a course-based, credit-bearing educational experience that allows students to participate in an organized service activity that meets identified community needs and to reflect on the service activity in such a way as to gain further understanding of course content and a broader appreciation of the discipline and an enhanced sense of civic responsibility.15 The American Association for Higher Education states that service-learning also benefits the curriculum as a method under which students learn through thoughtfully organized service that is conducted in and meets the needs of a community and is coordinated with an institution of higher education and with the community; helps foster civic responsibility; is integrated into and enhances the academic curriculum of the students enrolled; and includes structured time for students to reflect on the service experience.16 As an instructional practice, service-learning allows students to apply what they learn in class to real-life situations.
While the activities associated with service-learning are diverse, there is general consensus that service-learning must incorporate four essential elements: preparation, action, evaluation, and reflection.17 The elements and their proposed relationship are shown in Figure 1
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The action or implementation component of service-learning requires partnership and collaboration with the community. While multiple models of partnership exist, there are a number of common elements among these models. Sustained community partnerships, shared service-learning objectives, and broad preparation are identified as important components for ensuring successful service-learning partnerships.10
The impact of the service-learning experience occurs through planned evaluation of the effects on the institution and the community. Evaluation is defined as "the systematic collection of information about activities, characteristics, and outcomes of programs, personnel, and products to reduce uncertainties, improve effectiveness, and make decisions."19 Evaluation of students, community partner agencies, mentors, participating faculty, and recipients of the service should be considered at the start of each program or course.10
Reflection is a critical element connecting the service experience with the student’s personal thoughts, feelings, and values in meaningful ways. As represented in Figure 1
, reflection is connected to all aspects of service-learning—playing a particularly significant role in evaluation of the experience. Reflection provides a structured opportunity for three distinct aspects of the educational experience behind service-learning. Not only does reflection allow students to examine their beliefs, values, and assumptions; the process ideally includes construction of their own meaning and significance of their actions, resulting in a deeper understanding related to an action or experience.20 Elyer and Giles describe reflection as providing the connection for students between their service and their learning as represented in the hyphen in the phrase "service-learning."9
Effective strategies for fostering meaningful reflection are based on four key elements. The reflective process must be continuous throughout the service-learning experience and connected to the objectives of the course or activity. Through thought-provoking strategies, role modeling, and guidance, students are challenged to move from superficial to higher level thinking. Since self-discovery may be accompanied by uncomfortable feelings, it is important that an atmosphere of trust and mutual respect is maintained. Lastly, reflection is contextualized when related to the course topics and experienced in a meaningful way.9
One of the most widely used methods to foster constructive reflection is written journaling. Journaling is reportedly most meaningful when it includes guided questions before and following the service-learning experience.21 Meaningful reflection can also be accomplished in a discussion forum, by interview, or in the writing of a final summary paper at the close of the service experience. Student presentations to classmates and faculty about their experiences are also considered a useful method of reflection.
Yoder describes the ten components of service-learning as academic link, sustained community partnerships, service-learning objectives, broad preparation, sustained service, reciprocal learning, guided reflection, community engagement, ongoing evaluation and improvement, and opportunities for community-engaged scholarship.10 This comprehensive description provides a useful framework for dental educators to create successful service-learning opportunities and provides a standard for evaluation.
The purpose of this study was to evaluate the outcomes of a service-learning course on special needs patients that was implemented for dental hygiene students by considering student reflections, community site coordinators’ feedback, and faculty reflections in a qualitative analysis.
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Methodology |
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The course director contacted six community sites to discuss mutually beneficial goals. Individualized programs were planned by the course director and the community partners to concomitantly enhance student competence and meet the needs of the community.
After setting out the general expectations for the organization and the academic institution with the various site coordinators, the course director presented the six community organizations to the students for selection. Students understood that it was their responsibility to research the organization, identify the needs of the target population, and prepare and implement an appropriate activity or series of activities for the target group in concert with broad goals already established by the course director and site coordinators. They also volunteered to participate in the study and provided the appropriate informed consents as approved by the institutional review board. Students were then asked to evaluate their experiences through self-reflection journaling immediately following their community rotations and to share their experiences with their classmates upon completion. Table 1 identifies the six community sites, the type of special needs patients targeted at each site, the services provided at each site, the number of clock hours of service provided, and the number of students participating in the project at each site. The two-credit hour, semester-long course included a series of preparatory sessions on each of the target groups, while allowing students to conduct research on their chosen group. Orientation visits were organized to assess the needs of the specific population and become familiar with the local environment. In some cases, these orientation sessions allowed the target population to become familiar with the students. Classroom time was limited so that students could attend to their sites as scheduled. Upon completion of all community activities, students delivered PowerPoint presentations describing their experiences in the community setting and discussed how it applied to classroom materials. This allowed students to learn about all six projects while experiencing one site first-hand with a significant involvement.
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shows the integration of the service-learning process into the overall grading rubric for the course.
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In addition to the journal reflections, students were asked at the end of the course to assess their projects and indicate what they gained from participation, what they like best, and what they liked least. This data was then used to triangulate data from the reflective journals in order to enhance the validity of the study.24
Prior to graduation, students completed a curriculum survey and rated each course in the program on a five-point scale—one being the lowest and five being the highest. Data from the school-wide survey were analyzed by a statistician not connected to this study. The rating for the service-learning course discussed in this study was used to further validate data from other sources.
To determine the impact on the community sites, the course director contacted each community coordinator to conduct a telephone interview. A series of questions was asked to determine if the service-learning partnership was successful from their perspective and provide them an opportunity to express suggestions for the future.
To assess the educational aspect of the academic service-learning course, the course director and graduate assistant reflected on the experience during an interview with a coauthor. Their perspectives provided yet another source of data for use in triangulation with multiple sources of data as recommended by Yoder.10
Several strategies were used to check the accuracy of the findings as suggested and described by Creswell.24 Examining evidence from different data sources and using it to build a coherent justification for themes is known as triangulation. "Member-checking" refers to taking the final report back to participants and determining whether these participants feel that the data are accurate. This was done with the faculty interviews. Using "rich, thick descriptions" to convey findings that give the reader a sense of the setting and experience was done by including original quotes in the results. "Peer debriefing," defined as locating a person to review and ask questions about the qualitative study so that it will resonate with people other than the researchers, was also used to enhance the accuracy of the account.
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Results |
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outlines the overall project parameters and lists the specific services provided at each site.
Analysis of the journal reflection papers provided insight into the impact of the service-learning experience on the students. Table 3 displays emergent categories with representative themes for each. Since the reflection papers were a requirement of the course, all twenty-three students submitted reflections for analysis. In the first stage of the analysis using the constant comparative method, a team of four faculty members unitized the data and found that ten themes emerged: knowledge applied, knowledge gained, sensitivity, cultural competence, positive learning experience, professionalism, collaboration, confidence, validation, and frustration/disappointment. These initial themes served as the basis from which faculty were able to reach consensus and resulted in three major categories: 1) awareness, 2) higher order thinking, and 3) professionalism.
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provides a summary of the data, specific student comments provide a rich context to express the manifestations of each concept. The following comments illustrate an increased awareness of challenges faced by special needs populations and their families:
I really respect those who choose to work with special needs individuals. It is not an easy job. The staff at Sherwood center really seemed to love those children and they were all committed to their jobs. They are making a difference in the children’s lives and they made a difference in mine.Though some kids opened right up and didn’t mind the screening, others were resistant and afraid. One poor little boy ended up in tears; he looked so fragile and afraid. It broke my heart to see that.
This project reinforced my attitude towards the geriatric community because I was able to see first-hand how some of the geriatrics were maintaining their dentures. Many had heavy build-up visible just when they were speaking; many did not realize that they should clean their dentures 2–3 times per week and at least rinse and brush their dentures following each meal. I was also able to get an idea of how many geriatric patients did not know how to manage the xerostomia that resulted from their medications.
The service-learning experiences also gave students an awareness of how important teachers, staff, and health care providers are to these special needs populations:
The children were not as comfortable with me as they were with their teacher and staff that they see everyday. This is how it will be when I am presented with this situation in the dental office. This rotation has taught me that when I am working with patients with special needs that I need to take things slow and to be grateful for any progress that we (the patient and I) make.I can only imagine how frightening it might have been to the very young children to have complete strangers, wearing rubber gloves, shining a bright light into their mouth, and at time holding their heads.
This project made me more aware of the eating disorders issue in general. It opened my mind to the fact that there are these patients out there and I could see one at anytime. I now know what things to look for and how to address the issue. Eating disorders are more common that we think; and actually going out in the community made this a reality for me. It is a sad situation.
In the higher order thinking category, the following quotes illustrate the students’ depth of learning:
I had learned that one of the most effective tools for working with autistic children is to use the tell-show-do approach. With "Bob," I opened a toothbrush and told him that we needed to brush his teeth. I then had him look at me while I brushed my teeth. When I gave him his toothbrush, he started banging the table. "Mary" and I were able to help him hold the brush up to his mouth and he started to mimic me brushing my teeth.During this rotation I learned many important skills that I can apply to clinic and private practice. All of the students I saw required some alteration in treatment. Having to communicate without words required me to think of ways that I could demonstrate effectively the point I was trying to get across.
I have learned communication methods that will help me in a clinical setting, such as explaining procedures before I begin treatment, repeating instructions using the same words each time, and telling patients what I need them to do rather than offering choices that might confuse them.
The next two quotations are examples of how students suggested solutions to perplexing situations. They reflect a desire to make changes based on the learning that took place in the community experience.
One thing I did not find a lot of was online support groups. I was really surprised about this. A support group was the one major factor that I felt was missing from most programs, including ours. One should be started here at the school. I thought that because patients were constantly switching students, it might be good to have another person here at the school that they knew they would always be able to contact for assistance. We really need some sort of continuity in order to be truly successful.I think that having products there meant more than just telling them about products. They were able to see what to look for and have an explanation on how to use them. I actually now keep these products in my kit so I can educate my own patients on the products.
A sense of professionalism emerged from the data. The following quotes express students’ sense of value and dedication to serving special needs patients:
Our presentation was very professional and we really were able to reach people with our information. It’s presentations like this that make me realize what a specialized skill I have and how people rely on me for information. After this presentation, I felt like a real dental hygienist. This presentation gave me the confidence to pursue doing more presentations on my own after I graduate to other special needs groups. It’s nice knowing that I am able to give someone information that can improve their quality of life.We as hygienists need to be able to identify the signs and symptoms of eating disorders and be able to have a comprehensive understanding so that we can refer these patients to the necessary health team for help. Hygienists play a crucial role because we are often the first health care professional that identifies the disorder.
In the future, I would like to obtain an extended care permit that would enable me to provide community services to special needs children.
Multidisciplinary approach is needed with several health care providers such as psychologists and other medical health teams; they all need to work together.
Table 4 identifies the impact on recipients of the service-learning project including the special needs patients as well as the staff and family members who were involved in providing care for them. The data emerged from the students’ reflection journals as students talked about their experiences with patients, family members, and staff at various community partner sites. Overall, students reported that participants demonstrated an interest in the topics students selected to discuss with the group by asking questions, taking notes, and thanking them for the free samples, which included such items as toothbrushes, toothpaste, xylitol gum, denture care products, and informational handouts. Students also reported that patients, family members, and staff described having many of the oral health care needs that students discussed in their presentations. The data in this section were confirmed by feedback from interviews with the community partners.
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I couldn’t have asked for a better experience. They were so innocent and a lot of fun. All in all the experience was worthwhile. I would enjoy doing it again. The community exercise of working with people with special needs was a good educational experience.Another student said,
From what I have learned about autism both in class and through this project, I feel much more prepared to be able to treat them once I graduate.
And finally,
It made me realize how important a dental hygienist can be to a community just by offering information and strategies on oral hygiene care. I was amazed at how appreciative the caregivers were of the information that we gave them. For the first time, I felt the impact of how valuable dental hygienists can be when using their education to educate others who are less knowledgeable in a specific field.
The students’ course assessments confirm the data emerging from their reflective journals. Table 5 describes the themes expressed by students on what they gained from the experience, what they liked best, and what they liked least. Students indicated that they gained experience and knowledge in working with special needs populations (higher order thinking) as well as an increased confidence and comfort level with their interpersonal communications with the people they met (professionalism). For one student, it opened the door to new volunteer opportunities. She has made arrangements to volunteer at the site beyond the expectations of the course—which demonstrates her commitment to community service and the values of professionalism. The students enjoyed working and caring for people, being out in the community, and learning about special needs patients. They expressed concern for the organizational challenges associated with providing services to these specific special needs groups. Time was an issue for students as they worked to complete their projects during a busy semester with many competing tasks. Students also expressed an awareness of the struggles faced by special need patients (awareness).
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The interview data from the community partners is presented in Table 6 and reveals that, overall, the community partners were pleased with the partnership. They expressed satisfaction with the student presentations and projects, indicating that these programs were consistent with the mission of their organization. One site coordinator reported that the site is now using the students’ presentation outline in a special training program for caregivers. There was some disappointment in the number of patients and families attending the presentations, but it was acknowledged that participant attendance was beyond the control of both the community coordinators and the students. The coordinators indicated that they would like to have the partnership continue and in some cases expanded.
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summarizes these perspectives. Developing community partnerships that were mutually beneficial was time-consuming, and it was challenging to communicate the importance of this activity to both community partners and students. The need to establish clearly defined expectations for students and community partners, getting an earlier start on program planning and coordination, and learning more about the specific sites, their organization, and their populations were learning issues for the faculty. However, faculty reported that students were asking good questions and were more engaged in the content even prior to the experience than in previous years, suggesting that the service-learning pedagogy was well worth the additional time it took for coordination activities.
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Discussion |
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In our study, students spent an average of 8.78 hours working with community sites. As reported by the course director, students commented this was somewhat of a time burden because they were only released from four hours of classroom time. This concern about the amount of time service-learning takes is frequently noted as a disadvantage of courses implemented in this format.26 Service-learning literature also indicates a minimum of twenty hours of community interactions is necessary for students to fully encounter growth and develop a sense of civic responsibility.27 Within the confines of this single course, students did not spend this amount of time on their community project. However, students participate in service-learning activities throughout their two-year tenure in the dental hygiene curriculum that far exceed twenty hours of community interaction. The hours per community site in this course ranged from 6.17 to 19.25. The large range was due to the amount of preparation time necessary for each project. With the exception of the smoking cessation program development, all of the community projects required additional preparation time by students away from the community site. This was not included in the clock hours noted on Table 1 and explains why the hours at UMKC Special Patient Care clinic were significantly higher than the others.
Student data from reflection journal and project assessments in this study were consistent with these findings as demonstrated by their satisfaction in working with people while they developed a greater understanding and knowledge of people with special needs. All of the students were in their senior year of the dental hygiene program and very eager to learn how to assess and manage special needs patients. The data show an increase in their confidence level when working with special needs patients and indicate that they enjoy the community interactions. The literature suggests that this experience will lead to an increased sense of social responsibility and a commitment to community service after graduation.28 The community connections stimulated at least one student to pursue volunteer activities beyond the structure of the course, which illustrates a sense of professionalism.
Students expressed concern for the organizational challenges and showed a concern for the struggles face by special needs patients. This is where awareness, higher order thinking, and professionalism converge. The first-hand exposure to these issues provided students with an increased awareness that can be difficult to communicate in the classroom setting alone. The service-learning course allowed them to apply what they learned in class, thinking at a higher level and using their professional behaviors and attitudes to make a difference in the lives of others. By triangulating the data from multiple sources using the reflective journals, the end of course project assessments, feedback from the community partners, and the faculty interviews, the accuracy of the data in this qualitative study was validated. The curriculum survey results also confirm that students were generally satisfied with the course.
Service-learning has found support in the literature regarding the themes identified in this study. In a study that conducted in-depth pre- and post-semester problem-solving interviews with sixty-six college students from six colleges and universities, results indicated that students in a service-learning course showed more change in the complexity of their problem analysis, their assessment of the locus of problem and solutions, and their critical thinking ability when compared with students in programs with no service options. They also were more likely to apply knowledge to their problem analysis and develop practical strategies for community action than students in programs with no service component.9 The emergent themes in this study are also similar to those identified by Gadbury-Amyot et al.29 Their research on a service-learning ethics course found exposure/awareness and professional role in oral health care systems as emergent themes from student reflective papers.29
The Health Professions Schools in Service to the Nation (HPSISN) program conducted a comprehensive assessment of the impact of service-learning on students, faculty, and community partners and found that service-learning can provide students with "transformational learning experiences," especially when students are placed in nonclinical community environments. The investigators found that service-learning increased community understanding among faculty and even brought new direction and confidence to the teaching and scholarly pursuits of faculty involved. The HPSISN study revealed that the primary motivating factors for faculty are a belief in the educational value of service-learning, the need to improve current health professions education processes, and personal value systems. HPSISN investigators also found that community partners received economic, operational, and social benefits from their participation in service-learning. Community partners placed high value on the relationships they developed with faculty and expressed an eagerness to be seen as teachers and experts themselves.30
Our study confirmed these findings as students reported an awareness and respect for community caregivers and staff, viewing them as teachers and learning from them how to care for patients with special needs. In some cases, students described this "transformational experience" in their reflections as illustrated by this comment from one student: "This experience makes me realize what a specialized skill I have and how people rely on me for information."
In a review of the research on critical thinking in college students, Tsui found that instruction factors associated with growth in critical thinking included preparing a paper for critique by an instructor, conducting independent research, working on a group project, and giving a presentation.31 Each of these elements was included in this service-learning course, and the data from this study suggest that students were engaged in critical thinking.
"Higher order thinking" as a recurring theme in student reflections is a goal of health professions education. Lewis and Smith suggest using this term to broaden the concept of critical thinking. They suggest that higher order thinking "occurs when a person takes new information and information stored in memory and interrelates and/or rearranges and extends this information to achieve a purpose or find possible answers in perplexing situations."32 This definition includes problem solving, critical thinking, creative thinking, and decision making. The student reflections capture these qualities as they describe the judgments they made, the learning they applied, the creative applications of previous and new knowledge, and the recommendations they suggested for future interactions.
Professionalism is described by the American Council for Graduate Medical Education as "a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population."33 The educational environment, whether formal or informal, appears to influence student attitudes and behavior.34 Cruess and Cruess state the knowledge of the cognitive aspects of professionalism provides a theoretical basis for students; however, experiential learning is essential so that behaviors characteristic of the professional become part of the day-to-day life of the practitioner.35 The ability to reflect on professional issues places them in a personal context, and the curriculum should be designed to foster self-reflection.
The faculty involved in this study reported a belief in the educational value of the program and have become leaders themselves in promoting service-learning across the curriculum in dental hygiene education. And the community partners have expressed an eagerness to continue with the partnerships as new students progress through the program. This is consistent with the findings of the HPSISN, which found most community partners reported that the benefits of service-learning far outweigh the challenges of communication and logistics.31
In the future, better efforts to concomitantly capture the qualitative and quantitative impact of the clients served by the service-learning projects must be included in the overall program evaluation. Special needs patients, their families, care providers, and staff are also affected by the interactions and should be included in the evaluation process. This was considered a limiting factor in our study. An effort was made to elicit some data from the student reflections. However, it would be more meaningful to hear from the participants directly.
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Acknowledgments |
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