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
Dental School of the University of
Puerto Rico
ADEA
2
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 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 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
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
21st 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
21st Century (ADEA)



Assess patient goals, values, and
concerns
Provide patient education
Obtain psychosocial and behavioral
histories
8
Competences for the Dentist of the
21st 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
21st 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:

Application of behavioral sciences

Patient-centered oral health promotion

Managing a diverse patient population

Skills for a multicultural work
environment
11
Dental School Accreditation
Standards (excerpts)


Evaluating models of oral health
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 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 CommunityBased Dental Education
13
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
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 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 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 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
Active Experimentation
Abstract Conceptualization
19
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 (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
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:
-
-
Reciprocal learning
Reflective practice
Developing citizenship skills
Achieving social change
23
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
24
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
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 designed to
respond to limitations of traditional
student learning:


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 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
28
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 1st 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)
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 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
31
Reflection in Service Learning


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.
32
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 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 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 a
willingness to:



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:



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
-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, 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 university-community
relationships
 Recruiting tool for students and
faculty
40
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
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
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?

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?

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
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 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


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




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

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:
 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
51
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

52
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 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
54
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
Critical thinking/problem solving
Essays
56
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 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






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.html
 For training and technical assistance
 CCPH Consultancy Network
 Electronic and printed resources
 Collaboration between CCPH and ADEA
60
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 do know is that
the truly happy among you will be
those who have learned to serve.”
Albert Schweitzer
62