Dr. Pat Royal is an assistant professor in the Department of Health Services and Information Management in the School of Allied Health at East Carolina University. Prior to this appointment, Dr. Royal worked in the Department of Family Medicine at East Carolina University in the Interdisciplinary Rural Health Training Program. During this tenure, she worked with students involved in service learning in the rural communities, and has based this paper on the experiences gained during that time period.

Drs. Bonita Sasnett and Annette Greer both have gained experience in service learning while working with the Interdisciplinary Rural Health Program at East Carolina University. Dr. Sasnett is currently an assistant professor in the Department of Health Services and Information Management in the School of Allied Health. Dr. Greer is an assistant professor in the Office of Clinical Skills and Assessments with the Brody School of Medicine.

Abstract    

Students participating in the interdisciplinary rural health training program through East Carolina University have received invaluable community experience through service learning initiatives in rural underserved communities.  Knowledge and collaboration skills and civic responsibilities have been gained through the exposure of educational opportunities provided by the rural communities.  Participants in the program from various disciplines formed teams to address the barriers to health care delivery for rural communities. Implementation of community projects based on the unmet needs of the area provided the students and the community opportunities to learn from one another.  The students have bridged the gap between the university and the community creating a solidified relationship founded on mutual respect for each other.

 “The SPLE [Social, Political, Legal, Economic] seminar.  WOW! That really opened my eyes to the culture in rural North Carolina. Like I have stated in my journal, it made me want to offer anything I could to help them.”
HIM Student

The Service-Learning Impact of Interdisciplinary Students in Rural Communities

An important aspect of the need for interdisciplinary service learning results from a shift in the population demographics. This shift resulted in an increased number of older adults, and many of these individuals are living with chronic conditions. These health concerns warrant holistic healthcare services that can be best provided by an interdisciplinary team with exposure to the service delivery model (Betz et al, 1998). Primary care management of chronic conditions has relied on the use of interdisciplinary teams to address patient needs. Due to the complexities of such conditions as HIV, diabetes, cancer, and end-stage renal disease, the interdisciplinary team approach has been used for treatment of patients with these conditions (Hyer, et al., 2000). Service learning addresses needs of the chronic disease population and health promotion. Students are not only educated regarding the disease process and treatment, but also understand the community’s identified needs, issues, and problems, which may not necessarily be reflective of the educating institution. Service learning fosters civic and social responsibility, and allows students to apply the knowledge to real world situations (Clark, 99).

“This was a true learning experience for me about the needs in the rural schools regarding health education.” Nursing Student.

Attributes

Service learning in combination with interdisciplinary teams enhances existing curriculum in medical education. As teamwork becomes more recognized in the health industry, the need to educate health care professionals in interdisciplinary teams becomes more prominent (Cooper et al., 2001). An underlying assumption for this training model is that learning together will lead to working together, and enhance understanding of problems and solutions. As future healthcare providers, students learn to respect and trust people from other disciplines and accept responsibility and accountability for their own actions (Walker et al., 1998).

Students and communities benefit from service learning. The community members have an increased knowledge of resources available and feel more empowered with their experiences with students. Interdisciplinary students participating in service learning are able to provide patients with a holistic plan of care. The communities reap the benefits from being able to receive healthcare information from an array of disciplines.

Models

Collaboration between service learning and interdisciplinary training enhances the total package of healthcare education for students. Since the Interdisciplinary Health Education Panel, which was formed in 1996 by the National League for Nursing, several model interdisciplinary training programs have emerged, many of them focusing on community healthcare (Walker et al., 1998). Many universities are now incorporating interdisciplinary and service learning into its established curriculums. In 1991, two of Wisconsin’s medical schools were awarded grants to initiate an Area Health Education Center for the purpose of promoting interdisciplinary educational models for health professions students in a family practice center. The student disciplines involved in the program were nursing, social work, and medicine. The students were asked to work collaboratively to develop, implement, and test an alternate model of education by providing team-oriented care in a community-based setting. The students were exposed to health promotion and disease prevention, and encouraged to solve healthcare problems with a team- focused direction. The benefits included students gaining a much clearer understanding and appreciation of the roles, values, and experiences of other disciplines. The learners gained hands on practice with information gathering, processing, and developing plans of care. The patients benefited from the extra consideration given by the students, and the increased time devoted to patients to discuss their needs with healthcare providers (Lough et al., 1996).

 With the financial support of a grant sponsored by W.K. Kellogg Foundation, East Tennessee State University implemented a new program in 1991 entitled “Community Partnerships”. This model was designed to emphasize community-based, interactive learning and interdisciplinary team problem solving.  Students from the disciplines of nursing, medicine, and public health formed interdisciplinary teams to better meet the health needs of residents in rural Tennessee. The objectives for the student education included teaching them the importance of understanding the social, economic, and political structure of this community (Virgin and Goodrow, 1997).

In 1994, Cleveland State University, in collaboration with the Case Western Reserve University Schools of Medicine and Nursing, began a three credit hour elective focusing on interdisciplinary healthcare field experiences. Students from the disciplines of nursing, medicine, health administration, nursing, nutrition, social work, and epidemiology/biostatistics participated in the training program as a way to expand continuous improvement in education. Students participated in community-based, experiential learning by forming interdisciplinary teams and working in healthcare organizations to contribute to the continuous improvement of those agencies. Students completed projects and an analysis of team effectiveness. Based on the comments from the students and the program evaluation, the goal of Cleveland State and Case Western Reserve Universities is for the interdisciplinary training program to become a part of the core curriculum for all health profession students (Gordon et al, 1996).

Another university to join forces with Area Health Education Centers and community partners was East Carolina University.  The Interdisciplinary Rural Health Training Program began in 1993 in a rural community of North Carolina. The Brody School of Medicine in collaboration with Eastern Area Health Education Center recognized the need to recruit and retain healthcare professionals for rural underserved areas. Through their joint venture along with community partnerships and other health science schools, the program became one of the first interdisciplinary training programs in the country and continued to promote education in rural healthcare delivery for over twelve years.

Duplin County was selected as the first training site due to the area’s unique healthcare needs which included geographic and cultural barriers, inadequate insurance coverage, and limited resources and services. Throughout the past twelve years, the Duplin site grew to include two surrounding counties. Growth in the program continued which enabled the establishment of three other sites. 

Curricula

Although, the curriculum for the interdisciplinary program was modified slightly during the past years, the basic principal remained unchanged, thereby keeping the main components intact. Core components of the curriculum were case conferences, community visits, and community projects. Case conferences were team-oriented and intended to promote interdisciplinary plans of care for patients. The case conference process began with a community agency identifying a chronically ill patient. The student team reviewed the patient’s chart and conpleted a home visit to the patient. A holistic plan of care was developed and presented to preceptors, students, and the patient/family. Community visits involved students exploring different agencies and businesses in the community to examine healthcare problems associated with work environments. Community projects helped students identify and address unmet needs in the community. Students worked in teams to develop a project that would benefit the rural community.

To fully engage the community in guiding the needs of the projects, a community advisory council was established. Representatives from various disciplines and agencies were able to provide direction to students regarding the particular healthcare concerns in their areas. The advisory council members stayed abreast of the student numbers and disciplines by attending meetings established by regional site coordinators. Finally, members from the council attended student case conferences to promote interdisciplinary plans of care for the community members.

“Today we completed our community project at the elementary school. Our goal was to teach the kids about diabetes and ways to prevent type II diabetes. The day was very fulfilling and rewarding.  If our team made a difference in one child’s life and hopefully prevented at least one case of diabetes, it was all worthwhile.”
Pharm D student

One of the most beneficial components of the curriculum for both students and the community was the completion of community projects. To make a lasting impact in the community, most of the projects were longitudinal and have continued to provide the community with service learning benefits. The project selection for each site was based on the area’s specific needs and advisory council’s recommendations. Once the community needs were identified, student team members negotiated the project’s focus based on their education and skill level.

During the past twelve years of student participation in community projects, certain themes emerged which indicated the most prevalent needs in each region. The themes were divided into four subgroups and are listed in more detail below.  The four main categories for projects were: (a) Health Promotion, (b) Educational Materials, (c) Community Outreach, and (d) Health Training and Needs Assessments.

Health Promotion

Community projects focused on prevention and diagnosis of certain diseases. All regions contributed to the health promotion category. However, depending on the greatest needs in the community, the type of health promotion varied from community to community.  The initial community project focusing on health promotion began in 1995 in Duplin County.  The interdisciplinary students participated in an on-site health fair at a local industry. The employees of the company were screened for disease such as high blood pressure and diabetes.  With the success of this event, another major industry recognized need for employees to be screened. This particular industry was the largest in Duplin County and screened several hundred employees in 1996.  From this health fair a database was created and kept on file for follow up screenings of the employees who had indicators for certain diseases. Throughout the next several years, health fairs continued in the Duplin area and other regions. Students soon began to participate in health fairs targeted for seniors, middle school-aged children, and women’s health issues such as breast cancer awareness. With the rising increase in breast cancer, over ten community projects involving various disciplines emerged to create a driving force for women to conduct monthly self- exams and visit their health care providers on a routine basis. From 1996 through 2000 BCAP (Breast Cancer Awareness Project) became an important contribution from students to the women in the community. Outcomes and benefits from the BCAP projects included an increase in mammograms, and training for lay people to become certified in the education of self breast exams.

Another area of focus for health promotion was in the diabetic population. The prevalence of diabetes in eastern North Carolina has climbed steadily over the past few years (Valeriano et al, 2002).  Since diabetes is a primary contributor to renal disease, the need for dialysis has increased as well. To make the community more aware of the signs and symptoms of diabetes, the interdisciplinary program joined forces with a local dialysis unit and the National Kidney Foundation to promote the KEEP (Kidney Early Evaluation Program) screening. This screening occurred in three different counties as well as on-site industries. Interdisciplinary students from numerous disciplines helped contribute to the success of the KEEP screening in Duplin and surrounding counties. From 2001 through 2003, students assisted in screening more than 400 residents for risk factors related to diabetes.

“Today was a fantastic day. The children really seem to enjoy our puppet show. I feel like we did a good job getting our objective across to the kids. I have learned a great deal and feel that this has been a valuable experience for me.”
Nursing Student

Education Materials
Projects have primarily focused on brochures and handouts for the community related to a particular health care concern. Depending on the advice of the community advisory council and various agencies in the region, students presented an assortment of information pertinent to the needs of each region. For example, in Duplin County, since the increased prevalence of diabetes was a growing concern, numerous brochures were created to educate the community regarding this disease. Brochures examining foot care, safe walking trails to promote exercise, medication safety, and diet were a few of the informational handouts created to address the needs of the diabetic patient. Other informational materials focused on domestic violence, rape, baby bottle tooth decay, fetal alcohol syndrome, stress management, and sexually transmitted diseases. These brochures were placed at various community agencies such as health departments, home health agencies, medical clinics and dialysis units. Other educational materials included resource directories and guides listing phone numbers for hospitals, medical clinics, poison control, cooperate extension, and domestic violence shelters.   This idea stemmed from problems that arose during a major flood occurring in 1999 in eastern North Carolina. Due to the devastation of the flood, residents were faced with questions related to water safety, mold and mildew, and road closings. The resource guide provided a quick reference for phone beneficial numbers in a time of crisis.

Community Outreach and Health Training

This category of community projects addressed the recognition of various needs by communities, and ways in which health training in the area could occur. This type of outreach took place in church settings, nursing homes, schools, senior centers, and migrant workers’ campsites. The focal point of these projects was reaching out in the community and targeting a particular setting that may otherwise have been overlooked in addressing health care needs. Such projects as in-services examining agriculture related injuries and pesticide poisoning, medication in-services to seniors, and providing education on advance directives and living wills to nursing home patients are types of projects that were completed in this category. The goal was to provide a specific community group with knowledge needed to address health concerns relevant to the particular setting. The interdisciplinary students completed community needs visits and developed projects that focused on providing education and training to these targeted groups.

Project Utility

The student projects provided communities with resources that otherwise would not be available. Citizens of the different regions were able to utilize projects by incorporating them into their community educational programs. Such projects as health screenings afforded residents with opportunities to determine risk indicators for various diseases, and alert the resident to the need for follow up screenings. Also due to lack of health care providers in rural areas, students served as the extra manpower needed to initiate screenings.  Needs assessments provided the area with specific information required to apply for grant funding to address certain health concerns.  By having the students complete the assessment, the community was able to use the information for guidance in providing care and education in the future. 

Student Benefits

Service learning has greatly impacted the interdisciplinary students by providing them with hands on experience in rural communities. Through the completion of projects, home visits, and community visits, students received an education founded in the community. Didactic education can be acquired in the classroom setting, but the application can only be achieved in the real world.  Interdisciplinary students build communication and collaboration skills with other disciplines while reaping rewards of contributing to a rural community.  Exposure to the community and other disciplines enhances the student’s overall education and learning process. Participants are challenged to problem solve and think critically, assessing all dimensions of an issue while learning from their experiences. Additionally, students are exposed to the social, political, and economic make up of the community and the impact these factors have on health care delivery.  The learners form a partnership with the community which supports educational endeavors and forges a bond that strengthens the alliance between health care practitioners and patient relations.

The real benefits for students are evident in the following comments. These quotes were made by students who participated in community-based projects during their internships with the Interdisciplinary Rural Health Training Program in Duplin County, NC. These quotes were taken from student journals and course feedback forms.

“It was really nice to see the finished product of the community project and also see the impact that we had on the kids.”
HIM Student

Community Benefits

As mentioned earlier, the community greatly benefits from the resources that interdisciplinary students bring to the region. These resources range from community projects to providing health care services to residents. The community acquires new knowledge and fresh ideas to overcome the challenges of delivering health care in rural settings. Service learning creates the potential for students to form partnerships with the community and to improve the quality of care in the area.

Conclusion

Service learning in rural communities with interdisciplinary teams enhances the education of health care professionals. The student is more cognizant of the barriers to health care delivery and receptive to the collaboration of other disciplines. Service learning provides the student with real world experiences and bridges the gap between the university and the rural communities. Students, communities, and educational institutions become collaborators in preparing for future health providers.

References

Betz, L.C., Raynor, O.,  & Turman, J. (1998). Use of an interdisciplinary team for clinical instruction. Nurse Educator, 23(1), 32-37.

Clark, P.G. (1999). Service-learning education in community-academic partnerships: implications for interdisciplinary geriatric training in the health professions. Educational Gerontology, 25, 641-660.

Cooper, H., Carlisle, C., Gibbs, T., & Watkins, C. (2001). Developing an evidence base for interdisciplinary learning: a systematic review. Journal of Advanced Nursing, 35(2), 228-237.

Gordon, P.R., Carlson, L., Chessman, A., Kundrat, M. L., Morahan, P.S., & Headrick, L.A. (1996). A multisite collaborative for the development of interdisciplinary education in continuous improvement for health professions students. Academic Medicine, 71(9), 973-978.

Hyer, K., Fairchild, S., Abraham, I., Mezey, M., & Fulmer, T. (2000). Measuring attitudes related to interdisciplinary training: revisiting the Heinemann, Schmitt, and Farrell ‘attitudes toward health care teams’ scale. Journal of Interprofessional Care, 14(3), 249-258.

Lough, M.A., Schmidt, K., Swain, G., Naughton, T., Leshan, L., Blackburn, J., & Mancuso, P. (1996). An interdisciplinary educational model for health professions students in a family practice center. Nurse Educator, 21(1), 27-31.

Valeriano, E., Reaves, J., Porterfield D., & Munzo-Plaza, C. Diabetes in North Carolina: A Summary Report-2002. North Carolina Division of Public Health. North Carolina Department of Health and Human Services. Raleigh, North Carolina.

Virgin, S. & Goodrow, B. (1997). A community crossword puzzle. An interdisciplinary approach  to community-based learning. Nursing and Health Care Perspective, 18(6), 302-307.

Walker, P.H., Baldwin, D., Fitzpatrick, J.J., Ryan, S., Bulger, R., DeBasio, N., Hanson, C., Harvan, R., Johnson-Pawlson, J., Lacey, B., Ladden, M.J., McLaughlin, L.S.,  Sluyter, D., & Vanselow, N. (1998). Building community: developing skills for interprofessional and health   professions education and relationship-centered care. Journal of  Gerontological Nursing,  24(3). 45-49.

The curriculum and program exemplars showcased here have been contributed by educators in the field. Many were originally featured in Community Works Journal, or in Connecting Service-Learning to the Curriculum. We thank our contributing educators and their students for making their work available to us. Please contact us if you would like to share and 'exemplar" or reflection of your own. CWI EXEMPLARS: Exemplars Main l K-8 Exemplars l 9-12 Exemplars l Higher Ed Exemplars l Community Based Exemplars l Community Works Journal