BACKGROUND AND PURPOSE
The Commission on Accreditation in Physical Therapy, through its evaluation criteria, requires that physical therapy (PT) entry-level education programs cultivate professional behaviors in students as outlined in the American Physical Therapy Association (APTA) core values.1,2 Thomas Merton, the Trappist monk, said, “the least of the work of learning is done in classrooms.”3 Moving the work of teaching and learning outside the classroom and into patient care experiences through focused service learning (SL) opportunities4–6 is a potentially valuable high-impact practice7 to support the development of professionalism in PT practice.
The expansion of PT entry-level education curriculum to include SL can benefit the community, underserved populations, and students.8 Through SL, students engage in “a structured teaching and learning experience that meets identified needs of the community with explicit learning objectives, preparation and reflection.”9 Service learning can expose students to community health problems while gaining real-life experience within the field and reinforcing didactic coursework.8
There are multiple examples of successful implementation of SL within a course or as a single project into PT entry-level education.8,10,11 One study described the promotion of mastery of essential competencies in geriatric PT through a specific service learning clinic (SLC) in which students learned to recognize challenges associated with the development of a plan of care and management of multifaceted needs of the older adult.12 Another study describes implementation of pediatric PT SL within a program for children with cerebral palsy.13 Service learning demonstrates a positive effect on communities in which the projects are implemented, a positive impact on students' knowledge of working with a community partner, and positive changes in PT students' behavior and professionalism.4,5,10,11,14 Similar outcomes are described in the entry-level education of other health professionals.15
Programs aim to prepare students to evaluate and treat individuals with various conditions within the scope of practice, which includes, but is not limited to, areas in geriatrics, neurology, pediatrics, and orthopedics. The development of specialty SLCs could be a valuable means of preparing students and integrating coursework with clinical practice. Additionally, specialty SLCs could provide curious students with experience in a unique setting prior to graduating and joining the work force.
Recently “A Compendium for Teaching Professional Level Physical Therapy Neurologic Content, v. 2016” was published by the Academy of Neurologic Physical Therapy of the APTA for educators to assist with the task of delivering innovative education specific to neurologic practice.16 The authors of the compendium advocate for the use of integrated clinical experiences and community-based learning. Student participation in a neurologic SLC within the curriculum may enhance essential competencies in the clinical management of the neurologic population. To our knowledge, there is no research published to date describing implementation or students' experiences in a neurologic-specific SLC in a program in the USA. The purpose of this educational case report was to describe the implementation and the students' experiences of participating in a neurologic SLC in a PT entry-level education program. The SLC was created based on community need while meeting current curriculum demands of the educational program.
Bellarmine University is a private, Catholic, liberal arts and sciences university in Louisville, Kentucky. Guided by the mission of the university and PT program, SLCs were implemented in 2004 and have since expanded in scope based on community need and to optimize student learning with expansions made geographically, by setting, and by patient population. The goals of the SLCs are to meet the needs of the community and the program. What started out as one orthopedic based, pro bono outpatient SLC, which primarily served the university faculty, staff, and students, has turned into 8 pro bono local clinics offering therapy for various patient populations (eg, neurologic, orthopedic, sports, geriatric, and pediatric) and 3 international SL experiences.
The SLCs are integrated into the curriculum in which students are assigned to one of the 8 SLCs through a mandatory 2-credit hour course during each of the fall and spring semesters over the first 2 years in the program (4 semesters and 8-credit hours in total). Course learning objectives for the SLC classes are outlined in Table 1. The curricular integration of the SLCs supports the program in meeting some of the standards set forth by the Commission on Accreditation in Physical Therapy Education are met (Table 2).
Specific to the neurologic SLC, a partnership was established in 2015 between the program and Norton Healthcare, specifically with the Cressman Neurological Rehabilitation Center (CNRC). The CNRC includes an outpatient clinic that serves patients with neurologic disorders. Two university program faculties also work clinically in the Norton Healthcare system. One is the residency director of the Bellarmine University and Norton Healthcare Neurologic Residency and the other is a physical therapist who treated patients weekly in the CNRC. These relationships between the faculty and the CNRC, in addition to the support from both the university and the hospital leadership, made the establishment of the SLC within a neurologic outpatient clinic possible.
Students assigned to the neurologic SLC completed one rotation at the clinic during either the fall or the spring semester of the first or second year in the program. The timing structure for the neurologic SLC at the CNRC was established in accordance with the structure used for all SLCs in the program, twice a week with up to 2 hours per session available for planning, consultation with mentors, and patient care. The CNRC clinic space and equipment were available for patient care. To avoid congested clinic space, the timing of the students' patient care was scheduled to primarily occur when the CNRC therapists were on lunch break. A variety of patients were recruited by the faculty mentors and therapists at the CNRC to participate in the SLC with a variety of diagnoses, including Parkinson disease, multiple sclerosis, essential tremor, and Huntington disease.
An orientation and information packet was created to serve as an initial guide for expectations of students participating in the SLC. The packet included general information such as site information, time of treatment, directions to the clinic, parking, and attire. The packet also included the documentation format for patient sessions (the Subjective-Objective-Assessment-Plan [SOAP] note format), the mock billing form, the Current Procedural Terminology code definitions and examples, and common neurologic outcome measures utilized.
Supplemental research and patient documentation were added to a common confidential online location that students could access to prepare for patients with a specific diagnosis. While implementing this SLC, a single online system, only accessible to faculty and students, was utilized to upload the SOAP notes created by the students after each treatment session. This system was available to each crew of students who participated in the SLC, which assisted in preparing successive students prior to the start of their CNRC rotation. The single online system was also used for faculty mentors to review the documentation and as a common destination for any additional resources that may be pertinent to patient care for every student in the SLC.
Thirty-seven first- and second-year students were assigned by the SLC Coordinator and participated in the neurologic-specific SLC site during the first year of the clinic (Table 3). Second-year students mentored first-year students while treating patients with a neurological disorder. Each semester included 3 sequential crews of different student groups. Each crew treated patients for 4 weeks. Sessions were held twice a week and included planning time, intervention time (45 minutes), and debriefing time. Figure 1 shows the timeline and description of SLC site assignments examined for this case report. For each crew, a student dyad conducted individualized treatment for a patient once a week and led an exercise group tailored to individuals with Huntington disease once a week. The other student pairs provided individualized treatment to patients they saw twice a week.
Students were responsible for mock billing and completing daily documentation notes based on patient treatment sessions, which were reviewed by a supervising faculty member. Two faculty members who supervised the student participants were course directors for the program's neurologic-related coursework and certified as neurologic clinical specialists by the American Board of Physical Therapy Specialties. Ultimately, a fully functional and sustainable SLC was created that provided students an opportunity to learn and implement neurologic-specific treatment and provided individuals with neurological disorders the opportunity to overcome barriers (eg, financial) to continue exercise and activity.
In other work, successful implementation of SL and achievement of SL objectives was assessed by utilizing reflective journaling and surveys describing the impact SL had on students who participated.10 Previous research has suggested the value of self-reflection in regards to promoting active assessment of one's comprehensions, abilities, and engaging in ongoing learning to transition classroom knowledge to a clinic environment.17 With this research supporting the positive integration of self-reflection, all students were required to submit a reflection paper at the end of each semester based on experiences in the SLC (Table 4).
Students were at various levels in the curriculum based upon which crew and semester they were assigned to the SLC. First-year students in the fall SLC had previously completed 11 credit hours in the summer, including coursework on teaching and learning in PT practice, psychosocial responses to disability and health care, introduction to acute care, and applied clinical anatomy. In addition to the SLC course in the fall semester, these students were also taking coursework in research, pharmacology, functional anatomy, musculoskeletal examination, human performance and health promotion (HPHP), and gerontology for a total of 21 credit hours. First-year students enrolled in the spring SLC course were also completing the following classes: neuroscience, orthopedics, biophysical agents, HPHP II, and wound care for a total of 18 credit hours.
Prior to the second-year SLC courses, students completed 13 credits of summer classes, including neurology, research II, principles of community partnerships, orientation to clinical education, and a 6-week clinical clerkship. Second-year students in the fall SLC course were also completing coursework in extremity musculoskeletal dysfunction, gross anatomy, pediatric PT, leadership and operational administration, and cardiopulmonary PT for a total of 21 credit hours. Second-year students in the spring SLC course were also enrolled in bioethics, adult neurorehabilitation, differential diagnosis, rehabilitation techniques, and spine for a total of 19 credit hours. After the first 2 years in the program, students continue matriculation through three 12-week clinical internships, a capstone course, an elective course, and a professional and legal issues course.
This research was approved by the Institutional Review Board of Bellarmine University (#408) and informed consent was waived. The qualitative analysis was performed via retrospective analysis of student participants' de-identified SLC reflection papers to evaluate the students' experiences of participating in the SLC for common themes.18 Data were manually coded for meaningful descriptions regarding their experiences in the SLC (Figure 2). As the culmination of the data analysis process, the research team discussed the findings on 3 occasions to reach consensus on common themes and ensure accurate interpretation.19 A plan for addressing instances in which consensus was not reached involved a senior research team member as a tie-breaking vote but this procedure was not warranted.
To establish trustworthiness, several methods of verification strategies were employed, including the use of multiple data gatherers, an audit trail, indirect member checking, and a modified peer debriefing. Direct member-checking was not possible given the de-identification of the reflection papers. The findings were presented during a program research event, however, and all students in the program were invited to attend. The researchers invited feedback on the overarching themes and received broad-range consensus that the themes adequately conveyed students' SLC experiences. The peer debriefing was modified in the sense that it was not a purely external audit. Two of the researchers assisted with the study design but were not involved in the initial process of coding and theme development. These 2 researchers individually reviewed the analysis to determine the extent to which the themes fit the data and offered suggested revisions.
Three themes emerged from the analysis of student reflection papers: 1) “Out of my comfort zone”: Challenges for Novices, 2) “Find my ‘PT Self’”: Professional Growth, and 3) “Out of the books and into the real world”: Bringing Curriculum to Life. An overview of the themes with associated concepts is provided in Table 5.
“Out of my comfort zone”: Challenges for Novices
Students described the challenges of being a novice—both a novice to the PT profession in general and a novice to a neurological clinical setting.
I was forced out of my comfort zone into applying what I've learned in the classroom, to what I've only slightly experienced outside of the classroom.
The emotions that can come from being a novice as well as the lack of knowledge and experience to draw upon were perceived by students as challenges regarding participating confidently and comfortably in the SLC initially.
The overall depth of feeling out of one's comfort zone was more prominent for first-year students in light of their stage of matriculation. The first-year students described the challenges of having the SLC experience prior to neurologic-related coursework at even the foundational levels of neuroscience and neuropathology.
Earlier and progressive exposure to neurology courses would better prepare students for this course and patients with neurological diseases.
While second-year students had a year of coursework completed, including a 6-week clinical education clerkship, second-year students described the challenges of not yet completing the adult neurorehabilitation course focused on evaluation, treatment, and advanced documentation skills.
I think I could have been more prepared by being aware of some common exercises that would focus on the deficits of the diseases my patients had. We had been prepared in prior classes to know the physiology of how the diseases affected the person, but we have not yet had much experience with how their diseases are affected by exercise.
One area where I felt ill-prepared was with their documentation style. I did not realize how specific I should document when describing my patient's transfers throughout the session.
Both first- and second-year students shared perceptions of being a novice relative to their roles as mentor or mentee. First-year students attributed limited coursework and previous neurologic experience to reservations about what they would be able to contribute to patient care and to assisting their second-year mentor.
This rotation was a great challenge. I was intimidated and worried that having only seen a few patients post-stroke while observing in previous years, I did not know enough about working with patients with neurological deficits to really be of help.
Second-year students in the fall semester were in their first position of serving as a mentor, and for some, this was out of their comfort zone.
I did feel inadequate being a second year mentor for a first year student.
Confidence improved over the course of their time in the SLC, which students attributed to the value of the first-year, second-year student dyad mentor/mentee approach (My second year was very helpful in calming my nerves and helping me through the clinical process), guidance and assistance from the faculty mentors, supplemental information about neurological patient care (eg, articles, textbooks), and increased experience in working with the patients over time. There was a sense by first-year students that they realized the profession is continuously changing and evolving and there will likely be many times in the future in which they feel outside of their comfort zone but can rise to the challenge (eg, by searching the literature to prepare for sessions, through collaboration with others). Overall, students described a process of grappling with initially being out of a comfort zone that was ultimately rewarding regarding professional growth, the second theme identified.
I believe in order to grow in this career, one must be put in situations where you feel uncomfortable or ill-prepared because it shows how good you are at thinking on your feet, which is a large part of being a physical therapist.
“Find my ‘PT Self’”: Professional Growth
The second theme that emerged from the data centered on professional growth experienced by the students and coming into one's own identity as a physical therapist. Second-year students in particular were able to reflect on the extent of their professional growth over time given the ability to think back over 5–6 semesters in the program. Whereas first-year students reflected on coming to better understand the broad scope of PT practice, themselves as future physical therapists, and identifying areas of growth to continue to work on. Overall, students felt better equipped to become a member of the neurologic health care team and collaboratively treat patients.
I also believe that leadership and teamwork are very important, but often times lacking within our class. This lack highlights the need for SLC time and the opportunity to learn and practice these much needed skills that a graduate program can sometimes limit. We are given the opportunity to work with people from outside the program and apply our teamwork skills to see if they are effective or need improvement. This is one of the best aspects of our rotations through SLC.
Both first- and second-year students noted professional growth in skills in interprofessional collaboration, patient and caregiver communication and education, and building patient rapport.
This course continues to help me grow in my interpersonal communication skills. I felt much more confident when speaking to the patient and was able to communicate effectively with my mentor about my patient care.
Communication and rapport development were primary factors in the learning experience of first-year students. They described the recognition through this experience of the profound role of nonverbal communication. Participation in the SLC served as an impetus to reflect upon their individual communication skills and styles. For second-year students, communication-related growth more specifically pertained to thinking on their feet, adjusting communication with the patient and first-year mentee, and recognizing the differences in communication with neurologic patient populations. Second-year students also recognized their growth in communicating through tactile handling methods to facilitate patients' movements.
First-year students came to realize what “patient-centered care” meant and could more clearly see how a plan of care was developed with the patient. Furthermore, empathy for patients, a construct poorly developed through a textbook, was cultivated, which strengthened students' resolve to provide the best care possible.
I have gained a different perspective on life in general as well (as) due to seeing the types of patients I have and the humbling experiences. I continuously learned from my patients that you cannot take walking, performing activities, and mobility for granted.
Second-year students described professional growth in taking the lead in progressing the treatment plan, enhancing neurohandling skills, becoming more observant of impairments (eg, manifestations of fatigue), and managing multisystem issues. Students noted enhanced problem-solving and critical and creative thinking skills related to neurological PT practice.
…flexibility and beginning to use critical thinking skills to problem solve and approach my patients more holistically have been the biggest areas of growth for me during SLC this semester.
I was challenged to think outside the box to come up with therapy interventions that were unique, effective, and challenging. Though I was challenged and struggled at times, this experience allowed me to gain comfort and confidence in my skills and ability as a student physical therapist.
Participation in the neurologic SLC afforded students the opportunity to work with a new patient population.
This was an eye-opening experience as I had never had exposure to this disease.
Typically, any previous patient care experience was limited to employment as technicians in outpatient orthopedic or sports clinics. This exposure to a new area of clinical practice expanded the landscape of potential future career avenues. Some described cultivating their identity as a future physical therapist, finding their niche, and wanting to further learn about neurologic PT. In some cases, students suggested it might have solidified their career calling to become neurologic therapists.
From this one class, I have begun to find my “PT self.” I now have an idea of what kind of physical therapist I want to be and have begun my exploration into what setting I would like to work in.
Now being exposed to a neuro PT setting, I really think this will help my career as a student PT and future DPT. Mainly because it has shown me a whole new area of interest that I found I am very passionate about.
“Out of the books and into the real world”: Bringing Curriculum to Life
The third theme that emerged is the concept of bringing the curriculum to life. The SLC offered the opportunity to bridge the classroom to the clinic.
SLC time is always a touchstone to what is important in physical therapy. It is a much needed and welcomed reality check that drags my head out of the books and into the real world of working with patients. It is a reminder that the hours of lectures will end and I will be interacting with a variety of people looking to me to retain that lecture information to use to help them feel and move better.
Participating in this SLC assisted students with reinforcing and solidifying didactic classroom work, especially the neurology-related classes.
Although I researched symptoms and impairments of these individuals, seeing and interacting with someone with this disease was a mind-opening experience. It was an excellent “light-bulb” moment where I connected theory to practice and got to expand my understanding of this disease in every aspect.
Making connections to neurology-related classes was particularly true for second-year students who had previously taken courses such as neuroanatomy and neuropathology.
I believe neuroscience prepared me the most for this rotation. I had a concept of what areas of the brain were affected in Parkinson's and Huntington's and I also had an idea of their presentation.
Additionally, second-year students shared that they were able to apply concepts of treatment planning and neuro-handling and motor learning skills introduced in pediatric (fall semester) and adult neurorehabilitation (spring semester) coursework to patients.
Our pediatrics class pushed me to analyze movement, communicate effectively and concisely and to be creative when designing interventions. The interventions we did helped me to come up with ideas when working with patients this semester.
I was able to absorb the things we were learning in class and apply that knowledge to benefit the patients that I was able to see during my time at this SLC site, particularly the Parkinson's unit.
Lastly, second-year students were able to see that life does not always imitate the book.
I also learned that every patient is going to be different, despite the same diagnosis. No one will present exactly how you learn in the textbook.
This theme was brought to life by first-year students as well, but with less specificity to neurologic coursework. They were able to make connections between concepts and skills in introductory courses to the SLC such as obtaining a subjective history, basic examination skills (eg, range of motion measurements), interpretation of vital signs, basic exercise prescription, and introductory documentation.
Acute care and HPHP (human performance and health promotion) classes as well as my previous schoolwork (undergraduate exercise science classes) definitely prepared me to be able to take accurate heart rate and blood pressure readings and to know the limits to be able to exercise.
Bridging the curriculum to clinical practice contributed to perceptions of improved preparedness for future full-time internships by second-year students who were rapidly approaching their third year in the program, which consisted of three 12-week internships.
Without this SLC I would not feel as prepared going out into my clinical rotations where I know I will have to work with patients in a neurological setting.
Furthermore, the SLC reminded students of what lies beyond the books and the internships—their future as a physical therapist.
Sometimes while in class for weeks at a time, you lose sight of your purpose… but service learning always reminds you of your purpose to help patients on all levels: physically, emotionally, psychologically, and socially.
DISCUSSION AND CONCLUSION
This educational case report is the first to describe the implementation of a neurologic SLC in a PT entry-level program and the experiences of PT students who participated. Analysis of student reflection papers revealed 3 themes: 1) “Out of my comfort zone”: Challenges for Novices, 2) “Find my ‘PT Self’”: Professional Growth, and 3) “Out of the books and into the real world”: Bringing Curriculum to Life.
The experiences and perceptions related to being a clinical novice noted in this study reflect similar experiences of therapists in their first year of clinical practice.20 The neurologic SLC allowed students to develop mentorship and professional relationships with faculty and peers that contributed to improving their confidence and professional growth. In an editorial on mentorship in PT in 2004, Dr. Godges21 discusses the importance of early mentorship in PT practice to guide the novice clinician. Work by Wainwright et al22 examines factors that impact clinical decision making in novice versus experienced therapists, one of which was faculty mentorship for novices. The integration of structured mentorship in entry-level programs, such as the tiered mentorship (student to student; faculty to student) in this case, could provide a foundation for early clinical decision making and engagement in professional dialogue by students prior to clinical internships. Service learning clinics provide an avenue for the integration of formal mentorship into entry-level curricula that could evolve into one's early career.
Ask individuals why they pursued a career in PT and a likely typical response is that the individuals became interested after experiencing a musculoskeletal sport-related injury and received PT. Anecdotally, employment as a PT aide in an orthopedic outpatient clinic appears to be a common experience shared by applicants to PT programs. These early pre-PT school musculoskeletal experiences possibly contribute to the large percentage of students who are interested in becoming orthopedic physical therapists. Orthopedic certified specialists are the largest group of specialists credentialed by the American Board of Physical Therapy Specialties at 14,368 (57.9% of all specialists) as of the summer of 2018.23 In contrast, there are only 2,648 neurological specialists. Smith and Crocker (2017) suggest that experiential learning opportunities such as SLCs can offer students exposure to specialty practice areas. Participants in this study described that exposure to neurologic PT through participation in this specialty SLC sparked an interest in an area of practice they had not previously seriously considered.
Participants described the evolution of clinical skills through the opportunity of connecting the didactic curriculum to clinical practice within the SLC. Specialty SLCs may be an important avenue for facilitating specific didactic coursework and preparing students for clinical internships and beyond. Research suggests that specialty learning experiences in geriatric-specific SL can improve students' attitudes toward older populations, which can subsequently enhance students' interactions within PT interventions.24 Future research is needed to examine the extent to which a neurologic SLC enables faculty to address components of the “Compendium for Teaching Professional Level Physical Therapy Neurologic Content.”
In light of calls for greater integration of experiential learning,25 such as SL, into entry-level programs, the descriptions of the implementation of the neurological SLC in this work may be beneficial to programs interested in developing similar opportunities. Implementation was successful due to a myriad of factors. First, the partnership between the university and the local health care organization that housed the neurological outpatient clinic provided necessary infrastructure. The program administration, faculty (who had dual clinical appointments at the hospital), and the hospital administration were supportive of the endeavor. The inclusion of SL as a curricular requirement (a 2 credit-hour course during 4 semesters) provided valuable academic structure that supported implementation (eg, syllabus, assessments, student learning objectives, scheduling, and faculty load). In addition to the information provided in this report about implementation, those interested in developing SLCs within an entry-level program are referred to work by McCallum8 that offers a planning model, “PRECEDE,” that promotes matching a community needs assessment with student learning objectives and curricular structure.
Limitations of this case report include the lack of an extended longitudinal perspective from the students, such as the effect of participation postgraduation. Another consideration is the nature of the qualitative data collection strategy—the reflection papers with preset prompts. This precluded in-person follow-up questions. The use of interviews and participant observations could be valuable in future research examining this topic. Ideas for future research include examining experiences of participating in a single SL experience versus a long-term SL experience. Examination of any relationship between participation in a neurologic SLC and subsequent performance on the Clinical Performance Instrument in a neurological internship would be valuable.
Given recent discussions about the future of physical therapist education and the upcoming work of the Education Leadership Partnership,26 continued evolution and examination of the role of specialty-specific SL in entry-level programs is needed. The data from this case report regarding the value for student learning and the challenges faced serve as a springboard for discussions and planning within other programs interested in integrating SL into the curriculum, particularly a neurologic-specific experience.