Introducing service-learning to dietetic students.

Abstract

Service-learning was introduced into a medical nutrition therapy class of senior level dietetics students. Students (n=11) developed and delivered lessons to diabetes education classes. Evaluation of the project showed it to be beneficial to clients and students. Clients demonstrated a 24% increase in knowledge following the classes. Seventy-two percent of students felt more comfortable working with others, and 67% said they became better at working in teams. Forty-five percent of students said they would like to see service-learning projects integrated into other classes.

Introduction

The Health Professions Schools in Service to the Nation program was established in 1995. [1, 2] Their first recommendation in the Pew Foundation report was: "Restructure the mission and organization of allied health education programs to focus on local community health needs identified through partnerships with delivery systems, professional associations, educators, regulators, consumers, and the public." [1, page 33] Service-learning pedagogy has been used effectively in the education of medical [3,4,5], nursing [4,6-8], and occupational therapy [9] students. Despite a recent study of dietetics education that showed 87% of respondents used some type of experiential learning to teach nutrition education [10], published references to SL in dietetics education are limited. [11-15] Service-learning exemplifies the way by which professional competencies for allied health professional students, including dietetics students, can be met. The Commission on Accreditation for Dietetics Education (CADE) of the American Dietetic Association outlines 99 Knowledge, Skills, and Competencies for Entry-Level Dietitians which must be met by all undergraduate students in a Didactic Program. [16] CADE competencies which can be satisfied by SL projects include, but are not limited to, knowledge of:

* public speaking

* interpersonal communication skills

* concepts of human and group dynamics 

* health behaviors and educational needs of diverse populations

* diversity issues

* medical nutrition therapy

CADE also stipulates that dietetics students should be able to demonstrate certain skills, such as:

* use oral and written information communications in presenting an educational session for a group

* work effectively as a team member

The purpose of this paper is to describe how SL can be integrated into a medical nutrition therapy course.

Review of Literature

A recent review of the SL literature discussed factors involved in integrating it into dietetics and nutrition education. [11] The authors concluded that integrating servicelearning into the dietetics curricula allows students "the opportunity to develop communication, collaboration, problem-solving, and critical thinking skills, while providing relevant experience and promoting citizenship." [11, p. 183] Kim and Canfield described how they integrated SL into a life cycle nutrition course. The community partner was a senior citizen center, and students helped prepare meals and provided nutrition education materials for clients. Students who were involved in the program said it was the best part of the course, and the evaluation demonstrated that it led to better retention of the subject matter. [12, 13] Further, many students expressed the desire to continue volunteering after the class was over. The authors felt that improved student learning and heightened student enthusiasm was important; however, they also observed that the project was time consuming and their efforts, presumably from university administration, were not adequately rewarded.

Students in an upper-level life cycle nutrition course at North Carolina State University were given the choice of completing a SL project or writing a term paper. Surprisingly, only eighteen students (40%) chose the SL project. Evaluation of the project showed that most students would take the same course again with SL and they would recommend a course with a SL component course to others. Forty-seven percent of the students said they achieved the greatest learning in the area of personal growth while 17% cited academic enhancement. Although no formal evaluation was performed at the service sites, one site coordinator thought the project was very successful and increased the ability of the site to carry out its mission. [14] In a Contemporary Issues in Nutrition class, senior dietetics students were given the option of choosing a section in which they presented a seminar to their classmates or to local dietitians, as part of a 3 hour continuing education workshop. [15] Students electing to take the SL section were more motivated, more sure of a career path, and had higher grade point averages when compared with the students electing the non-SL section. The SL students were also able to articulate the learning objectives of the course better.

Project Description

Students in an upper-level medical nutrition therapy (MNT) course were assigned a service-learning project. Eleven students were enrolled in the class and involved with the project. Diabetes is one of the disease states taught in this course, so a project involving diabetes education at a state-funded medical facility was chosen as the site for the project. The dietitians in the facility expressed enthusiasm about the project and a willingness to work with the students. Class time was allotted to introduce the students to SL. The expectations of the instructor were outlined, and students were told how the expected learning outcomes related to the course objectives. The students were given a written and verbal description of the project which included: 1) research on the prevalence of diabetes in the community and on health disparity; 2) an educational needs assessment of the population served by the diabetes education program; 3) development of three lesson plans; 4) presentation of the lessons to the diabetes education classes; 5) evaluation of lessons by the program participants; and 6) evaluation of the project by the students. Deadlines were assigned for each segment of the project. Each class member was instructed to keep an on-going double-entry reflective journal of everything they did and learned as they worked on the project.

After the project was explained to the class and the instructor was satisfied that the students understood the scope and expectations of the project, a "hands off" approach was taken by the instructor. One student voluntarily became the "project leader" and facilitated the division of responsibilities among the class and coordinated the completion of each phase of the project. Nine students began work on different aspects of the research paper. Two students developed the educational needs assessment tool. They interviewed the dietitians at the site to learn about the facility's clientele and diabetes education program. These students developed a seven-question survey which was approved by the dietitians at the medical center and by the instructor. The survey was distributed to the diabetes education classes. The clients ranked each question from one (most important) to three (least important). The three topics that were ranked most important to the clients were fast foods, portion sizes, and managing sick days. The MNT class then divided into groups. Each group chose a topic and began working on a lesson plan, fact sheet, a pre- and post-test, and an evaluation form for their presentation. Rehearsal presentations were given to the class of dietetic interns at the university. The interns advised the students to consider the literacy level of their audience when speaking and when developing handouts. They also recommended having more visual aids. Speech patterns like the repeated use of "uh" and "um" were pointed out, and the students were advised to practice their talks more before giving the actual lesson. The students described this as a good experience because the interns provided valuable advice and insight.

Next, each group presented their lessons to the diabetes education class at one of the scheduled meetings. They gave a pre-test before and a post-test following their lesson. The diabetes clients were also asked to complete evaluation forms for each presentation. Each group used the pre- and post-test information and the evaluation forms to assess their presentations. The students compiled a notebook including every segment of the project. Each student evaluated the project using an evaluation form provided by the instructor. The students also wrote a narrative evaluation of the project describing exactly what they did, what the other members of the group did, and what they learned from the project. Each student assigned a score to the other class members based on their participation in the project, and the average of this score was used in part to determine each student's grade on the project. The double-entry reflective journals were subjectively graded by the instructor for completeness and for the students' self-reflection and ability to think critically about the events they encountered.

Benefits to the community

A total of eighteen clients attended the three diabetes classes taught by the students. The average score on the pre-test for the lesson on fast food was 68% and the average score on the post test was 76%. The evaluation showed that 80% of the class rated the presentation as excellent and 20% rated it as very good. The average score on the pre-test for the lesson on portion sizes was 78% and the average score on the post test was 84%. The evaluation showed that 98% of the class rated the presentation as excellent and 2% as very good. The average score on the pre-test for the lesson on managing sick days was 30% and the average score on the post-test was 88%. The evaluation showed that 86% of the class rated the presentation as excellent and 14% as very good.

Overall, 88% of the patients attending the diabetes education class rated the presentations as excellent and 12% as very good. The combined post-test averages showed a 24% increase in the knowledge level of the members of the diabetes education class. Written comments from the clients included "enthusiastic presentation, fresh information" and "very good learning experience."

Benefits to the Students

Students were asked to evaluate their overall SL experience at the conclusion of the project by completing a survey consisting of seven statements that they rated from "strongly disagree" to "strongly agree." To evaluate the SL component of the course, students were asked:

* if the SL project helped them to see how what they learned in class will be used when they become a dietitian: 18% were neutral, 45% agreed, and 36% strongly agreed

* if participating in the project helped them to understand material from their coursework better: 45% were neutral, 27% agreed, and 27% strongly agreed

* if they took the project more seriously because they were a member of a group, 9% were neutral: 18% agreed, and 67% strongly agreed

* if they became a better team player as a result of working on this project, 9% disagreed: 18% were neutral, 9% agreed, and 67% strongly agreed

* if they learned to be more comfortable working with other people during this project: 9% disagreed, 18% were neutral, and 72% agreed

* if they would like to see more service-learning projects like this in other classes: 55% were neutral and 45% agreed

* if they learned more about their personal strengths and weaknesses while doing this project: 9% disagreed, 45% agreed, and 36% strongly agreed.

When asked what they liked most about the project, the students provided comments such as:

* "I began to ... realize what we were doing with our curriculum. The interaction was great."

* "I liked being able to actually be in a facility with real patients ..."

* "It taught us a lot about our community, things that I did not even think about."

When asked what they didn't like about the project, the students provided comments such as:

* "I didn't like the fact that we were the first class to try out this service-learning project, but I do hope we continue to have them because it is good experience."

* "It was hard to work in a group because of other people's schedules."

When asked what they would have done differently if they were the instructor, the students had very few comments. One particularly insightful comment was, "I would have taken the class to observe one of the diabetes education classes beforehand so we would know what to expect." The double-entry reflective journals reflected personal growth and an increase in knowledge by the end of the project. Some of the comments included:

* "I learned how to ask questions that would lead me to answers I was looking for."

* "I tried the talk out on my children. If they couldn't understand a word, I figured my audience wouldn't know what it meant either."

* "I didn't realize the importance of the (needs assessment) survey at first. However, it made it easier to choose our topics."

Discussion

One of the best outcomes from a SL project is a sense of teamwork among the group. The students' evaluations confirmed that this was accomplished. The project also made the work of a dietitian seem more meaningful. Many students in didactic programs of dietetics spend four years in the classroom studying to become a dietitian without any type of "hand-on" experiences. Since the Health Insurance Portability and Accountability Act (HIPAA) law (PL 104-191) was enacted, in part to ensure patient confidentiality, opportunities to interact with clients are especially limited in medical nutrition therapy classes. This project gave many students their first interaction with clients and helped them to understand more fully the role of a dietitian. Students were also exposed to the diversity of clients that dietitians see on a day to day basis.

At first, the students experienced frustration because they did not understand the concept of SL and had never participated in this type of project before. They were accustomed to having an instructor direct every aspect of their projects. Their journal entries reflected the fact that they didn't know where to look to begin the research paper. There were many complaints about this being a group project and the difficulty in getting the group to work together. The entries also reflect the fact that most of the students did not consider themselves adept at using the Internet as a research tool.

However, once they divided themselves into groups with specific assignments, they began to make progress. The results of the students' evaluation of the project show that despite complaints about this being a group project, they took the project more seriously because they were members of a team, and they considered themselves better team players as a result of this project. The highest rated benefit of the project was the students' agreement with the statement, "I learned to be more comfortable working with other people during this project." Future SL endeavors should include an introduction to using the Internet as a research tool if research is part of the project. While college students may be adept at using the Internet for a variety of purposes, they may not be proficient at using it for scholarly research. In addition, as one student so aptly pointed out, future endeavors should include a better introduction to the site being used for service-learning in order to familiarize the students with the facility ahead of time. Time restraints prohibited this for this project, but in anticipation of incorporating service-learning in the future, courses could be scheduled for longer time periods or in a time slot that corresponds with anticipated activities.

Conclusion

Many courses taught in dietetics curriculums offer potential for service-learning projects. Service-learning projects present dietetics students opportunities for personal and professional development, practical application of classroom learning, and increased self confidence. These attributes can help to create stronger dietetics professionals with a greater concern for community service and citizenship.

References

[1] Pew Health Professions Commission. Critical Challenges: Revitalizing the Health Care Professions for the Twenty-first Century, University of California at San Francisco Center for the Health Professions, San Francisco, CA 1995.

[2] Seifer SD, Connors K, O'Neil EH. Combining service and learning in partnership with communities. Acad Med 1996;71:527.

[3] O'Toole TP, Hanusa BH, Gibbon JL, Boyles SH. Experiences and attitudes of residents and students influence voluntary service with homeless populations. J Gen Intern Med. 1999;14:211-216.

[4] Sternas KA, O'Hare P, Lehman K, Milligan R. Nursing and medical student teaming for service-learning in partnership with the community: an emerging holistic model for interdisciplinary education and practice. Holist Nurs Pract. 1999;13(2);66-77.

[5] Young S, Bates T, Wolff, M, Maurana, CA. Service-learning in healthy aging for medical students and family medicine residents. Educ Health. 2002;15(3):353-361.

[6] Sedlak CA, Doheny MO, Panthofer N, Anaya E. Critical thinking in students' service-learning experiences. College Teaching 2003;51(3):99-103.

[7] Levy K, Lehna C. A service-oriented teaching and learning project. Pediatr Nurs. 2002; 22(3):219-221.

[8] Cohen, SS, Milone-Nuzzo P. Advancing health policy in nursing education through service learning. Adv Nurs Sci. 2001;23(3):28-40.

[9] Greene D. Reciprocity in two conditions of service learning. Educ Gerontol. 1998;24:411-424.

[10] Short JE, Chittooran MM. Nutrition education: a survey of practices and perceptions in undergraduate dietetics education. J Am Diet Assoc. 2004;104(10):1601-4.

[11] Chabot JM, Holben DH. Integrating service-learning into dietetics and nutrition education. Top Clin Nutr 2003;18(3):177-184.

[12] Kim Y, Canfield A. How to develop a service-learning program in dietetics education. J Am Diet Assoc. 2002;102(2):174-176.

[13] Kim Y, Clasen C, Canfield A.. Effectiveness of service learning and learning through service in dietetics education. J Allied Health. 2003;32(4):275-8.

[14] Ash, SL. Integrating service-learning into a college-level nutrition course. J Nutr Educ Behav. 2003;35:161-162.

[15] O'Neil CE, Matthews BL, Anton H. Choice of service-learning or non service-learning senior seminar section student characteristics, fulfillment of learning objectives, and instructor evaluation: a case study. J Am Diet Assoc. 2004; 104(8): A

[16] The Commission on Accreditation for Dietetics Education. CADE Accreditation Handbook. Available at: http://www.eatright.org/Public/Files/CADEHandbook.pdf. Accessed August 30, 2004.

Beth Fontenot, McNeese State University

Carol E. O'Neil, Louisiana State University 

Fontenot, MS, RD is an Instructor and DPD Director in the Dept of Family and Consumer Sciences. O'Neil, PhD, RD is an Associate Professor and DPD Director in the School of Human Ecology.