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Service-learning in healthcare education.

Abstract

Competing demands present a challenge for anyone wanting to include a Service-Learning (SL) course in any professional degree curriculum, particularly in healthcare education. The case for including SL requires an analysis and presentation of what it specifically can and does accomplish and how well, with respect to curricular demands. This paper describes a required SL course in a healthcare curriculum (specifically, pharmacy education), and assesses its success. Its outcomes support the presentation of this course as an exemplary model for SL in healthcare education.

Introduction

In most degree programs, curricular time is at a premium; this is especially true in professional degree programs, where students must master large bodies of knowledge critical for the profession. In such circumstances, the inclusion of yet another course in the curriculum, and especially a non-traditional course, such as a Service-Learning (SL) course, requires compelling justification by the proponents. It must be shown that the course will effectively accomplish learning objectives that are essential to the education of future professionals, and that it is unique in its ability to do so. If the above is true of professional degree programs in general, it is particularly true in the education of health care professionals. This is so because such professionals must master a broad range of material, from the social sciences, to law and ethics, to medical sciences, etc. In many of these areas, there is a rapidly expanding knowledge-base that the students must master, which creates growing demands in the curriculum.

Given these circumstances, can one make a compelling case for the incorporation of SL in such academic programs? In this paper, the argument will be made that SL-based courses do indeed make unique and important contributions to the achievement of essential objectives in the education of health care professionals. One course that may be viewed as an exemplary model for Service-Learning in healthcare education will be described: it incorporates some of the best practices in SL, it has been highly rated by students in institutional course evaluations, and various assessment tools have indicated positive learning outcomes from the course.

In the present paper, the reference-point is the education of pharmacists; but what is said here applies equally to the education of most other health care professionals (physicians, nurses, dentists, respiratory therapists, etc.). The education of health care professionals has long included a significant experiential component. In the case of pharmacy education, this experiential education typically involves students working, without pay, in a hospital or retail pharmacy under the supervision and guidance of a preceptor, who is both a health care professional and an educator. Educators and practitioners alike generally agree that this experiential education is clearly justified and essential. Service-Learning, as understood in the present paper and as generally understood by most practitioners, is different from the traditional experiential or clinical education described in the preceding paragraph. As such, it has goals and objectives distinct from the latter, and must be justified on a different basis in order to earn a place in the healthcare education curriculum. As summarized in the following two paragraphs, Connors and Seifer (1997) have differentiated SL from other types of experiential learning in the education of health care professionals, and have explained the unique educational role that SL can play.

In clinical training, students apply the theories and skills they have learned in the classroom to the care of patients. The students are generally viewed as experts in theory, who are aiming to become experts in practice. This contrasts with Service-Learning, where the students are viewed, and view themselves, more as contributor-learners. As such, they and the people and communities they serve are more reciprocal partners than simply helpers and recipients of assistance, respectively. In internships, the emphasis is on student learning. Obviously, all parties involved assume that patients will benefit from the activities of the intern; but this may be secondary to the student's learning. Service-Learning, on the other hand, gives more equal weighting to service and learning. Though the students are not paid, their work must meet real community needs, while at the same time providing them opportunities for learning. This highlights the reciprocity of Service-Learning. No one involved in the education of health care professionals would argue for removing clinical training or internships from the curriculum, because they meet essential educational goals. However, SL has the potential for meeting other critically important needs.

The current vision of the pharmacy profession is much broader than the dispensing of medications. (Similar statements could be made about other healthcare professions. For example, physicians view their role as broader than simply prescribing medicines to cure illnesses.) Practitioners today are more likely to speak of their role as the provision of pharmaceutical care. This includes a wide range of responsibilities, from working with other healthcare professionals to design optimal therapies to monitoring and improving health outcomes. Finally, many pharmacists highlight the importance of community pharmacy. This terminology is meant to emphasize that, in order to ensure optimal health outcomes, healthcare professionals need to be involved in the communities they serve, so that they better understand their patients, not just as consumers of medicines, but as whole persons. This is where Service-Learning can make an important and unique contribution to the education of pharmacists, and similarly, to that of all healthcare professionals.

A Model SL Course for Healthcare Education

A course will now be presented as a model for SL in healthcare education. The course, offered at the Worcester, MA, and Manchester, NH, campuses of the Massachusetts College or Pharmacy and Health Sciences (MCPHS), incorporates a variety of elements that tie together community involvement and reflective learning. This required course employs SL to achieve educational outcomes in a variety of areas important for students in the early stage of their professional education.

The students taking this course are in their-first year of a program leading to the Doctor of Pharmacy degree, the degree now required for anyone entering the pharmacy profession. Students entering the program must have completed prerequisite general education and basic science courses, but need not have received a baccalaureate degree. The course is offered each fall, has been being taught six times, and has evolved considerably since it was first offered. In the Fall of 2005, there were just under 200 students enrolled in the course, in five sections, on the two campuses. For the service portion of the course, students are required to perform two hours per week of community service work for 10-12 weeks. For this service work, students are assigned to one of approximately 30 partner-organizations, based on their interests and the organizations' needs. The types of organizations where students do their SL work include: schools and youth-service organizations (tutoring and mentoring), nursing homes and a senior center, free medical clinics, and shelters and outreach organizations.

Students are required to keep journals in which they make weekly entries. Beyond simply recording what they observe and do, they are instructed to reflect on what they can learn from their experiences. Students meet for a one-hour seminar each week. For some seminars, readings are assigned as the basis of discussion of topics, and students are required to write short reflective essays about some topics. In the seminars, students discuss the readings and/or other topics. Seminar topics for the first half of the semester are: reflection as the key to learning, service agencies in the local community (two sessions, featuring speakers from those agencies), communication skills, assessment of service, critical thinking and public debate, and cultural diversity and healthcare. Two of the assigned readings focus on reflection and assessment. Connors and Seifer (1997) discuss the importance of reflection for optimal outcomes from service-learning. Indritz and Hadsall (1999) identified five criteria that one could use to assess the quality of service in pharmacies, and the course highlights how these same criteria can be used to assess service-learning outcomes.

The final seminar of the first half of the course addresses the topic of cultural diversity. Practitioners and educators are increasingly recognizing the importance of multi-cultural competence for healthcare professionals (Galanti, 2005; Jones, Royeen & Crabtree, 2003; Zweber, 2002), and this seminar addresses this critical area. For the seminar, drawing on their own cultural backgrounds (more than 50% of the students represent ethnic minorities) and experiences, and the papers cited above, students write essays and give brief presentations about their own cultures, or cultures with which they may be particularly familiar. The value of drawing on students' diverse cultural backgrounds to educate fellow students was recently described (Bodenhorn, Jackson & Farrell, 2005). For this seminar, students also draw on their current SL work experiences, often with very diverse populations.

During the second half of the semester, the students become the teachers in the course. Each week, a group of students, usually doing similar types of work (e.g., working with senior citizens, or tutoring in schools), gives a presentation about their work. Presentations are required to cover two major areas: the service the presenters are providing (goals and progress to date) and what they are learning from doing the service and reflecting on it (goals and progress). The students are also required to briefly describe some part of their experience (e.g., a memorable incident) that will communicate to the class something about the uniqueness of their work. Students are encouraged to be creative in their presentations, and, in addition to an oral presentation, often show photographs or a short videotape, play audiotapes, use PowerPoint, or perform a short skit.

Assessment of the Course

How successful has this SL course been? One can address this question in several ways. The following paragraphs describe how the present course has been evaluated. On institutional course evaluations, students evaluate courses and instructors based on various criteria, and are invited to offer any comments. Over the past five years, students' average ratings of this course have been 4.5-4.7 on a scale of 1-5 (1 being least favorable, and 5 most favorable), making it one of the most highly-rated courses in the department in which it is offered. Comments have been quite positive. Surveys have been administered to students at the beginning and end of this course for several years. The surveys, students' responses to them, and analyses of the results have been described by Kearney (2004b).

Beyond numerical ratings, students" comments provide more information about what they learn from the course. Comments were submitted anonymously. Following are some of the key areas of learning that the course addresses, as supported by students' comments:

1. A healthcare professional needs to provide care to a wide diversity of people, and for optimal care there should be a good rapport between the patient and the provider. The ability to establish such a rapport, or "comfort level," cannot be taught in a classroom, but is one of the outcomes of SL experiences.

2. The distribution of medications is certainly one of the central responsibilities of pharmacists, but if positive health outcomes (maintenance and improvement of health) are the ultimate goal of pharmaceutical care, pharmacists need to keep this broader goal in mind. SL experiences can help them develop the habit of thinking broadly in this way.

3. If health professionals are to provide optimal care, they must understand not only drug therapy, but also their patients. This requires capacities such as patience and empathy, and the ability to listen. Such abilities are best fostered and learned not in a classroom, but through experiences and practice, such as are gained through SL.

4. Understanding diverse cultures is a critical ability for healthcare providers today. Classroom discussion of this topic, coupled with experiences in their SL work, contributes to the development of students' cultural competence. Several students indicated that they had appreciated and learned from the discussion of cultural diversity in the classroom, as well as learning from their SL work experiences.

5. Finally, one of the key educational advantages of SL is that it brings students into regular contact with "real life," and often a side of life which is less "rosy" than what most of us experience regularly; and that it asks students to reflect, think, and learn about how to improve the situations they encounter. Ordinarily, in the classroom, teachers try to organize material in such a way that students can learn it well. However, unlike this, life is often 'messy' and unorganized. SL has the ability to help students learn experientially from such real-life encounters, and so can better prepare them for these realities when they enter their profession.

The spontaneous and anonymous (and therefore presumably honest) comments of the students point to some of the probable learning outcomes of this course. They are, of course, somewhat subjective, but the students' ability to articulate what they have learned, without any specific prompting, suggests that the course has succeeded in terms of leading students to the desired learning outcomes.

Another way to evaluate success is to consider what the educational institution does to support Service-Learning. MCPHS allocates part of the work-time of two professionals to overseeing and teaching the Service-Learning program at its Worcester and Manchester campuses. In 2005 the College unveiled a new three-year strategic plan which explicitly noted the importance of community outreach and Service-Learning programs as part of its mission (Massachusetts College of Pharmacy and Health Sciences, 2005). These are indicators of the institution's support for Service-Learning.

Support for the program also comes from outside the institution. The Accreditation Council for Pharmacy Education has accredited the MCPHS-Worcester curriculum with the understanding that the Service-Learning course meets part of the Council's requirement for Experiential Education for pharmacy students. Locally, community partners from the organizations where students do their SL work have offered overwhelmingly positive feedback about the program. Several of them have invited the Director of Service-Learning to serve on their advisory boards, strengthening the ties between these organizations and the College. These community links affirm the value of the SL program in the eyes of the local community.

Discussion

In order to justify its inclusion in the healthcare education curriculum, SL must contribute to the achievement of educational objectives that are essential for healthcare professionals. These outcomes include goals that lead to the education of community-focused healthcare professionals, an emphasis which is increasingly understood to be critical in healthcare education. The value of SL in the education of healthcare professionals is recognized by many, and is supported by various organizations, such as Community-Campus Partnerships for Health. Within pharmacy education, many educators value and practice SL, and the American Journal of Pharmaceutical Education recently dedicated a special issue to this topic (Kearney, 2005a).

One way to assess the value of Service-Learning is to consider it with reference to generally accepted educational outcomes. The American Association of Colleges of Pharmacy specifies the expected outcomes for the education of pharmacists, and many of these could be applied broadly to the education of a wide range of healthcare professionals (Center for the Advancement of Pharmaceutical Education [CAPE], 1998). The SL course described above contributes to the achievement of many of these outcomes, especially the following: The CAPE outcomes speak of the ability to exhibit "empathy and a caring attitude," abilities developed in the SL course. They highlight the importance of critical thinking, being open to new ideas and avoiding ethnocentricity; all these, as noted above, are addressed in the course.

One of the outcomes reads, "Demonstrate the ability to place health care and professional issues within appropriate [contextual] frameworks, and demonstrate sensitivity and tolerance within a culturally diverse society." The SL experiences of students in this course bring them face-to-face with many of these contextual issues--especially the cultural, social and political frameworks--and the seminar addresses the issue of cultural diversity. Another outcome reads, "Demonstrate an appreciation of the obligation to participate in efforts to help individuals and to improve society and the health care system." This course is based on the premise that it is important for healthcare students and professionals to help individuals, and aims to reinforce the conviction that professionals have the ability and responsibility to improve the society in which they live and work.

By examining this course in reference to these educational outcomes established by the pharmacy profession, this paper has demonstrated how this course successfully contributes to the achievement of these outcomes. This validates SL as a pedagogy within healthcare education. Even though these comments are somewhat subjective, the students' ability to articulate specific learning outcomes, unprompted and without the prospect of receiving any reward for what they might say, suggests that the reported outcomes are real. Beyond the achievement of educational outcomes by students, the support of the educational institution that offers this course is a mark of success. As noted above, the college supports SL by the allocation of personnel, and by including SL in its strategic goals. Finally, the comments and actions of community partners indicate their positive assessment of the SL program. They are pleased to have students contributing to their organizations, and they have shown an interest in collaborating with college personnel in various ways, not just through the SL course.

References

Bodenhom, N., Jackson, A.D. and Farrell, R. (2005). Increasing personal cultural awareness through discussions with international students. International Journal of Teaching and Learning in Higher Education 17, 63-68

Connors, K. & Seifer, S. (1997). Service-Learning in health professions education: What is Service-Learning, and why now? In A Guide for Developing Community-Responsive Models in Health Professions Education (pp. 11-17). San Francisco: Community-Campus Partnerships for Health, UCSF Center for the Health Professions

Center for the Advancement of Pharmaceutical Education (CAPE) of the American Association of Colleges of Pharmacy (1998). Educational Outcomes. Retrieved October 28, 2005, from http://www.aacp.org/Docs/MainNavigation/ForDeans/5763_CAPEoutcomes.pdf

Galanti, G.-A. (2005). Cultural Diversity in Healthcare. Retrieved October 28, 2005 from http://ggalanti.com/

Indritz, M.E.S., & Hadsall, R.S. (1999) An active learning approach to teaching service at one college of pharmacy. American Journal of Pharmaceutical Education, 63, 126-131

Jones, R.M., Royeen, M., & Crabtree, J.L. (2003). Cultural considerations in patient assessment. In Jones, R.M., & Rospond, R.M., Patient Assessment in Pharmacy Practice (pp. 9-20). Baltimore: Lippincott Williams & Wilkins

Kearney, K.R. (2004a). Service-Learning in pharmacy education. In American Journal of Phannaceutical Education, 68 (1). Retrieved October 28, 2005, from http://www.ajpe.org/view.asp?art=aj680126&pdf=yes

Kearney, K.R. (2004b). Students' self-assessment of learning through Service-Learning. In American Journal of Pharmaceutical Education, 68 (1). Retrieved October 28, 2005, from http://www.ajpe.org/view.asp?art=aj680129&pdf=yes

Massachusetts College of Pharmacy and Health Sciences (2005). A strategic plan for the college. Retrieved November 4, 2005, from http://intranet.mcphs.edu/planning/docs/StratFINAL.pdf

Zweber, A. (2002) Cultural competence in pharmacy practice, American Journal of Pharmaceutical Education 66, 172-176

Kevin R. Kearney, Massachusetts College of Pharmacy and Health Sciences

Kevin R. Kearney, Ph.D., is Associate Professor of Biochemistry and Director of Service-Learning
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Author:Kearney, Kevin R.
Publication:Academic Exchange Quarterly
Date:Sep 22, 2006
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