As educators in nurse practitioner (NP) programs, we are challenged to ensure that our students acquire the content needed to meet required competencies. Each semester, new health care information, research, and guidelines force educators to add new evidence-based material to their curricula to keep pace with the constant evolution in practice. If educators do not keep pace, the outcomes of programs will be negatively impacted, and new graduates will be ill-prepared in practice. One such topic is children's oral health.

As early as 1978, early childhood caries (ECC) was identified as a problem in the United States. Today, it is the most common chronic infectious disease of childhood, five times more common than asthma, and it is the most likely cause of caries in permanent teeth (Clark, Slayton, & Section on Oral Health, 2014; Moyer & US Preventive Services Task Force, 2014). According to the American Academy of Pediatrics, 90 percent of infants and one-year-olds have seen a primary care clinician, yet fewer than 2 percent have seen a dentist (Clark et al., 2014).

As primary care clinicians are in the best position to provide preventive oral health care for infants and toddlers, it is important that NP programs educate future clinicians so that they are able to identify early signs of ECC, educate patient caregivers, and provide preventive oral health care services. Realizing this, our challenge became how to share this newly found information with our NP students in a meaningful way.

Our "a-ha moment" came to us as we sat in the back of the classroom listening to our guest lecturer, a dental school faculty member, as he shared his knowledge on the development of ECC with our NP students. We realized how much we did not know and how much we had learned. We had a long list of questions needing answers, and we set out to learn all that we could about, for instance, how dental caries is a communicable bacterial infection; how white lines on teeth close to the gums are an early reversible sign of caries; and how dietary grazing behaviors contribute to caries formation.

We researched ECC and oral health care guidelines and learned that, although these guidelines had been revised several times over the past few decades, many primary care providers do not provide the recommended care now promised by the Affordable Care Act (Moyer & US Preventive Services Task Force, 2014). Sending our students into primary care practice without knowledge of this important health determinant would be negligent. Therefore, we set in motion a plan of adding an oral health module into the coursework.

One solution to adding new information to a curriculum is to evaluate current teaching methodologies to make sure they are efficient yet effective. If they are not, how might we teach smarter? In our quest for answers, we found the STAR Legacy Cycle and decided to use it as a template for the development of a children's oral health module in our curriculum. This article outlines the content of our module based on the STAR Legacy Cycle.

STAR LEGACY CYCLE

The STAR Legacy Cycle was created to help facilitate the application of the How People Learn (HPL) theoretical framework (http://starlegacymodel.weebly.com). The HPL theory proposes that students learn best when information is organized and relates to their own past experiences (O'Mahony et al., 2011). Students should also be allowed to test their understanding of the content, which they explore with peers.

After an exhaustive literature review, it was not apparent that the STAR Legacy Cycle had been used in nursing education. However, it has been used extensively in other disciplines, such as technology and engineering education. Looking at pre- and posttest scores, research in these areas comparing this framework to a traditional lecture-based format demonstrated greater student satisfaction and increased knowledge (O'Mahony et al., 2011).

The STAR Legacy Cycle encompasses the basic principles of HPL and consists of five steps: a challenge, initial thoughts, perspectives and resources, wrap-up, and assessment. 1) The Challenge is an activity that piques interest and allows students to explore their tacit knowledge of a given topic. Examples include case scenarios, pretests, and storytelling. 2) Initial Thoughts is the starting point for knowledge acquisition; it is where students are made aware of their internal thoughts. 3) Perspectives and Resources can be accomplished, for example, through the use of topic experts, peer learning, hands-on experiences, and websites. 4) Assessment involves a formative evaluation of what the students have learned and provides an opportunity for review. 5) The Wrap-up summarizes the learning that has taken place, with students reflecting back on their initial thoughts for comparison.

Challenge

Two weeks prior to the face-to-face class, we challenged students with a 10-question pretest to assess their knowledge of children's oral health. Students were presented with the following scenario: You are an NP who works in a clinic. Today you will be seeing a nine-month-old child for a well-child exam. As you collect information from the mother, you notice that she has a missing tooth and visible cavities in several teeth. What are your thoughts?

Initial Thoughts

After reading the scenario and taking the pretest, students were asked to reflect on their thoughts in a short essay (at least half a page). This allowed reflection on their prior knowledge and provided a starting point to gauge the learning that would be achieved through the module.

Perspectives and Resources

In the next two weeks, students were given the following out-of-class assignments to further their knowledge of children's oral health care. They were to complete the "Smiles for Life" national oral health curriculum (see smilesfororalhealth.org) and submit certificates of completion for class credit. They then met face-to-face in class where experts lectured on children's oral health, including ECC, dental emergencies, and education perspectives. Students practiced screening exams and fluoride varnish application on one another in a quick, hands-on lab.

Assessment

Students were given the opportunity to reflect on the scenario given two weeks prior and share how their thoughts had changed. They also took a posttest that was identical to the pretest.

Wrap-up

Similar to the debriefing session commonly used in nursing education, learning was summarized by reviewing the pre- and posttests and discussion to compare reflections.

CONCLUDING REFLECTIONS

As graduate nursing faculty, we may believe that we should know everything related to health, but that is not realistic. Recognizing that we do not and cannot know everything, we learned facts about oral health in children that had eluded us previously. This new knowledge changed our professional practice and the course of our professional scholarship. We have learned how important oral health care is for the lives of our youngest patients and their families, and we are both writing about prevention and advocating at the state level. Our advocacy focuses on reimbursement for fluoride varnish and for educational programs aimed at preventing ECC for all patients cared for by our NP students.

Based on anecdotal feedback, we found that the delivery of educational content based on the STAR Legacy Cycle was feasible and favorable to the students' learning experience. Going forward, we will administer a more rigorous assessment focused on pre- and posttest scores. In addition, we will analyze student satisfaction scores and investigate teaching time reductions to evaluate the usefulness of this innovation.

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