Service Learning Comes of Age

On a chilly Friday night last November, the area underneath the wide expanse of the Jefferson Street Bridge in downtown Nashville became a scene of rare opportunity for the city’s homeless. The Salvation Army Soup Wagon was there, as could be expected, but some friends had joined them. A foldout table was set up nearby, lit by car headlights and manned by students of the Vanderbilt University School of Medicine and School of Nursing. It was a student service project in the form of a vaccine clinic offering tetanus and pneumonia vaccine, as well as the much-needed annual flu shot.

Jerry Michael Howard was one of the first volunteers to receive the vaccines. He wanted all three and said he appreciated the students for providing such a valuable service. “We don’t have a choice, and this environment can be tough on your health,” Howard said.

The white coats worn by Vanderbilt medical and nursing students were bright spots in that cold night. Volunteers bringing protective vaccines to the homeless where they all too often eat, sleep and live provide a service with incredibly high benefits for the community. To be viewed as a “bright spot” because of their participation in a community service project is a great thing for students, but the students themselves hold a different view. They see projects like this as one of the best opportunities to learn.

Elizabeth Morse, a family nurse practitioner student at the Vanderbilt School of Nursing, says community service renews her energy and keeps her grounded. But she also says it can be a more effective way to learn than the traditional classroom setting.

“I could sit in a coffee shop all weekend memorizing microbiology and antibiotics, but the act of giving a flu shot to a homeless man under a bridge animates that skill set. Caring for someone at risk for losing his or her foot to infection makes the learning feel urgent,” Morse says. “It reminds me that I am one part of something much larger.”

The concepts of service and learning are evolving at Vanderbilt. As a top academic medical center, Vanderbilt University is well respected for its rigorous classroom learning and clinical experiences for students in health-related disciplines. At the same time, student involvement in service projects has long been encouraged, even strongly recommended. But a new trend seeks to blend the two, to accomplish academic goals in a community service setting. The concept is called service learning, and its goal is to formalize the learning that happens in community service projects, in effect taking the curriculum into the community.

One of the most venerable examples is the Vine Hill Clinic a few blocks east of the Vanderbilt campus, where nurses and nursing students have been providing primary health care to Nashville’s underserved populations since 1990. More recently, in 2004 Vanderbilt medical students opened the Shade Tree Clinic to offer health care in East Nashville while enhancing their medical education through hands-on experience.

And now a core of undergraduate courses like Health Service Delivery to Diverse Populations (HOD 2510)—an interdisciplinary course based at Peabody College and taught by human and organizational development professors Sharon Shields, PhD’76, and Leigh Gilchrist, BS’92, MEd’00, EdD’07—are planting seeds to better connect service with formal learning. (See sidebar, right.)

When you bring an academic institution into the mix, ideas begin to evolve quickly, says Shields, professor of the practice of health promotion and education and lead instructor in HOD 2510. Dedicated students go into the community to serve, they see the issues, they hear the ideas, and then they connect the dots.

“There is a real desire to do this work,” says Shields. “This integrates us so we work together. We continue to work on service learning and developing more formalized and structured forms so we can integrate the foundations of service learning into our courses and encourage more students to connect theory with practice.”

Experiential Learning

Few disciplines are more service minded than health care, so it is natural that service projects are common and quite successful in Vanderbilt’s health-related schools. But at a time when demand for primary care is increasing as insurance coverage declines, formalized service learning takes on a new urgency. Vanderbilt enjoys the advantage of long experience at Vine Hill Clinic where, for more than 20 years, service learning has been the goal.

“Service learning is a nursing model,” observes Bonnie Pilon, senior associate dean for clinical and community partnerships at the Vanderbilt School of Nursing. “Community work is part of nursing training, so Vine Hill was the right thing to do. We received a Kellogg grant based on our knowledge of how to meet an underserved community’s health needs, as well as the need for advanced-practice nurse education.”

The business model for Vine Hill is complex and involves a partnership agency, but the clinical teaching is like any offered at Vanderbilt University Medical Center: high quality and steeped in academics. Vine Hill provides critical “safety net” health services to the underserved of Nashville and is run by nurses who also serve as faculty at the Vanderbilt School of Nursing. Advanced-practice nursing students take clinical rotations there, allowing them to focus on the care of uninsured and underinsured patients during school hours.

Temeka Tunstall, another family nurse practitioner (FNP) student at the Vanderbilt School of Nursing, says experiencing the systems she will need to know in practice is valuable, but she signed on for a clinical rotation at Vine Hill because of the service she felt she could provide.

“When I used to work in the ministry, I saw the needs of families with serious health concerns, how it could break families up,” says Tunstall. “I enjoyed helping families, so I asked to come here.”

On a typical Friday, working with FNP Iris Padilla, assistant professor at the School of Nursing, Tunstall sees some 16 patients. In the space of just 20 minutes, she works with a man in his 30s who has a serious heart problem and is not taking his medicines as directed, and then with a woman over age 80 whose middle-aged son must help communicate her many health issues, including serious hearing impairment and memory problems. Neither patient has adequate insurance coverage, and both can benefit from a provider well trained in patient education as well as social services.

“It’s a lot,” Tunstall says, “but I love this work.”

The Vine Hill concept has now grown to include five sites designated as providing care to the underserved around the region. Vanderbilt nursing students are able to apply to complete their clinical experiences at these sites. It’s not just a good thing for the community and students; it’s an excellent way to ensure the spirit of service is upheld long into the future.

“At Vine Hill it’s all hands on deck as well as brains on deck,” Pilon says. “Out of that has come the result that more than half of our graduates go to work in underserved communities.”

Work for full credit, as at Vine Hill, is the ideal—but it remains the exception in service learning. A number of pilot projects at Vanderbilt are exploring the concept of service learning for credit, but the concept can be incredibly complex to carry out in real life.

Shields is assisting with a pilot project called the Interprofessional Fellowship, in which a couple dozen students from Vanderbilt’s schools of medicine and nursing come together with students in pharmacy and social work from other area academic institutions. They work as a team in community clinics that provide primary care to the under- and uninsured in Nashville.

“The community’s role cannot be overstated in this,” Shields says. “It is reciprocal learning. The community partners are teachers with us. Together we look at need and services needing to be honed. In those places of greatest need, you have the greatest learning.”

Service First

The student-run Shade Tree Clinic is the model for the pilot Interprofessional Fellowship project. Still, the majority of student work at Shade Tree is volunteer-only. But students say they aren’t so concerned about a model that will offer them credit; they just want the opportunity to serve.

On a typical Tuesday night at the Shade Tree Clinic, fourth-year medical student Shane Michael Magee, BE’07, and second-year students Natalia Plotnikova and Jill Neely crowd around a patient named Emilia Mayorga.

Mayorga’s current health concerns are complex. Dr. Robert Miller, MD’82, the clinic’s mentor and medical director, finds a bit of space and sits at the patient’s side to guide the conversation while Neely, a native of Nicaragua, interprets for Mayorga, who only speaks Spanish.

As the senior student who has worked at Shade Tree for years, Magee knows Mayorga and has the knowledge and experience to suggest changes of medications. Plotnikova, who also speaks Spanish, takes furious notes, and everyone learns his or her share, including Mayorga. After two years of receiving care here, Mayorga, who is in her 50s and uninsured, says her diabetes, back pain and high blood pressure have all improved.

“I have learned a lot,” Mayorga says. “I have to be constant at the things I do for my health and stay positive. I am willing to do what they ask because the students give so much.”

Neely and Plotnikova say they enjoy the opportunity to care for patients like Mayorga and to practice bilingual interpretation.

“One of the biggest lessons I have learned is that good patient education can go a long way. Here you can connect with the patients on such a personal level,” Neely says. “You have to be able to love them and have the knowledge and somehow learn to merge the two.”

Magee is the only student getting class credit for his time here. He is one of the first participants in a new one-hour elective for fourth-year students. In short, he is living an ideal service learning experience, but he thinks both models—with and without credit—are necessary.

“Early in medical school, volunteering was a great way to learn, but later it became less about what I could get out of it and more about what I could provide,” Magee says. “The elective provided a means for me to frequently attend clinics at a time when we are generally too busy to volunteer.”

Second-year medical student Ben Deschner, who co-directs the Shade Tree Clinic this year, says the lack of academic credit is not likely to dissuade students from volunteering.

“It’s such a rare opportunity to have this level of contact with patients and with physicians at this stage in our training. The hours get long sometimes, but when I’m here the clinic gives me energy.” Deschner smiles as he stands in a cramped hallway filled with fellow students squeezing back and forth, in and out of patient rooms, stopping to consult with a kidney transplant expert and medical co-director and endocrinologist Dr. Mike Fowler. The faculty volunteers clearly enjoy this as much as the students do.

Fowler, a longtime volunteer at another free health clinic, says volunteerism benefits mightily here from strong ties to an academic medical center. Services available here are simply not available in other free clinics, including social work and lab services. Because the service is linked with an institution of higher learning, more service is possible.

Deschner says the view from this hallway has dramatically changed his view of a doctor’s role in health care. He says he now believes Shade Tree’s social worker is the single most important provider here. He cannot wait to get his hands on a pink booklet provided by social workers to third- and fourth-year students, a source referral for community services.

“I don’t care what kind of doctor you are, if you are not thinking about how your patients get their food, or about their family, their life situation, you cannot truly help them in a complete way,” Deschner says. “And I learned that here.”

While both the community and the students would theoretically gain from more formalized service learning, many want to proceed with caution. At Shade Tree the spirit of service still comes first, and no one here wants that to change. Class credit is nice, but not if there is a chance the lessons learned here could shift focus too much on academics at the expense of service.

An attitude of service is something Deschner, Magee, Plotnikova and Neely’s patients will appreciate one day. And it’s an attitude the Nashville community can take to the bank right now in the form of many volunteer service projects. But while the contributions of bright and energetic providers from top academic institutions are highly valued by the community, and proponents believe these bright young providers will carry service-mindedness into the future—making it better, more effective and more affordable—challenges do remain. Academic institutions face increasing pressure to demonstrate ever-greater scholastic results, which in turn exerts multiple demands on students and faculty alike. Time and money are always short, and true service learning takes both.

Sharon Shields says she continues to work on finding ways to prove the value of service learning to those who make decisions about curriculum at Vanderbilt. She and others have already made serious headway in efforts to take students out of the classroom and bring the curriculum to them in the community. Research is under way to provide the numbers needed to turn the philosophical benefits into something more tangible.

“This is the scholarship of application and discovery and teaching and work across all disciplines,” Shields says. “We have to frame our work and capture its impact in qualitative ways.”

An expanded emphasis on service learning couldn’t come at a more critical time for society as a whole, Pilon says.

“I’m hoping we go the distance. People who have never had exposure to serving the marginalized populations have very naive ideas about this world. Until it happens to you, it is not on your radar screen. The more we walk the walk, the more we can describe it to the world.”