Service-Learning in Health Professions Education: A Multiprofessional Example.

Abstract

The education of health professionals must meet many challenges in a changing health care environment. Both service-learning and multiprofessional education are methods which can successfully prepare students for practice as professionals in new settings and conditions. This article describes the use of service-learning principles in a multiprofessional course taught through the coordinating efforts of the Center for Healthy Communities (CHC). The authors maintain that this type of course is a viable model for meeting the changing demands of the market and student concerns regarding the relevance of heath professions education.

Introduction

Students, employers, and funders are the major constituents in today's academic and economic environments. As most educators are aware, these constituents demand an education that is both relevant and marketable. This realization has also impacted the education of health care professionals, especially given the growing emphasis on community-based health care. As the focus of health care shifts from an illness model to wellness, these issues challenge the traditional teaching hospital approach to the training of health care professionals. Moreover, it has been stated that these trends argue for a community-based multiprofessional approach to training (Cauley, Maurana & Clark, 1996; Furco, A. 1996; Bailey, Carpenter & Harrington, 1999). Service-learning (SL) is a teaching method which health professional educators should consider in responding to the shift toward multiprofessional community-based training. The advantage of service-learning is that it is a method that can meet the needs of all the above referenced constituents. It also addresses academic and community imperatives by integrating theoretical and applied training while simultaneously addressing real community needs (Bailey, et al., 1999). This article presents information on introducing the principles of service-learning into a multiprofessional course presented to health professions students through the coordinating efforts of the Center for Healthy Communities (CHC). The authors assert that this type of course is a viable model for meeting the changing demands of the market and student concerns regarding the relevance of heath professions education as well as other programs of higher education.

Service-learning and Multiprofessional Education at the CHC

The Center for Healthy Communities (CHC) is a community-academic partnership among Wright State University, Sinclair Community College, and the Dayton, Ohio community, established to provide an innovative model of primary health care delivery, multiprofessional education, and research. One initiative of this partnership was to establish a venue for health professions students to work together in community settings to provide care to underserved populations. The goal is to familiarize students with different populations, educational processes, and professions. A second initiative of the CHC has been the promotion of service-learning as a teaching methodology in the education of students in the health professions. We articulated a series of six principles to guide the use of service-learning in health professions. Below, we describe how these two initiatives have been combined.

Service-learning Protocol for Health Professions Schools (SLPHPS)

Service-learning has been readily accepted into curricula of K-12 schools as well as many institutions of higher education. This methodology has been slower to take hold in health professions education, in part because health professions faculty frequently believe that they are already practicing service-learning. Health professions students have traditionally spent a significant number of clinical hours in acute care or clinic settings, and some faculty believe that students' learning in clinical settings equates to providing service to the community, regardless of whether the students' work meets community-identified needs. However, health professions students and faculty increasingly find themselves in a variety of community-based clinical and non-clinical settings. Instead of treating the acutely ill in a traditional "controlled" setting, they are emphasizing prevention of hospital and clinic admissions via health promotion/disease prevention teaching and screening activities. Attention to SL principles provides a way to enhance student learning in these activities. It also provides incentives for community sites to be student learning centers by offering real benefits to the sites (Bailey, et al., 1999; Miles-Curry, Hickok, & Cauley, 1998).

In 1994, the CHC received a grant from the Corporation for National Service to meet the challenge of integrating SL into health professions education in private and state supported programs in Ohio. To accomplish this mandate, the Ohio Faculty Institute (OFI) was formed. The OFI is a multidisciplinary team composed of representatives from nursing, medicine, psychology, social work, dental hygiene, and other allied health fields. For the past two years the team has included a working group of seven faculty who research, develop, and implement educational workshops and technical assistance in SL techniques for other educators.

A critical tool used by the OFI is a set of principles called the "Service-learning Protocol for Health Professions Schools (SLPHPS)." These principles were developed by the Center for Healthy Communities to serve as a template for integrating service-learning into health professions education. They were used to guide development of the service-learning component of the multiprofessional course. The six components of the SLPHPS are:

* Expand clinical training opportunities into more community and neighborhood sites,

* Create and maintain long term relationships with the community,

* Develop clinical training experiences in concert with a community partner,

* Provide an orientation component as part of the experience,

* Develop a reflection component, and

* Actively promote the ethic of service beyond formal training.

Integrating Service-learning into the Multiprofessional Course

The Multiprofessional Course (MPC) was developed with initial support from the Pew Charitable Trust and the Robert Wood Johnson Foundation. The course has been taught once yearly since 1993. Content includes instruction about professional roles and focuses on team building, components of primary health care, barriers to delivery of care, health policy, and legal and ethical issues related to multiprofessional practice. Before addition of the service-learning component, student requirements included completion of a journal, a team case study, attendance at a community/agency meeting, and a group presentation on a health promotion/disease prevention issue. Beyond student attendance at a meeting, there was very little actual student contact with the community or its health and human service agencies.

To achieve the best service-learning experience, the needs of the community should be identified and addressed. Community agencies were invited to one of the first class sessions to describe their agency, population served, and services performed. The students were then allowed to choose an agency with which they wished to work. Students were assigned to teams on the basis of their interests. Each team consisted of at least two different health disciplines.

The faculty teaching team for the winter 2000 MPC consisted of faculty members from Wright State University Schools of Medicine, Nursing, Professional Psychology, and School of Social Work; Sinclair Community College Department of Dental Hygiene; and Kettering College of Medical Arts Physician Assistant program. A total of forty-six students registered for the course, with representation from each faculty discipline except dental hygiene. Prior to this quarter, class size had averaged about twenty-five students.

The course syllabus reflected a design that used content related to team building, facts about health profession disciplines, service-learning, cultural diversity and cultural competence, health promotion and disease prevention, and primary care concepts. The class time was about equally divided between classroom didactics and exercises and time spent on-site at the agencies.

Building Orientation into the MPC

Orientation, a key component to successful service-learning, is a three-way process in which faculty, community partners, and students are all oriented to the experience. The faculty member is usually responsible for establishing a relationship with a community partner who can offer an appropriate educational experience related to a community-identified need. Faculty and partner are mutually oriented to the experience by covering topics such as the course learning objectives, students' abilities, the partner agency's mission statement, communication procedures, and the expectations of each party. The faculty and community partner should meet face-to-face frequently, and the faculty member should become familiar with the environment in which the experience will take place. Information to note includes agency location and directions to get there, parking, available space at the agency, and the names of key staff. This information is shared with the students.

Orientation of the students to the agency begins when students are introduced to the community partner, which usually occurs after students have been oriented to the course/clinical. This introduction ideally occurs at the agency site, but if this is not possible, the partner can be invited to attend a class session. Student orientation includes the mission of the agency, characteristics of the population served, relevant features of the neighborhood, and agency expectations and procedures. Information that should be provided to the agency includes the times the students will be available to provide services and students' ability levels.

Another important facet of orientation for students and faculty alike is gaining some familiarity with the community as a whole and the specific population being served. During the MPC, students were sent out in their teams on a "scavenger hunt." Some of the assignments given them were to find a place for three people to stay overnight free for three nights, locate free HIV testing, and fred daycare for a teen mother with an infant and a three-year-old. Students were provided with a two dollar bill and were forbidden to use their own cars, money, or cell phones. The students enjoyed this exercise and found it enlightening. Some of the challenges they reported included finding change for a two dollar bill, finding a phone in a public place, and just being "on the street."

The Service Component of the MPC

The heart of service-learning is the combination of learning experiences with meeting needs the community has identified. It is through discussion and interaction between faculty and/or students and community partner that mutual requirements can be determined. In the MPC, for example, some of the community agencies had specific projects in mind that students could fulfill. In other cases, students visited the agency, talked with staff and clients, and were able to brainstorm and come up with some great ideas for service based on what they had learned. Thus, while it is good for the faculty and the community partner to have ideas for potential projects for the students in mind, we learned that students are often able to develop their own focus and direction. Some examples of community needs met through the MPC student teams are presented.

Working in real-life service settings also can require students to show ingenuity and flexibility. For example, one student team developed a short health needs survey for the clients in a halfway house, who are making the transition from incarceration to parole. During the first week the students administered the survey, discussed the results and planned for the next week's activities based on that information. However, the following week, they found that the clients were not the same ones that had completed the survey. They were able to regroup and work with the clients present that day.

Students spent three hours in class each week for the first five weeks. For the second half of the course, students spent approximately three to four hours a week on their projects, though this varied somewhat by agency. Flexibility on the students' part was necessary, as it was not always possible to fulfill their commitment to their projects during the hours set aside for class time. The students worked hard to coordinate their busy schedules and meet the agencies' needs.

Building Reflection into the MPC

Reflection is a core element in regard to the use of service-learning as a teaching method. A number of best practices for reflection are noted in the literature (Eyler, et al., 1998). In the MPC, there was a conscious effort by the faculty to make reflection continuous, contextual, challenging, and connected. These four principles were at first implemented as individual elements and presented in each weekly module. As the course progressed, the principles became more integrated and seamless. Reflection in regard to the mission, goals, and methods of the course was continuous at multiple levels of the instructional process. Student reflection occurred through the medium of a journal they were required to keep and submit weekly, as well as less formally through the teams' verbal discussions with the faculty.

The projects produced bonding among team members. The evidence of this effect was apparent with changes in the affective tone and the content of the reflections that were shared by students at the end of the class, as well as by an observation of realignment of professional boundaries between members of different disciplines. Students expressed a desire to continue relationships with students from other disciplines. Perhaps even more importantly, students wanted to maintain contact with the agencies where they provided service.

Evaluation of the Multiprofessional Course with a Service-learning Component

We evaluated the MPC by soliciting feedback from the students and community partners. In addition, student attitudes toward community service, multiprofessional practice, and diversity issues and a self-assessment of knowledge of the community were evaluated both before and after completion of the course.

The community partners were very pleased with the experience. They appreciated the students' energy and enthusiasm, and reported that the students were effective and were not a burden to supervise. They recognized the very real benefits to students of participation in service-learning. Partners appreciated the fact that they were able to guide the student participation in ways that truly met community needs. Each of these partners has expressed willingness to participate in the MPC next year.

A total of 36 students completed evaluations of the class, and the great majority were very positive. Most students (58%) reported that they had not been involved in a service-learning experience before. Seventy-four percent reported that they felt they had learned more than they would have from more traditional teaching methods. The orientation and reflection components of the experience were viewed very positively, with 92% of students agreeing that their orientation was either adequate or excellent, and 89% reporting that reflection added to their learning. Almost universally, the students agreed that they wished they had had more time to spend in and with the community, and almost all (97%) stated that they would be willing to participate in a course with a service-learning component again.

An instrument designed to measure students' attitudes toward multiprofessional practice, service to the underserved, diverse populations, and their knowledge of community resources and barriers to health care was administered both before and after the MPC. Pre- and post- means were compared by matched t-tests. There were significant differences in students' self-reported knowledge of community resources, health care needs, barriers to receiving health care, and responsibilities of other health care professionals (p 0.01 [pounds sterling]). After the course, there were highly significant positive changes (p 0.001 [pounds sterling]) in agreement with the statements "I feel well prepared to practice my profession in a community similar to my placement site," "I would like to work in settings where health care professionals are underrepresented," and "I would like to work with patients/clients of various cultural backgrounds."

Students' verbal reflections as part of the group presentation of their project on the last day of class reinforced these results. Many students stated that their expectation had been to provide "help" to community members, and while they felt that they had done so, what they had received from the community was so much greater than they expected. Several students repeated variations of "We expected to teach the community a lot, but instead we learned so much from them." Many verbalized a new awareness of and respect for the abilities, knowledge, and resilience of the people they had viewed as "underprivileged."

As part of the written evaluation, students were asked if they thought they had gained unique knowledge from this clinical experience which differed from knowledge gained in courses lacking a clinical component. Twenty-eight students answered with some form of "yes," often capitalized and/or with exclamation marks. Many reported that the hands-on aspect definitely enhanced the learning; that actual service is where the learning occurs. As one student wrote "Putting what you learn into practice makes it much more real and concrete." Another said "Our other classes all focused on the health care component, something this class went beyond ... We learned to relate to others as humans."

Conclusion

It is possible to build service-learning into an existing course. The time and effort required to find and build partnership with community agencies were well repaid in the case of the multiprofessional course by the enthusiasm and increased learning reported by the students and by the gratification of the agencies who saw students making a real contribution to the agency mission.

By keeping in mind the principles of working closely with a community partner, providing orientation to all involved, and building in opportunities for students to reflect on their experiences, the MPC course was successful in meeting the learning goals for the students while promoting the ethic of service.

Community needs met by student learning projects.

Community Need                        Student Project

Heighten awareness of the       ??    Survey, informational
general public,                       pamphlets, and video
especially women of                   presentation to about
childbearing ages,                    300 college students
about folio acid.

Tutoring of African American    ??    Designed and implemented
youth to improve economic             tutoring strategies in
viability and                         collaboration with public
job readiness                         school and enrichment
                                      program teachers

Development of a breast         ??    Designed and placed posters
cancer health promotion               to advertise screening
and disease prevention                program
campaign

Provide                         ??    Provided resource information
comprehensive-intensive               based on a student-initiated
support to a homeless                 needs assessment
population

Acknowledgements

The authors gratefully acknowledge the support of the Pew Charitable Trust, the Robert Wood Johnson Foundation, and the Corporation for National Service in supporting the development and implementation of a multiprofessional health education class with a service-learning component.

References

Bailey, P., Carpenter, D., & Harrington, P. (Eds.) (1999). Integrating community service into nursing education: A guide to service learning. New York: Springer.

Cauley, K., Jaballas, E., & Holton, B. (2000). Medical students go back to kindergarten: Service learning and medical education in the public schools. In: Norbeck, J., Connoly, C., and Kerner, J., (Eds.), Concepts and Models for Service Learning in Medical Education. Washington, D.C.: American Association for Higher Education.

Cauley, K., Maurana, C., & Clark, M. (1996). Service learning for health professions students in the community: Matching enthusiasm, talent, and time with experience, real need, and schedules. In Raybuck, J., and Taylor, B. (Eds.). Expanding Boundaries: Serving and Learning. Washington, D.C.: Corporation for National Service.

Connors, K., Seifer, S., Cora-Bramble, D., Sebastian, J., & Hart, R. (1996). Interdisciplinary collaboration in Service-Learning: Lessons from the health professions. Michigan Journal of Community Service Learning, 3, pp. 113-127.

Furco, A. (1996). Service learning: A balanced approach to experiential education. In Raybuck, J., and Taylor, B. (Eds.). Expanding Boundaries: Serving and Learning. Washington, DC: Corporation for National Service.

Eyler, J., Giles, D. & Schmiede, A. (1996). A Practitioner's Guide to Reflection in Service-Learning: Student Voices and Reflections. Nashville: Vanderbilt University.

Miles-Curry, D., Hickok, K., & Cauley, K. (1998). Nursing clinical education in an urban public school system. In: Norbeck, J., Connoly, C., and Kerner, J., (Eds.), Concepts and Models for Service Learning in Nursing Education. Washington, D.C.: American Association for Higher Education.

Peterson, S., & Schaffer, M. (1999). Service Learning: A strategy to develop group collaboration and research skills. Journal of Nursing Education, 38(5).

Annette Canfield, RNC, MS, is Assistant Director of the Division of Health Professions Education, Center for Healthy Communities and has a faculty appointment in the College of Nursing and Health. <[e-mail]> Carla Clasen, MPH, RN, is the Assistant Director of the Division of Research and Evaluation at the Center for Healthy Communities. <[e-mail]>. James Dobbins, PhD, ABPP, is a professor in the School of Professional Psychology. Kate Cauley, PhD, is the Director of the Center for Healthy Communities and holds faculty appointments in the Schools of Professional Psychology and Medicine. Sheranita Hemphill, RDH, MS, has a faculty appointment in the Department of Dental Hygiene. Marilyn Rodney, RN, MS, is the Assistant Director of the Division of Community Health Advocacy at the Center for Healthy Communities and holds a faculty appointment in the Department of Nursing. Gordon Walbroehl, MD, is a professor in the Department of Family Medicine.

Annette Canfield, Wright State University, OH
Carla Clasen, Wright State University, OH
James Dobbins, Wright State University, OH
Kate Cauley, Wright State University, OH
Sheranita Hemphill, Sinclair Community College, OH
Marilyn Rodney, Sinclair Community College, OH
Gordon Walbroehl, Wright State University, OH