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Evolution and assessment of a service-learning nutrition pharmacy program
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Currents in Pharmacy Teaching and Learning ] (2014) ]]]–]]]
Research
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Evolution and assessment of a service-learning nutrition pharmacy program$ Wesley Nuffer, PharmD, BCPS, CDEa,*, Jodi K. Duke, MPHb a
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO b Department of Health Systems, Management and Policy, Colorado School of Public Health, Aurora, CO
Abstract Introduction: A service-learning nutrition course was established for pharmacy students at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in 1999. This program has been sustained and improved upon as an integral part of the curriculum over the last 13 years. Methods: A partnership was established with Aurora Public Schools to allow first-year pharmacy students to deliver a series of nutrition and healthy lifestyle lessons to children in third, fourth, and fifth grade in 28 classrooms across four different elementary schools. Results: Pharmacy students reported satisfaction with lesson delivery, team dynamics, and improved communication, listening, and leadership skills. Elementary school teachers reported satisfaction with the lessons and increased learning and enjoyment from their students. Teachers scored pharmacy students high (average of 95.4% and 94.3%) across two semesters for their performance. Conclusions: A pharmacy student service-learning program has been maintained and improved upon, meeting goals for both the pharmacy students as well as elementary school children. This partnership is perceived as valuable from all parties involved. r 2014 Elsevier Inc. All rights reserved.
Keywords: Service-learning; Pharmacy; Curriculum; Nutrition; Healthy lifestyles
Introduction The utilization of service-learning as a teaching and learning methodology within health professions education has been well described in the literature.1–5 The National Youth Leadership Council defines service-learning as a philosophy, pedagogy, and model for community development that is used as an instructional strategy to meet learning goals and/or content standards.6 It is defined by ☆
This program was partially funded through the generous support of the Wal-Mart Foundation. * Corresponding author: Wesley Nuffer, PharmD, BCPS, CDE, Department of Clinical Pharmacy, 12850 E. Montview Blvd., C238-V20, Aurora, CO 80045. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.04.016 1877-1297/r 2014 Elsevier Inc. All rights reserved.
the Community Campus Partnerships for Health as a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided. Further learning from the experience includes students identifying the connection between their service and their academic coursework, and their roles as citizens.7 Within pharmacy education, the Accreditation Council for Pharmacy Education (ACPE), the national accrediting body for Doctor of Pharmacy (PharmD) degree programs, published Standards 2007.8 These standards recognize the use of appropriate and relevant servicelearning activities as components of experiential coursework in the PharmD curriculum.8 Three necessary criteria
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have been identified for a successful academic servicelearning experience: relevant and meaningful service within the community, purposeful civic learning, and enhanced academic learning.9 Nutrition education is well suited for service-learning activities. National data continue to show an alarming increase in obesity across the United States, a condition that contributes to a myriad of chronic illnesses including the top three national causes of death: heart disease, cancer, and stroke. Research has established a strong link between poor childhood nutrition habits and adult obesity.10–14 The American Academy of Pediatrics 2011 guidelines for cardiovascular risk reduction in children identify that childrenʼs diet habits can be safely improved with teaching, and, while the evidence is mixed on the success of these interventions, nutrition and diet education should be part of a strategy for preventing cardiovascular disease in children at high risk.12 Educating children about making positive, healthy nutrition choices early in life may lead to better eating behaviors and diminish the likelihood of obesity in adulthood.13,14 The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) first implemented a service-learning nutrition course in 1999. The description and formation of this initial course has been previously described in the literature.15 Over the last 13 years, the service-learning course has evolved and been adapted based on changing resources and needs of both the SSPPS and the partnering elementary schools. This paper describes the expansion and evolution of a service-learning partnership between the SSPPS and four elementary schools. Design Program logistics The original purpose for this service-learning course has been previously described in an evaluation of 173 first-year pharmacy students (P1s) who participated in seven visits to one of two elementary schools over a two-year period.15 The current iteration of the course has incorporated the service-learning activities into the required first-year experiential course, with the entire class of 160 P1s broken into teams of five to six students and each team being assigned to one of 28 classrooms of third, fourth, or fifth grade students in one of four public schools located close to the SSPPS campus (Fig. 1). Partnering elementary schools were selected based on proximity and need. Importantly, of the approximately 900 elementary school children engaged in this program annually an average of 92% qualify as low income. Each pharmacy student team is responsible for delivering lessons developed in advance by nutritional experts to their assigned classroom during both semesters of the P1 year. Lessons, held one afternoon per week during a dedicated 45-minute time block, usually conclude with a healthy snack that is prepared by and shared among the
pharmacy and elementary students. Each student team meets with its class on alternate weeks; hence, half of the P1 class is engaged in an elementary school classroom one week and the other half attends the following week. The lessons require various supplies, both consumables used for the healthy snack, as well as accompanying preparation tools (knives, napkins, cutting boards, etc.) and props that are used for specific lessons, such as laboratory supplies for the dissolution lesson. These supplies are organized into storage bins at the SSPPS. Each student team is responsible for checking-out supplies prior to the lesson and returning them after the lessonʼs completion. While one student is a designated team leader for each lesson, all members of the team are expected to actively engage and participate in teaching the class for every lesson. Experiential education component The initial service-learning nutrition education elective course established at the SSPPS occurred during one semester and encompassed six visits to elementary school classrooms, grades 1 through 5. It has evolved into a longitudinal experiential education activity spanning both semesters of the first year in the entry-level PharmD curriculum and focuses on grades 3 through 5. Despite its various iterations, it has been a required component of the P1 curriculum for every student since its inception. Although changes have occurred over time, the strong connection between the desired learning outcomes of the PharmD curriculum and the learning opportunities afforded via service-learning activities has contributed to it being maintained as a valuable required component. Starting with the initial design of the PharmD curriculum in the late 1990s, clear themes were identified that translated into fundamental skills that an entry-level pharmacist should possess. Communication skills, in particular, have continuously been identified as highly valued within the practice of pharmacy.16,17 Developing these communication skills may present challenges to novice pharmacy students for several reasons. First, there is a subset of students for whom English is not their primary spoken language. Second, students who tend toward introversion can be reluctant to engage in conversation, making the notion of having to routinely engage and counsel patients very intimidating. Third, students who lack confidence in recalling and providing salient information in a logical and understandable manner may represent an additional barrier. As such, allowing P1 students to communicate relatively lowcomplexity information to a more approachable, less intimidating population fosters the incremental development of tools, skills, and strategies that can be carried forward to higher levels of the curriculum. An additional beneficial educational theme within this service-learning course is the opportunity to take advanced concepts about health and nutrition and translate them into a lesson plan that can be delivered to and understood by elementary children at the
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SSPPS
Parklane
35
160
35
Montview
3rd grade class
4th grade class
3rd grade class
4th grade class
3rd grade class
4th grade class
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5th grade class
5th grade class
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Laredo
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Paris
3rd grade class
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3rd grade class
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4th grade class
4th grade class
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4th grade class
5th grade class 5th grade class 5th grade class
SSPPS = Skaggs School of Pharmacy & Pharmaceutical Sciences Numbers reflect pharmacy students’ distribution across schools
Fig. 1. Distribution of pharmacy students into four elementary classrooms (Parklane, Montview, Laredo, and Paris Public Schools).
third- through fifth-grade levels. Implicitly, this incorporates the use of lay language appropriate to children and the development of a lesson that will maintain the childrenʼs attention while simultaneously being fun and educational. There are obvious parallels between these approaches and those likely to be effective in patients who have low levels of education and/or cognition. Reflection The longitudinal aspect of these lessons, viz., delivery across the entire first year of the curriculum, allows the students to reflect on their performance and allows for the opportunity to improve any number of skills as progression occurs through the year. This is a critical aspect of the service-learning concept, i.e., purposeful reflection on the activity, in this case, with the intention of identifying value in educating the children and learning within the experience, as well as self-identifying areas for future improvement. Each
student is required to submit a pre-activity reflection writing prior to the first elementary school visit. This assignment is designed to encourage the students to explore any biases, expectations, or beliefs that they have about service-learning as well as their assigned neighborhood, school, or classroom. It also allows them to explore their thoughts about the role pharmacists play in overall health beliefs and attitudes of others. Course facilitators trained in service-learning methodology review these submissions and respond with feedback and follow-up questions aimed at guiding each student through an introspective process. A post-activity reflection paper is required after one semester of classroom visits has been completed. This paper is designed to help the students reflect upon their original beliefs and biases and to evaluate any changes that occurred in their perspectives through their engagement in the experience. As part of this process, each team of students is also expected to work closely with the elementary teacher to identify difficulties they encountered during lesson
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delivery and to develop strategies to overcome these challenges in subsequent visits. Together, the reflection papers and consistent teacher–student interactions are expected to lead to (i) improved individual and team performance, (ii) better communication skills, and (iii) a higher level of confidence when delivering health-related information. Nutritional lessons The initial six nutrition modules designed and delivered to children upon the programʼs inception have been modified and improved upon as the program has evolved. In approximately 2003, the SSPPS formed a partnership with the Integrated Nutrition Education Program (INEP), a University of Colorado School of Medicine program primarily funded by a grant from the United States Department of Agriculture. INEP developed an evidence-based nutrition curriculum for the K-fifth grades and established an infrastructure to deliver nutrition supplies and curriculum books to elementary schools throughout most of the Denver metropolitan area and some key rural areas, at its height reaching nearly 50,000 students. Through this partnership, the SSPPS utilized the INEP nutrition resources and infrastructure, allowing the pharmacy students to teach the nutrition lessons to partnering schools. The overall number of lessons provided to the students increased to 19 (from the original six), providing a much greater depth and breadth of information taught to the children across the year. INEP also developed age-appropriate variations on the lesson “themes,” such that each grade level would receive education on the same topics, but teaching strategies and lesson formats would vary depending on the elementary studentsʼ grade level. This helped the school children perceive each lesson as “new,” regardless of whether they received similar information the previous year. Lessons were based on Aurora Public Schoolsʼ math and science standards, incorporating fun activities and hands-on active components and ending with a healthy snack that was jointly prepared by students and the children and shared across the class. The economic downturns experienced in the United States in 2008 resulted in loss of INEP funding. Consequently, the service-learning program was forced to substantially downsize. The SSPPS decided to continue the service-learning component of the experiential curriculum, taking responsibility for all organization and coordination of the lessons. Faculty and support staff within the Office of Experiential Programs interviewed pharmacy students who had just completed the INEP curriculum in an effort to identify which lessons were the best to maintain and carry forward. Based on this feedback, the number of lessons was reduced to ten. Curricular redesign In 2010, the SSPPS began to plan a curricular redesign that was launched in Fall 2012. One of the specific goals of this redesign was to directly link various components of the
didactic curriculum with the skills and application of this knowledge. The goals were to allow students to apply newly acquired skills and knowledge from their classroom lessons in experiential settings on or close to the time they learned them. The intention was that application of skills and knowledge in actual practice settings would serve to reinforce the learning and show the relevance of the information to the students. Within the service-learning program, this led to a further evolution of the lessons. While the nutrition-focused theme was maintained, the lessons expanded to incorporate new topics more directly linked to the practice of pharmacy and identified as having a high importance by the elementary school teachers and staff. These included lessons about allergies and why they occur, a dissolution lesson focused on dissolving solid materials into water (correlating to how medications work in the body) and a new smoking-avoidance lesson. These new lessons served to more directly align the service-learning activities with the didactic education pharmacy students received at the time (Fig. 2). Methods Pharmacy student survey As part of on-going quality-assurance analyses of the P1 experiential course, a course evaluation is distributed at the end of each academic year to all first-year students. The specific evaluation used for this paper was established in 2009 and has been used since that time. Thirteen questions relevant to the service-learning lessons were identified from the 2012 course evaluation and analyzed to assess perceptions regarding the program. All data analyses were performed using JMP 5.0.1.2 (JMP Statistical Discovery Software, SAS Institute). These questions, as well as the teacherʼs survey mentioned later, were designated exempt by the universityʼs institutional review board. The selected questions sought to gauge studentsʼ understanding of the link between the elementary school lessons and the pharmacy curriculum, as well as to quantify perceived benefits pharmacy students received from delivering the lessons to school children. Other questions assessed the individual dynamics within the team environment, the studentʼs perception of the teacher, and their role within the program (Tables 1 and 2). Elementary teacher feedback Faculty and staff from the SSPPS meet with elementary school teachers at the end of each academic year to collect feedback and reflect upon the yearʼs activities. These informal “debriefs” are extremely valuable for qualityassurance changes and as a mechanism to further solidify the partnership between the public schools and the School of Pharmacy. During debriefs conducted in 2012, one group of teachers expressed interest in more directly evaluating the pharmacy studentsʼ performance. Exploring this during
W. Nuffer, J.K. Duke / Currents in Pharmacy Teaching and Learning ] (2014) ]]]–]]] month August
Pharmacy curriculum course topic Interprofessional Course orientaon development
lesson
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Fall
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Elementary school topic
1
October
Mechanisms of Disease
Allergens
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Self-care 1
Various self-care topics
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Pharmacotherapy 1
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Pharmacotherapy 1
Nutrion/obesity prevenon Osteopenia/osteoporosis
March April
Pharmaceucs Self-care 2; Pharmacotherapy 1
Dissoluon of drugs Smoking cessaon
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Introducon to classrooms What is a pharmacist? Allergies Self-care topic
5
Good fats, bad fats
6 7 8 9
Bone health My plate Dissoluon Smoking avoidance
Fig. 2. Curricular alignment with service-learning lessons.
meetings across all four schools, it became clear that the large majority of teachers were in favor of providing this formalized feedback. Recognizing the value this feedback would have to pharmacy students, a graded group evaluation component was added to the service-learning course, where teachers would provide summative feedback and essentially grade their team of pharmacy students (Table 3). This assessment was evaluated, revised, and approved by the schoolʼs experiential education committee prior to dissemination. The score generated from the assessment was integrated into each studentʼs overall grade in the course. Additionally, a brief questionnaire was designed and distributed to all teachers for completion during the 2013 debrief sessions. The development and refinement of this questionnaire was done using a small focus group of teachers prior to dissemination. The questionnaire allowed documentation of teachersʼ impressions regarding the service-learning program (Table 4).
Results The 13 questions from the 2012 P1 student survey data are reported in Tables 1 and 2. One hundred and twenty-one students completed the survey, representing a 77% response rate. All questions utilized a five point Likert scale and were anonymously scored by the responding students. Results reflect the percentage of students that selected each Likert value. On average, students were positive in reporting their relationship with the elementary school teachers, their perceptions of the teacherʼs feelings about the lessons and the teacherʼs level of engagement during the lessonsʼ delivery. Pharmacy student team dynamics were also reported positively. Students reported strong group dynamics where disagreements were easily solved; 100% of student responders rated “agree” or “strongly agree” about feeling comfortable sharing their ideas and opinions within the group. Table 2 focused on the studentsʼ perceptions of their
Table 1 P1 students' perceptions regarding their service-learning activities, 2012 Reported value (% respondents)
My elementary school teacher is easy to work with My elementary school teacher seems genuinely happy to have pharmacy students teaching nutrition My elementary school teacher is engaged in the nutrition lessons and helps with discipline when necessary Each group member contributed equally to the nutrition activities in the elementary classroom My team was able to have respectful, constructive, and productive discussion(s) about any issues we disagreed upon I feel comfortable openly sharing my ideas and opinions with the group N ¼ 121. Survey response rate was 77%.
Strongly agree
Strongly Agree Undecided Disagree disagree
77 68
20 25
2 4
0 2
1 1
58
35
5
1
1
75
22
2
1
0
67
29
4
0
0
70
30
0
0
0
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Table 2 P1 students' perceptions of their skills changing as a result of the service-learning activities, 2012 Reported value (% responses) A Not at Definitely Probably Somewhat little all I I I I
feel more confident as a leader am a better communicator am a better listener have improved my ability to effectively communicate with an individual who has low English-language proficiency My patient-counseling skills have improved (examples: I ask open-ended questions, check that my message was received accurately) I am better able to manage unexpected problems I am more confident in my ability to collaborate with my colleagues
32 26 30 20
42 39 39 30
22 26 24 29
4 9 6 7
0 0 1 14
16
34
28
15
7
30 36
35 39
19 20
14 5
2 0
N ¼ 121. Survey response rate was 77%.
skills improving through delivery of these service-learning lessons. Pharmacy students reported that these lessons increased their communication skills, their listening skills and their leadership ability. Many also reported learning how to communicate with individuals with low English literacy, and the majority reported an increase in patient-counseling, problem-solving, and working as an effective team. Elementary school teachersʼ evaluations of teams were obtained to assess how students performed in their activities. All 28 teachers completed the evaluation, resulting in a 100% response rate, for both spring and fall semesters (Table 3). Overall, the average team score assigned to students for the fall semester 2012 was a 95.3% (range: 84.5–100%) and for the spring semester 2013 the average team score was 94.3% (range: 82.1–100%). Across all classrooms, all but two student teams received grades in the A range (90–100%) for both semesters; one team received a 86.8% for spring and one team received a 84.5% for fall and 82.1% for spring (Table 3). The teachersʼ survey data are presented in Table 4. Quantitative answers were based on an eight point Likert scale. These data are reported in numbers of teachers that selected each Likert value, and also showed positive responses. The majority of teachers reported value with the lessons, and reported their elementary students enjoyed the lessons and received learning from them. Pharmacy students were perceived as being professional, knowledgeable and most were reported as coming into the classrooms organized and prepared to deliver lessons. Qualitative comments were also collected and evaluated for common themes; these comments are available upon request from the author. All but one teacher reported wanting to participate in the service-learning lessons next year; that teacher provided comment that she was moving out of the school district, and did value the program. Discussion Service-learning activities in health professions programs have been established as showing value to the
students, educating them on various skills they will need as a health care professional while demonstrating the positive effects that these programs can have on the populations who receive the services.1,9,18 In the elementary Table 3 Summative team grades assigned to pharmacy student teams by elementary school teachers for 2012–2013 school year School Parklane
Montview
Laredo
Paris
Classroom grade
Fall semester team (%)
Spring semester team (%)
Third grade Third grade Third grade Fourth grade Fifth grade Fifth grade Fourth grade Fourth grade Fourth grade Fifth grade Fifth grade Fifth grade Third grade Third grade Third grade Fourth grade Fourth grade Fourth grade Fourth grade Third grade Third grade Third grade Fourth grade Fourth grade Fourth grade Fifth grade Fifth grade Fifth grade
100 95 91.9 96.9 100 98.8 84.5 95 91.3 99.2 90 99.7 100 98 95 97.8 100 96.2 91 92 95 95 95 93.4 90.7 96.5 97.1 92.5
95.9 97.3 98.3 99.1 99.7 98.9 82.1 97.1 91.3 99.7 97.2 94.3 100 97.8 95.3 98.8 95.3 86.8 98 98.9 97.2 95 98.2 98.5 95.6 98.2 98.6 94.3
Grading completed through a rubric questionnaire, available from author upon request.
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Table 4 Elementary school teachers' perceptions regarding the service-learning lessons, 2013 Reported value (no of respondents)
What value do you place on the collaboration between the School of Pharmacy and your classroom? Please rate the elementary students' learning from the lessons delivered Please rate the elementary students' enjoyment from the lessons delivered How were the pharmacy students' professionalism and responsibilities with the lessons? How would you rate the pharmacy students' knowledge of the lessons they delivered? How were the pharmacy students' preparation and organization in delivering lessons? How likely will you be to participate in the program next year?
8 (Highest)
7
1 6 5 4 3 2 (Lowest)
9 7 16 19 16 14 18
12 9 6 5 9 9 6
3 7 5 2 0 2 1
3 2 0 1 1 1 1
0 0 1 0 0 0 1
0 1 0 1 2 1 0
0 2 0 0 0 1 0
1 0 0 0 0 0 1
N ¼ 28. Survey response rate was 100%. 8-Point Likert scale defined as 8 ¼ excellent and 1 ¼ poor except for the last two questions, where 8 ¼ extremely likely and 1 ¼ unlikely.
school environment, nutritional education in particular is valuable, as obesity in the United States and the comorbid conditions that accompany obesity continue to be a top priority for education and prevention by national organizations, such as Healthy People 2020.19 This manuscript describes the further development and evolution of a service-learning nutrition component within the entry-level doctor of pharmacy program at the SSPPS. The primary goals of this program are to facilitate the development of communication and patient education skills for first year students while teaching them the value of servicelearning activities. This is accomplished by requiring students to utilize information and concepts obtained in their didactic coursework in the delivery of education to third, fourth, and fifth grade children in elementary school classrooms. The benefits of this program extend beyond those obtained by the pharmacy students, as the nutrition and healthy lifestyle themes of the lessons should help educate the elementary school children on selecting better food options and making healthy choices. With 92% of these children qualifying as low-income and 90% falling into ethnic categories that are disproportionately affected by obesity and chronic diseases, the importance of these lessons becomes even more apparent. Qualitative data demonstrate that the pharmacy students form strong bonds with these children during the year they work together, so there may be secondary benefits to these youngsters, as the pharmacy students serve as role models and mentors, instilling the idea that college and higher education could be a future option. There are currently several initiatives being taken by the School of Pharmacy to bring some of the children to campus and give them a “taste” of pharmacy school for a day, to further develop this idea of pursuing a career and education after high school. Better assessment tools are also currently being developed in an effort to quantitatively measure the impact that these lessons and mentorship may have on these children. Pharmacy students are required to reflect on these experiences and identify the perceived importance of service-learning within a health professions curriculum. In this process, they gain insight on how to (i) give back to
communities and (ii) self-evaluate their performance through reflection, an important step in building the foundation of life-long learning. Reflection is a theme that continues to be woven throughout the next three years of the curriculum, so this is an important foundational exercise for students to complete. It is also consistent with the Universityʼs values of demonstrating that health professionals need to give back to the communities they serve. Teachers from the elementary schools are very supportive of the partnership that has been established and grown across the past 14 years, as seen with the self-reported survey data as well as the objective team scoring assigned for the first time in the 2012–2013 school year. Allowing these teachers to have an impact on the pharmacy studentʼs final grade in the course gives further validation to the importance of these lessons and allows for students to receive feedback and to learn from these teachers, all who are well-versed in education. The fact that these summative grades were high (averages of 95.3% for fall and 94.3% for spring with only two teachers assigning less than a 90% team grade for either semester) reinforces the positive perspectives of the teachers for the studentsʼ team performance. Qualitative comments from the elementary school teachers have likewise been positive, both those collected from written surveys as well as the spoken comments given every year at the debrief sessions, where pharmacy faculty meet to discuss how the lessons went and collect feedback for quality improvement. Teachers speak to how much the elementary school students enjoyed the lessons, how well their pharmacy students performed, and overall what a worthwhile partnership the program was. As mentioned previously, a successful service-learning program should show the three components: relevant and meaningful service within the community, purposeful civic learning, and enhanced academic learning. The elementary school teacher data show that the services offered by pharmacy students are relevant and meaningful both to the teachers and to the children within their classroom. The nutrition and healthy lifestyle focus of the lessons have been clearly documented as relevant topics for children within this age group and have been shown to help modify behaviors
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that contribute to chronic disease. Studentsʼ self-reported learning shows that the lessons are, indeed, enhancing their academic learning, specifically in areas of communication, listening, problem solving, group dynamics, and leadership. The data presented include only the last year of student perceptions due to the assessment tool changing slightly year to year, but consistent trends have been observed with student perceptions since the programʼs inception. Accreditation standards for Schools and Colleges of Pharmacy in the United States are very clear about students within the Doctor of Pharmacy program having extensive opportunities for direct patient interaction throughout all years of the curriculum.7 This can be somewhat challenging in the first year because students do not yet have the requisite didactic knowledge and skill set to meaningfully contribute in pharmacy practice environments. This servicelearning program affords the opportunity for this interaction in a less threatening environment and helps build fundamental skills of communication, listening, and reflection while allowing students to apply their acquired learning to educate children about healthy eating and healthy lifestyles. A program of this scope is not successful without a large amount of logistic support put into it. Coordinating with four different elementary schools to schedule lessons across an entire school year involves numerous conversations and e-mails from all parties involved. The Pharmacy School has to coordinate around elementary school events, such as standardized testing and special holiday parties. Logistics such as where pharmacy students should meet when entering the elementary schools, what badges to display, what entrance to come in, and how best to collect feedback from teachers after the lessons all need to be decided upon. These elementary schools are all on the traditional track, so there is very little contact during the summertime after the spring classes have let out. The fact that this program continues to receive strong support from both the elementary schools involved as well as the School of Pharmacy after 14 years demonstrates that the delivery of the lessons is worth the logistical work undertaken and that partnerships can be established for the betterment of all individuals involved. Conclusions A service-learning program within the Doctor of Pharmacy curriculum has been maintained and improved upon, accomplishing numerous goals both for the pharmacy students delivering the education as well as to the children who receive the lessons. This partnership is perceived as valuable from both the pharmacy studentsʼ perspective as well as that from the teachers and their students. Acknowledgments The authors would like to recognize Dr. Catherine Jarvis and Dr. David Thompson for their invaluable help with reviewing and editing this manuscript.
References 1. Seifer SD. Service-learning: community-campus partnerships for health professions education. Acad Med. 1998;73(3): 273–277. 2. Leung AY, Chan SS, Kwan CW, et al. Service learning in medical and nursing training: a randomized controlled trial. Adv Health Sci Educ Theory Pract. 2012;17(4):529–545. 3. Heiss CJ, Goldberg LR, Weddig J, et al. Service-learning in dietetics courses: a benefit to the community and an opportunity for students to gain dietetics-related experience. J Acad Nutr Diet. 2012;112(10):1524–1527. 4. Rosenkranz RR. Service-learning in higher education relevant to the promotion of physical activity, healthful eating, and prevention of obesity. Int J Prev Med. 2012;3(10):672–681. 5. Brondani MA. Teaching social responsibility through community service-learning in predoctoral dental education. J Dent Educ. 2012;76(5):609–619. 6. National Youth Leadership Council. K-12 Service-Learning Standards for Quality Practice. 〈http://nylc.org/sites/nylc.org/files/ files/Standards_Oct2009-web.pdf〉; 2008 Accessed April 4, 2014. 7. Community-Campus Partnerships for Health. Definition of Service Learning. 〈http://depts.washington.edu/ccph/servicelear ningres.html〉 Accessed April 4, 2014. 8. Accreditation Council for Pharmacy Education. Accreditation Standards for Continuing Pharmacy Education Adopted June 2007. 〈https://www.acpe-accredit.org/pdf/CPE_Standards_Final. pdf〉 Accessed April 4, 2014. 9. Howard J. Michigan Journal of Community Service Learning: Service-Learning Course Design Workbook. Michigan: Ginsberg Center; 2001. 10. Charney E, Goodman HC, McBride M, et al. Childhood antecedents of adult obesity. Do chubby infants become obese adults? N Engl J Med. 1976;295(1):6–9. 11. Court JM. Childhood obesity. Med J Aust. 1976;1(4 Spec suppl):5–6. 12. American Academy of Pediatrics. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011; 128(5):S213–S256. 13. Nicklas TA, Baranowski T, Cullen KW, et al. Eating patterns, dietary quality and obesity. J Am Coll Nutr. 2001;20(6): 599–608. 14. Parsons TJ, Power C, Logan S, et al. Childhood predictors of adult obesity: a systematic review. Int J Obes Relat Metab Disord. 1999;23(suppl 8):S1–S107. 15. Jarvis C, James VL, Giles J, et al. Nutrition and nurturing: a service-learning nutrition pharmacy course. Am J Pharm Educ. 2004;68(2): Article 43. 16. Thompson DC, Nuffer W, Brown K. Characteristics valued by the pharmacy practice community when hiring a recently graduated pharmacist. Am J Pharm Educ. 2012;76(9): Article 170. 17. Vlasses PH, Patel N, Rouse MJ, et al. Employer expectations of new pharmacy graduates: implications for the pharmacy degree accreditation standards. Am J Pharm Educ. 2013;77(3): Article 47. 18. Matthews RL, Parker B, Drake S. Healthy ager: an interprofessional, service-learning, town-and-gown partnership. Nurs Educ Perspect. 2012;33(3):162–165. 19. Healthy People.Gov. Healthy People 2020. 〈http://www. healthypeople.gov/2020/default.aspx〉 Accessed April 4, 2014.
Currents in Pharmacy Teaching and Learning ] (2014) ]]]–]]]
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http://www.pharmacyteaching.com
Evolution and assessment of a service-learning nutrition pharmacy program$ Wesley Nuffer, PharmD, BCPS, CDEa,*, Jodi K. Duke, MPHb a
Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy & Pharmaceutical Sciences, Aurora, CO b Department of Health Systems, Management and Policy, Colorado School of Public Health, Aurora, CO
Abstract Introduction: A service-learning nutrition course was established for pharmacy students at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in 1999. This program has been sustained and improved upon as an integral part of the curriculum over the last 13 years. Methods: A partnership was established with Aurora Public Schools to allow first-year pharmacy students to deliver a series of nutrition and healthy lifestyle lessons to children in third, fourth, and fifth grade in 28 classrooms across four different elementary schools. Results: Pharmacy students reported satisfaction with lesson delivery, team dynamics, and improved communication, listening, and leadership skills. Elementary school teachers reported satisfaction with the lessons and increased learning and enjoyment from their students. Teachers scored pharmacy students high (average of 95.4% and 94.3%) across two semesters for their performance. Conclusions: A pharmacy student service-learning program has been maintained and improved upon, meeting goals for both the pharmacy students as well as elementary school children. This partnership is perceived as valuable from all parties involved. r 2014 Elsevier Inc. All rights reserved.
Keywords: Service-learning; Pharmacy; Curriculum; Nutrition; Healthy lifestyles
Introduction The utilization of service-learning as a teaching and learning methodology within health professions education has been well described in the literature.1–5 The National Youth Leadership Council defines service-learning as a philosophy, pedagogy, and model for community development that is used as an instructional strategy to meet learning goals and/or content standards.6 It is defined by ☆
This program was partially funded through the generous support of the Wal-Mart Foundation. * Corresponding author: Wesley Nuffer, PharmD, BCPS, CDE, Department of Clinical Pharmacy, 12850 E. Montview Blvd., C238-V20, Aurora, CO 80045. E-mail: [email protected] http://dx.doi.org/10.1016/j.cptl.2014.04.016 1877-1297/r 2014 Elsevier Inc. All rights reserved.
the Community Campus Partnerships for Health as a structured learning experience that combines community service with preparation and reflection. Students engaged in service-learning provide community service in response to community-identified concerns and learn about the context in which service is provided. Further learning from the experience includes students identifying the connection between their service and their academic coursework, and their roles as citizens.7 Within pharmacy education, the Accreditation Council for Pharmacy Education (ACPE), the national accrediting body for Doctor of Pharmacy (PharmD) degree programs, published Standards 2007.8 These standards recognize the use of appropriate and relevant servicelearning activities as components of experiential coursework in the PharmD curriculum.8 Three necessary criteria
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have been identified for a successful academic servicelearning experience: relevant and meaningful service within the community, purposeful civic learning, and enhanced academic learning.9 Nutrition education is well suited for service-learning activities. National data continue to show an alarming increase in obesity across the United States, a condition that contributes to a myriad of chronic illnesses including the top three national causes of death: heart disease, cancer, and stroke. Research has established a strong link between poor childhood nutrition habits and adult obesity.10–14 The American Academy of Pediatrics 2011 guidelines for cardiovascular risk reduction in children identify that childrenʼs diet habits can be safely improved with teaching, and, while the evidence is mixed on the success of these interventions, nutrition and diet education should be part of a strategy for preventing cardiovascular disease in children at high risk.12 Educating children about making positive, healthy nutrition choices early in life may lead to better eating behaviors and diminish the likelihood of obesity in adulthood.13,14 The University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) first implemented a service-learning nutrition course in 1999. The description and formation of this initial course has been previously described in the literature.15 Over the last 13 years, the service-learning course has evolved and been adapted based on changing resources and needs of both the SSPPS and the partnering elementary schools. This paper describes the expansion and evolution of a service-learning partnership between the SSPPS and four elementary schools. Design Program logistics The original purpose for this service-learning course has been previously described in an evaluation of 173 first-year pharmacy students (P1s) who participated in seven visits to one of two elementary schools over a two-year period.15 The current iteration of the course has incorporated the service-learning activities into the required first-year experiential course, with the entire class of 160 P1s broken into teams of five to six students and each team being assigned to one of 28 classrooms of third, fourth, or fifth grade students in one of four public schools located close to the SSPPS campus (Fig. 1). Partnering elementary schools were selected based on proximity and need. Importantly, of the approximately 900 elementary school children engaged in this program annually an average of 92% qualify as low income. Each pharmacy student team is responsible for delivering lessons developed in advance by nutritional experts to their assigned classroom during both semesters of the P1 year. Lessons, held one afternoon per week during a dedicated 45-minute time block, usually conclude with a healthy snack that is prepared by and shared among the
pharmacy and elementary students. Each student team meets with its class on alternate weeks; hence, half of the P1 class is engaged in an elementary school classroom one week and the other half attends the following week. The lessons require various supplies, both consumables used for the healthy snack, as well as accompanying preparation tools (knives, napkins, cutting boards, etc.) and props that are used for specific lessons, such as laboratory supplies for the dissolution lesson. These supplies are organized into storage bins at the SSPPS. Each student team is responsible for checking-out supplies prior to the lesson and returning them after the lessonʼs completion. While one student is a designated team leader for each lesson, all members of the team are expected to actively engage and participate in teaching the class for every lesson. Experiential education component The initial service-learning nutrition education elective course established at the SSPPS occurred during one semester and encompassed six visits to elementary school classrooms, grades 1 through 5. It has evolved into a longitudinal experiential education activity spanning both semesters of the first year in the entry-level PharmD curriculum and focuses on grades 3 through 5. Despite its various iterations, it has been a required component of the P1 curriculum for every student since its inception. Although changes have occurred over time, the strong connection between the desired learning outcomes of the PharmD curriculum and the learning opportunities afforded via service-learning activities has contributed to it being maintained as a valuable required component. Starting with the initial design of the PharmD curriculum in the late 1990s, clear themes were identified that translated into fundamental skills that an entry-level pharmacist should possess. Communication skills, in particular, have continuously been identified as highly valued within the practice of pharmacy.16,17 Developing these communication skills may present challenges to novice pharmacy students for several reasons. First, there is a subset of students for whom English is not their primary spoken language. Second, students who tend toward introversion can be reluctant to engage in conversation, making the notion of having to routinely engage and counsel patients very intimidating. Third, students who lack confidence in recalling and providing salient information in a logical and understandable manner may represent an additional barrier. As such, allowing P1 students to communicate relatively lowcomplexity information to a more approachable, less intimidating population fosters the incremental development of tools, skills, and strategies that can be carried forward to higher levels of the curriculum. An additional beneficial educational theme within this service-learning course is the opportunity to take advanced concepts about health and nutrition and translate them into a lesson plan that can be delivered to and understood by elementary children at the
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Parklane
35
160
35
Montview
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4th grade class
3rd grade class
4th grade class
3rd grade class
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5th grade class
5th grade class
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Laredo
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Paris
3rd grade class
3rd grade class
3rd grade class
3rd grade class
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4th grade class
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4th grade class
5th grade class 5th grade class 5th grade class
SSPPS = Skaggs School of Pharmacy & Pharmaceutical Sciences Numbers reflect pharmacy students’ distribution across schools
Fig. 1. Distribution of pharmacy students into four elementary classrooms (Parklane, Montview, Laredo, and Paris Public Schools).
third- through fifth-grade levels. Implicitly, this incorporates the use of lay language appropriate to children and the development of a lesson that will maintain the childrenʼs attention while simultaneously being fun and educational. There are obvious parallels between these approaches and those likely to be effective in patients who have low levels of education and/or cognition. Reflection The longitudinal aspect of these lessons, viz., delivery across the entire first year of the curriculum, allows the students to reflect on their performance and allows for the opportunity to improve any number of skills as progression occurs through the year. This is a critical aspect of the service-learning concept, i.e., purposeful reflection on the activity, in this case, with the intention of identifying value in educating the children and learning within the experience, as well as self-identifying areas for future improvement. Each
student is required to submit a pre-activity reflection writing prior to the first elementary school visit. This assignment is designed to encourage the students to explore any biases, expectations, or beliefs that they have about service-learning as well as their assigned neighborhood, school, or classroom. It also allows them to explore their thoughts about the role pharmacists play in overall health beliefs and attitudes of others. Course facilitators trained in service-learning methodology review these submissions and respond with feedback and follow-up questions aimed at guiding each student through an introspective process. A post-activity reflection paper is required after one semester of classroom visits has been completed. This paper is designed to help the students reflect upon their original beliefs and biases and to evaluate any changes that occurred in their perspectives through their engagement in the experience. As part of this process, each team of students is also expected to work closely with the elementary teacher to identify difficulties they encountered during lesson
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delivery and to develop strategies to overcome these challenges in subsequent visits. Together, the reflection papers and consistent teacher–student interactions are expected to lead to (i) improved individual and team performance, (ii) better communication skills, and (iii) a higher level of confidence when delivering health-related information. Nutritional lessons The initial six nutrition modules designed and delivered to children upon the programʼs inception have been modified and improved upon as the program has evolved. In approximately 2003, the SSPPS formed a partnership with the Integrated Nutrition Education Program (INEP), a University of Colorado School of Medicine program primarily funded by a grant from the United States Department of Agriculture. INEP developed an evidence-based nutrition curriculum for the K-fifth grades and established an infrastructure to deliver nutrition supplies and curriculum books to elementary schools throughout most of the Denver metropolitan area and some key rural areas, at its height reaching nearly 50,000 students. Through this partnership, the SSPPS utilized the INEP nutrition resources and infrastructure, allowing the pharmacy students to teach the nutrition lessons to partnering schools. The overall number of lessons provided to the students increased to 19 (from the original six), providing a much greater depth and breadth of information taught to the children across the year. INEP also developed age-appropriate variations on the lesson “themes,” such that each grade level would receive education on the same topics, but teaching strategies and lesson formats would vary depending on the elementary studentsʼ grade level. This helped the school children perceive each lesson as “new,” regardless of whether they received similar information the previous year. Lessons were based on Aurora Public Schoolsʼ math and science standards, incorporating fun activities and hands-on active components and ending with a healthy snack that was jointly prepared by students and the children and shared across the class. The economic downturns experienced in the United States in 2008 resulted in loss of INEP funding. Consequently, the service-learning program was forced to substantially downsize. The SSPPS decided to continue the service-learning component of the experiential curriculum, taking responsibility for all organization and coordination of the lessons. Faculty and support staff within the Office of Experiential Programs interviewed pharmacy students who had just completed the INEP curriculum in an effort to identify which lessons were the best to maintain and carry forward. Based on this feedback, the number of lessons was reduced to ten. Curricular redesign In 2010, the SSPPS began to plan a curricular redesign that was launched in Fall 2012. One of the specific goals of this redesign was to directly link various components of the
didactic curriculum with the skills and application of this knowledge. The goals were to allow students to apply newly acquired skills and knowledge from their classroom lessons in experiential settings on or close to the time they learned them. The intention was that application of skills and knowledge in actual practice settings would serve to reinforce the learning and show the relevance of the information to the students. Within the service-learning program, this led to a further evolution of the lessons. While the nutrition-focused theme was maintained, the lessons expanded to incorporate new topics more directly linked to the practice of pharmacy and identified as having a high importance by the elementary school teachers and staff. These included lessons about allergies and why they occur, a dissolution lesson focused on dissolving solid materials into water (correlating to how medications work in the body) and a new smoking-avoidance lesson. These new lessons served to more directly align the service-learning activities with the didactic education pharmacy students received at the time (Fig. 2). Methods Pharmacy student survey As part of on-going quality-assurance analyses of the P1 experiential course, a course evaluation is distributed at the end of each academic year to all first-year students. The specific evaluation used for this paper was established in 2009 and has been used since that time. Thirteen questions relevant to the service-learning lessons were identified from the 2012 course evaluation and analyzed to assess perceptions regarding the program. All data analyses were performed using JMP 5.0.1.2 (JMP Statistical Discovery Software, SAS Institute). These questions, as well as the teacherʼs survey mentioned later, were designated exempt by the universityʼs institutional review board. The selected questions sought to gauge studentsʼ understanding of the link between the elementary school lessons and the pharmacy curriculum, as well as to quantify perceived benefits pharmacy students received from delivering the lessons to school children. Other questions assessed the individual dynamics within the team environment, the studentʼs perception of the teacher, and their role within the program (Tables 1 and 2). Elementary teacher feedback Faculty and staff from the SSPPS meet with elementary school teachers at the end of each academic year to collect feedback and reflect upon the yearʼs activities. These informal “debriefs” are extremely valuable for qualityassurance changes and as a mechanism to further solidify the partnership between the public schools and the School of Pharmacy. During debriefs conducted in 2012, one group of teachers expressed interest in more directly evaluating the pharmacy studentsʼ performance. Exploring this during
W. Nuffer, J.K. Duke / Currents in Pharmacy Teaching and Learning ] (2014) ]]]–]]] month August
Pharmacy curriculum course topic Interprofessional Course orientaon development
lesson
Spring
Fall
September
Elementary school topic
1
October
Mechanisms of Disease
Allergens
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Self-care 1
Various self-care topics
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Pharmacotherapy 1
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Pharmacotherapy 1
Nutrion/obesity prevenon Osteopenia/osteoporosis
March April
Pharmaceucs Self-care 2; Pharmacotherapy 1
Dissoluon of drugs Smoking cessaon
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2 3 4
Introducon to classrooms What is a pharmacist? Allergies Self-care topic
5
Good fats, bad fats
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Bone health My plate Dissoluon Smoking avoidance
Fig. 2. Curricular alignment with service-learning lessons.
meetings across all four schools, it became clear that the large majority of teachers were in favor of providing this formalized feedback. Recognizing the value this feedback would have to pharmacy students, a graded group evaluation component was added to the service-learning course, where teachers would provide summative feedback and essentially grade their team of pharmacy students (Table 3). This assessment was evaluated, revised, and approved by the schoolʼs experiential education committee prior to dissemination. The score generated from the assessment was integrated into each studentʼs overall grade in the course. Additionally, a brief questionnaire was designed and distributed to all teachers for completion during the 2013 debrief sessions. The development and refinement of this questionnaire was done using a small focus group of teachers prior to dissemination. The questionnaire allowed documentation of teachersʼ impressions regarding the service-learning program (Table 4).
Results The 13 questions from the 2012 P1 student survey data are reported in Tables 1 and 2. One hundred and twenty-one students completed the survey, representing a 77% response rate. All questions utilized a five point Likert scale and were anonymously scored by the responding students. Results reflect the percentage of students that selected each Likert value. On average, students were positive in reporting their relationship with the elementary school teachers, their perceptions of the teacherʼs feelings about the lessons and the teacherʼs level of engagement during the lessonsʼ delivery. Pharmacy student team dynamics were also reported positively. Students reported strong group dynamics where disagreements were easily solved; 100% of student responders rated “agree” or “strongly agree” about feeling comfortable sharing their ideas and opinions within the group. Table 2 focused on the studentsʼ perceptions of their
Table 1 P1 students' perceptions regarding their service-learning activities, 2012 Reported value (% respondents)
My elementary school teacher is easy to work with My elementary school teacher seems genuinely happy to have pharmacy students teaching nutrition My elementary school teacher is engaged in the nutrition lessons and helps with discipline when necessary Each group member contributed equally to the nutrition activities in the elementary classroom My team was able to have respectful, constructive, and productive discussion(s) about any issues we disagreed upon I feel comfortable openly sharing my ideas and opinions with the group N ¼ 121. Survey response rate was 77%.
Strongly agree
Strongly Agree Undecided Disagree disagree
77 68
20 25
2 4
0 2
1 1
58
35
5
1
1
75
22
2
1
0
67
29
4
0
0
70
30
0
0
0
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Table 2 P1 students' perceptions of their skills changing as a result of the service-learning activities, 2012 Reported value (% responses) A Not at Definitely Probably Somewhat little all I I I I
feel more confident as a leader am a better communicator am a better listener have improved my ability to effectively communicate with an individual who has low English-language proficiency My patient-counseling skills have improved (examples: I ask open-ended questions, check that my message was received accurately) I am better able to manage unexpected problems I am more confident in my ability to collaborate with my colleagues
32 26 30 20
42 39 39 30
22 26 24 29
4 9 6 7
0 0 1 14
16
34
28
15
7
30 36
35 39
19 20
14 5
2 0
N ¼ 121. Survey response rate was 77%.
skills improving through delivery of these service-learning lessons. Pharmacy students reported that these lessons increased their communication skills, their listening skills and their leadership ability. Many also reported learning how to communicate with individuals with low English literacy, and the majority reported an increase in patient-counseling, problem-solving, and working as an effective team. Elementary school teachersʼ evaluations of teams were obtained to assess how students performed in their activities. All 28 teachers completed the evaluation, resulting in a 100% response rate, for both spring and fall semesters (Table 3). Overall, the average team score assigned to students for the fall semester 2012 was a 95.3% (range: 84.5–100%) and for the spring semester 2013 the average team score was 94.3% (range: 82.1–100%). Across all classrooms, all but two student teams received grades in the A range (90–100%) for both semesters; one team received a 86.8% for spring and one team received a 84.5% for fall and 82.1% for spring (Table 3). The teachersʼ survey data are presented in Table 4. Quantitative answers were based on an eight point Likert scale. These data are reported in numbers of teachers that selected each Likert value, and also showed positive responses. The majority of teachers reported value with the lessons, and reported their elementary students enjoyed the lessons and received learning from them. Pharmacy students were perceived as being professional, knowledgeable and most were reported as coming into the classrooms organized and prepared to deliver lessons. Qualitative comments were also collected and evaluated for common themes; these comments are available upon request from the author. All but one teacher reported wanting to participate in the service-learning lessons next year; that teacher provided comment that she was moving out of the school district, and did value the program. Discussion Service-learning activities in health professions programs have been established as showing value to the
students, educating them on various skills they will need as a health care professional while demonstrating the positive effects that these programs can have on the populations who receive the services.1,9,18 In the elementary Table 3 Summative team grades assigned to pharmacy student teams by elementary school teachers for 2012–2013 school year School Parklane
Montview
Laredo
Paris
Classroom grade
Fall semester team (%)
Spring semester team (%)
Third grade Third grade Third grade Fourth grade Fifth grade Fifth grade Fourth grade Fourth grade Fourth grade Fifth grade Fifth grade Fifth grade Third grade Third grade Third grade Fourth grade Fourth grade Fourth grade Fourth grade Third grade Third grade Third grade Fourth grade Fourth grade Fourth grade Fifth grade Fifth grade Fifth grade
100 95 91.9 96.9 100 98.8 84.5 95 91.3 99.2 90 99.7 100 98 95 97.8 100 96.2 91 92 95 95 95 93.4 90.7 96.5 97.1 92.5
95.9 97.3 98.3 99.1 99.7 98.9 82.1 97.1 91.3 99.7 97.2 94.3 100 97.8 95.3 98.8 95.3 86.8 98 98.9 97.2 95 98.2 98.5 95.6 98.2 98.6 94.3
Grading completed through a rubric questionnaire, available from author upon request.
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Table 4 Elementary school teachers' perceptions regarding the service-learning lessons, 2013 Reported value (no of respondents)
What value do you place on the collaboration between the School of Pharmacy and your classroom? Please rate the elementary students' learning from the lessons delivered Please rate the elementary students' enjoyment from the lessons delivered How were the pharmacy students' professionalism and responsibilities with the lessons? How would you rate the pharmacy students' knowledge of the lessons they delivered? How were the pharmacy students' preparation and organization in delivering lessons? How likely will you be to participate in the program next year?
8 (Highest)
7
1 6 5 4 3 2 (Lowest)
9 7 16 19 16 14 18
12 9 6 5 9 9 6
3 7 5 2 0 2 1
3 2 0 1 1 1 1
0 0 1 0 0 0 1
0 1 0 1 2 1 0
0 2 0 0 0 1 0
1 0 0 0 0 0 1
N ¼ 28. Survey response rate was 100%. 8-Point Likert scale defined as 8 ¼ excellent and 1 ¼ poor except for the last two questions, where 8 ¼ extremely likely and 1 ¼ unlikely.
school environment, nutritional education in particular is valuable, as obesity in the United States and the comorbid conditions that accompany obesity continue to be a top priority for education and prevention by national organizations, such as Healthy People 2020.19 This manuscript describes the further development and evolution of a service-learning nutrition component within the entry-level doctor of pharmacy program at the SSPPS. The primary goals of this program are to facilitate the development of communication and patient education skills for first year students while teaching them the value of servicelearning activities. This is accomplished by requiring students to utilize information and concepts obtained in their didactic coursework in the delivery of education to third, fourth, and fifth grade children in elementary school classrooms. The benefits of this program extend beyond those obtained by the pharmacy students, as the nutrition and healthy lifestyle themes of the lessons should help educate the elementary school children on selecting better food options and making healthy choices. With 92% of these children qualifying as low-income and 90% falling into ethnic categories that are disproportionately affected by obesity and chronic diseases, the importance of these lessons becomes even more apparent. Qualitative data demonstrate that the pharmacy students form strong bonds with these children during the year they work together, so there may be secondary benefits to these youngsters, as the pharmacy students serve as role models and mentors, instilling the idea that college and higher education could be a future option. There are currently several initiatives being taken by the School of Pharmacy to bring some of the children to campus and give them a “taste” of pharmacy school for a day, to further develop this idea of pursuing a career and education after high school. Better assessment tools are also currently being developed in an effort to quantitatively measure the impact that these lessons and mentorship may have on these children. Pharmacy students are required to reflect on these experiences and identify the perceived importance of service-learning within a health professions curriculum. In this process, they gain insight on how to (i) give back to
communities and (ii) self-evaluate their performance through reflection, an important step in building the foundation of life-long learning. Reflection is a theme that continues to be woven throughout the next three years of the curriculum, so this is an important foundational exercise for students to complete. It is also consistent with the Universityʼs values of demonstrating that health professionals need to give back to the communities they serve. Teachers from the elementary schools are very supportive of the partnership that has been established and grown across the past 14 years, as seen with the self-reported survey data as well as the objective team scoring assigned for the first time in the 2012–2013 school year. Allowing these teachers to have an impact on the pharmacy studentʼs final grade in the course gives further validation to the importance of these lessons and allows for students to receive feedback and to learn from these teachers, all who are well-versed in education. The fact that these summative grades were high (averages of 95.3% for fall and 94.3% for spring with only two teachers assigning less than a 90% team grade for either semester) reinforces the positive perspectives of the teachers for the studentsʼ team performance. Qualitative comments from the elementary school teachers have likewise been positive, both those collected from written surveys as well as the spoken comments given every year at the debrief sessions, where pharmacy faculty meet to discuss how the lessons went and collect feedback for quality improvement. Teachers speak to how much the elementary school students enjoyed the lessons, how well their pharmacy students performed, and overall what a worthwhile partnership the program was. As mentioned previously, a successful service-learning program should show the three components: relevant and meaningful service within the community, purposeful civic learning, and enhanced academic learning. The elementary school teacher data show that the services offered by pharmacy students are relevant and meaningful both to the teachers and to the children within their classroom. The nutrition and healthy lifestyle focus of the lessons have been clearly documented as relevant topics for children within this age group and have been shown to help modify behaviors
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that contribute to chronic disease. Studentsʼ self-reported learning shows that the lessons are, indeed, enhancing their academic learning, specifically in areas of communication, listening, problem solving, group dynamics, and leadership. The data presented include only the last year of student perceptions due to the assessment tool changing slightly year to year, but consistent trends have been observed with student perceptions since the programʼs inception. Accreditation standards for Schools and Colleges of Pharmacy in the United States are very clear about students within the Doctor of Pharmacy program having extensive opportunities for direct patient interaction throughout all years of the curriculum.7 This can be somewhat challenging in the first year because students do not yet have the requisite didactic knowledge and skill set to meaningfully contribute in pharmacy practice environments. This servicelearning program affords the opportunity for this interaction in a less threatening environment and helps build fundamental skills of communication, listening, and reflection while allowing students to apply their acquired learning to educate children about healthy eating and healthy lifestyles. A program of this scope is not successful without a large amount of logistic support put into it. Coordinating with four different elementary schools to schedule lessons across an entire school year involves numerous conversations and e-mails from all parties involved. The Pharmacy School has to coordinate around elementary school events, such as standardized testing and special holiday parties. Logistics such as where pharmacy students should meet when entering the elementary schools, what badges to display, what entrance to come in, and how best to collect feedback from teachers after the lessons all need to be decided upon. These elementary schools are all on the traditional track, so there is very little contact during the summertime after the spring classes have let out. The fact that this program continues to receive strong support from both the elementary schools involved as well as the School of Pharmacy after 14 years demonstrates that the delivery of the lessons is worth the logistical work undertaken and that partnerships can be established for the betterment of all individuals involved. Conclusions A service-learning program within the Doctor of Pharmacy curriculum has been maintained and improved upon, accomplishing numerous goals both for the pharmacy students delivering the education as well as to the children who receive the lessons. This partnership is perceived as valuable from both the pharmacy studentsʼ perspective as well as that from the teachers and their students. Acknowledgments The authors would like to recognize Dr. Catherine Jarvis and Dr. David Thompson for their invaluable help with reviewing and editing this manuscript.
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