Integration of evidence-based decision making within the dental hygiene curriculum.
To address this, in 2003, the University of Michigan (U-M) Dental Hygiene Program began a systematic effort to integrate EBDM within the curriculum and translate this into clinical practice. Steps to do so occurred incrementally over a five-year period and continue to evolve today. In conjunction with curricular changes, a focus was placed on faculty professional development. Dental Hygiene: Focus on Advancing the Profession, a report by the American Dental Hygienists' Association (ADHA), cited employing evidence-based practice (EBP) as a core competency for dental hygiene educational programs. (2) The literature supports that two major outcomes must be achieved to accelerate the translation of research findings into clinical practice: (a) dental hygiene educators must develop sufficient EBP knowledge and skills to advance evidence-based care in clinical settings, and (b) educators must teach their students the EBP process to instill lifelong skills to deliver the highest-quality care. (3) In addition, the Commission on Dental Accreditation Standards for Dental Hygiene Education requires programs include EBDM in the curriculum. (4)
Although patient outcomes improve substantially when clinical care is based on evidence versus steeped-in-tradition recommendations, only a small percentage of dental hygienists base their practice on the best evidence from research. (5) A survey of 235 U.S. dental hygiene program directors found that over three-quarters of the respondents did not feel their faculty have adequate EBP skills. (6)
Dental hygiene education at both the baccalaureate and master's levels has historically focused on preparing dental hygienists to generate research rather than use evidence to efficiently translate research findings into practice and improve clinical care. Research courses have taught students in-depth content on hypothesis testing and specific research methods, with the end product being a written research proposal or table clinic. (6) Furthermore, critical thinking skills and literature assessment have been taught in isolation of clinical situations and, thus, students have failed to see the application of an evidence-based approach to clinical practice. (7)
Although a few authors have described the need to integrate EBP into dental hygiene curricula, (8-11) there is limited information on strategies employed for exposure to EBDM practices and to what extent the faculty incorporate EBDM into clinical situations with students. However, studies do support teaching students to find, evaluate and incorporate current scientific evidence into their clinical decision making, thus closing the gap between what is known (research) and what is practiced. (5), (10), (11) The U-M Dental Hygiene Program has been addressing this gap. Although U-M confers a baccalaureate degree with students enrolled for three years, the principles and practices outlined can be applicable to any dental hygiene program.
The Millennial Student
To understand how students best learn and integrate EBDM into their practice, their learning profile should be assessed. A significant number of U-M dental hygiene students are from the "millennial generation," the name sociologists have given to those born between 1982 and 2002. (12) These students are technologically competent and rely heavily on electronics. (13) They multi-task with many activities, function well in group environments, and need the reassurance of immediate feedback. (12), (13) In helping others and identifying social problems, millennials are both generous and practical, in addition to being optimistic about their professional future. (12), (13)
A study conducted by Blue determined that millennial dental hygiene students strive for accuracy. (13) Thus, making subjective judgments and application-based decisions is not initially within their comfort zone. Their learning is processed in the context of their own life experiences. So if an experience is "new," faculty members are faced with assisting students in understanding why content is important. Faculty are also challenged to guide students to successfully apply content to real-life situations.
To maximize the learning of the millennial student, the U-M Dental Hygiene Program utilized experiential evolutionary scaffolding. (14) This model incorporates authentic, active learning with students engaged in exploration and analysis of real-world experiences. (15) Evolutionary scaffolding consists of prompted content, materials and tasks used in conjunction with peer and instructor support. (16) Through combining authentic learning and scaffolding theories, the complexity of the learning experiences increases over time (evolution). This allows the millennial student to move from externally developed scaffolds to those that are internal, driven by their own learning experiences. (14) This model was used as the basis for integration of EBDM throughout the U-M Dental Hygiene Program.
Table I. University of Dental Hygiene EBDM Curriculum Overview Year of EBDM content Learning activities program incorporated in courses First year Clinical Clinical case (Sophomore) Seminar I & II scenario/topic application of: Survey of * PICO question Dental Hygiene Oral Anatomy * PubMed searching Special * Paraphrasing, Patients citations Second year Research Literature-based (Junior) Methods readings, review skills and EBDM application activities for: Clinical * Cases Seminar III & IV Periodontics 2 * Products Nutrition * Conditions Community * Community program Dentistry development Community * Clinical care Practicum Biomaterials Third year Scientific * Literature-based (Senior) Communications readings and application-based discussions/activities Clinical * Original research or Seminar V & VI review of the literature project development Practice * Critical analysis, Management review of the literature papers Periodontics 3 * Comprehensive case presentations * Discussion focusing on challenges/solutions of utilizing EBDM in practice
Integration within the Curriculum
With EBDM identified as a critical element in dental hygiene education and clinical patient care, it was determined to introduce this to U-M students within the first month of the program. Students are provided foundation knowledge about EBP in a didactic course that integrates an application-based learning activity within the library orientation. The hands-on orientation session includes an introduction to accessing electronic databases. Through the use of a basic inquiry about "halitosis," students are guided through the process of developing a PICO (Patient/Problem, Intervention, Comparison, Outcomes) question. Then, using the keywords that emerge from the PICO question, students complete a PubMed search for relevant literature on the subject.
Following this introductory activity, student teams are provided with a patient-care-related clinical scenario (e.g., difference between waxed and unwaxed floss, power brush verses manual brush effectiveness). A worksheet guides teams to search PubMed to find five journal articles on the clinical question, determine the three that most appropriately address their question, and identify three to five key points from those articles.
Several days later, students attend an orientation with the university's writing center. At that time, they work with additional elements of the worksheet, including citing the journal articles and synthesizing the key elements of each article into a paraphrased summary paragraph. The student teams also orally present their clinical scenario, PICO question and the evidence-based results within the didactic course.
This type of learning activity is repeated using case simulations and topic-specific research (e.g., medical history condition, special patients) an additional six times throughout the first year of the program within five courses (Table I). Use of technology, group work, and application to real life are all pillars of these assignments. With faculty guidance, students begin to develop their understanding of why EBDM is important to practice and how it supports quality patient care.
In the junior year of the U-M program, scaffolding of EBDM expands with more complex content and learning activities (Table I). The important millennial learner pillars of technology, group work and application continue to combine as the foundation of assignments this year and the next. The Research Methods course introduces skills to review primary research using a series of team-based worksheets. Students move on to develop case presentations using the literature to support their information and/or care plans. EBDM is integrated within two community dentistry courses through incorporation of the literature in developing community profiles and needs assessments, providing the basis of support for oral health promotion programs. In Biomaterials, student teams choose from a list of whitening products and are required to identify associated clinical trials and their results, as a component of their presentation. Journal articles that support topics within a number of courses are included as readings and are applied to discussions within class and clinic.
The senior year culminates with a greater infusion of literature-based readings and application-based discussions (Table I). Within Scientific Communications, student teams develop a poster presentation based on involvement in original research or a review of the literature on a selected topic. In conjunction with this, students write a critical analysis paper evaluating a research study, compose a literature review, develop a comprehensive case presentation from their patient care experience, and engage in a discussion about challenges/solutions related to utilizing EBDM in practice. This final year of the program provides students with a greater understanding of the value of EBP as well as opportunities to apply it to their professional practice and recognize it as an ethical responsibility of providing patient care.
As students gained EBDM experiential evolutionary scaffolding, so did the faculty. Time was scheduled during in-service for EBDM presentations. To build upon the EBDM basic concepts, sessions were scheduled in the School of Dentistry computing lab so that faculty could gain hands-on database searching skills. Multiple noon-time sessions were offered in an effort to capture all part- and full-time faculty. Faculty meetings incorporate journal articles with discussion about application to student learning and clinical patient care. As the faculty is dynamic, strategies for professional development and updating EBDM skills are ongoing.
Translation into Practice
Access to evidence-based information is an important component of EBP. About a decade ago, the U-M School of Dentistry Patient Care Clinics introduced Internet access to the four clinics, one computer per clinic. In 2008, each cubicle was equipped with its own computer. However, in the midst of providing patient care, searching databases for scholarly information and reading/synthesizing information from research studies are most often not feasible.
The translational practice emphasis in the U-M program is on the importance of practitioners staying current on professional research related to oral/systemic issues, trends in treatment, products, and health promotion and disease prevention. Students are challenged and assessed to be sure that their clinical decision making and care are evidence-based. As questions arise from patients, taking time to investigate an appropriate evidence-based response after the appointment and then following up with the patient to provide them with recommendations is an appropriate strategy. Discussion among faculty and students during patient care is another approach to integration of EBDM.
With millennial students being practical and optimistic about their professional future, they tend to see EBP as an important element of their patient care and are serious about the importance of its application. U-M seniors were asked about their EBDM skills acquired and applied during their dental hygiene education.
Faculty expect and encourage us explore our own recommendations using the skills we have developed. Only after the student thinks critically and looks for supporting scientific information are the faculty members willing to share their viewpoints and their clinical experience. Because the faculty members have the understanding that EBDM is the standard, it makes it easier for students to learn and utilize EBDM in the clinic. If we didn't have faculty with a unified understanding, it would be very difficult to apply these skills. EBDM is incorporated into the curriculum through the whole educational experience. The faculty are very knowledgeable about EBDM and demonstrate it well. Many class sessions focus on taking an issue or chief concern and thinking it through using the PICO process to create a researchable question. It is great that we learn this right from the beginning and have experience using these skills when we graduate. We analyze data from creditable sources and provide our care based on that, experience, and what the patient thinks will work for them. We learn about EBDM from the very beginning of this program so that we can use this skill when treating patients. Although it may have been overwhelming at first, we learned how to properly ask a question, research it, evaluate the research, and utilize the information learned to apply it to patient care.
EBP is fundamental to the profession of dental hygiene and EBDM a skill that is important for all dental hygienists to acquire. It is a responsibility of educational programs to integrate EBDM within their curricula as well as to facilitate its translation to clinical practice. The process of integrating EBDM and EBP is one that has been a work in progress for close to a decade at the University of Michigan. Graduates and faculty acknowledge the importance of EBP and value it as critical element of patient care.
This article is sponsored by an educational grant from Procter & Gamble.
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L. Susan Taichman, RDH, MS, MPH, PhD, and Anne Gwozdek, RDH, BA, MA
L. Susan Taichman, RDH, MS, MPH, PhD, is a recipient of the Procter & Gamble ADHA/Institute for Oral Health Fellowship. She is an assistant professor/research scientist at the University of Michigan School of Dentistry, Ann Arbor, Mich. She graduated from Lansing Community College in 1986 and holds a BSDH, MS, MPH and PhD from the University of Michigan. Her research focuses on women's oral health, specifically investigating oral health for breast cancer patients/survivors. She teaches the research methodology and evidence-based practice courses for both the U-M E-Learning (online) degree completion and the entry-level dental hygiene programs.
Anne Gwozdek, RDH, BA, MA, is director of dental hygiene degree completion programs at the University of Michigan, Ann Arbor, Mich. She has served in leadership positions in the American Dental Hygienists' Association and the American Dental Education Association. A 1973 graduate from the University of Michigan's dental hygiene program, she obtained her BA in journalism and public relations from Madonna University and her MA in educational media and technology from Eastern Michigan University. Her research interests include education with a focus on learning technologies and program evaluation.
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|Author:||Taichman, L. Susan; Gwozdek, Anne|
|Date:||Jul 1, 2011|
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