INTRODUCTION
Incessant threats to health (eg, emerging diseases and inequities in health care) create a need for health professionals able and willing to address society's evolving health needs.1,2 Physical therapists, like other health professionals, are enjoined to scale up efforts as unmet rehabilitation needs increase worldwide.3 In the Philippines and similarly in other low- to middle-income countries, these needs include the rising prevalence of noncommunicable diseases, sequelae of communicable diseases, and incidence of injuries,4,5 compounded by socioeconomic and environmental barriers that hinder health.3,4,6 Health professions education institutions are therefore called to strengthen their transformative role, resulting in more socially responsible graduates acting on societal health issues.1,7
Social responsibility (SR) is an increasingly important professional behavior among health professionals as it encourages better engagement with societal issues. Many health professions view SR as a moral imperative to uphold social justice in health, that is, changing social structures that contribute to health inequities.8–11 In physical therapy (PT), the idea of SR is foregrounded by the professions' transition toward a societal identity. This involves an ethical framework expansion to include not only patient-centered care but also working with the larger community to ensure universal access to PT.12,13 This is evidenced by the inclusion of social dimensions in the code of ethics of various PT associations across the world. Examples are working with the community to respond to societal health and wellness needs14–18 and addressing social injustices that affect people's health.15,19,20 In the Philippines, an interview study with PT leaders and practitioners suggests that Filipino physical therapists can embody SR through altruistic responses to pressing health issues. In particular, the responses entail ensuring that the profession is able to extend its reach to underserved members of society amidst health care system barriers.21
Physical therapy education programs are therefore expected to prepare students for their societal obligations.22,23 As recommended by global guidelines for entry-level PT programs,23 demonstrating SR is one of the minimum outcomes expected of entry-level PT graduates in the Philippines.24 A Bachelor of Science in PT (BSPT) degree is the academic requirement for being admitted to the profession in this country. Despite the importance of SR as a professional behavior, there is a lack of scholarly discourse on the topic, especially in Philippine PT education. Research into SR in PT is timely given the profession's transition to a more societal ethical framework.12,13 Furthermore, educating for values and professional identity formation is likely to involve large-scale, complex changes in education culture and perspectives, such as transitioning from traditional to more critical and transformative approaches. Research into SR in PT education is therefore needed, especially in the university providing the setting for the current study wherein SR is an institutional core value. Thus, this study aimed to explore the perspectives of this university's PT educators about their practice of educating for SR and to identify potential changes to strengthen their practice. It builds on the findings of a related study, which defined SR for Filipino physical therapists and identified a need to reform PT education going forward.21
REVIEW OF LITERATURE
Publications in medical and nursing education document the potential of some educational strategies to develop SR outcomes among students.25–32 Fewer papers are available in PT education, and these mainly focus on service learning as a strategy.33–37 For example, a study showed that improved SR was one of the perceived advantages of international over domestic service learning experiences among Doctor of Physical Therapy (DPT) students.36 Volunteering in community-engagement curricular activities34 and participating in a community-based project that used an interprofessional model33 also showed positive SR outcomes in some studies. Service learning is a highly endorsed strategy for building future health professionals' awareness of health care inequities.26,28,38 However, more than relying on service learning alone to develop students' SR, literature suggests integrating SR more widely into students' academic experience to allow a more meaningful and holistic development.10 For example in a nursing school, in addition to including SR in their formal curriculum, institutional approaches were adopted to enact SR (eg, declaration of institutional core values, opportunities for professional and political action).10 Concerted institutional efforts enable students to fully engage with SR by tapping into both the formal and the hidden curriculum. This suggests that although a service learning course/project could lead to students' improved SR, student development could be further enriched by integrating it in their entire learning environment.10
Fostering critical consciousness is also suggested in medical education literature to facilitate SR development. Critical consciousness about social justice in health involves analytical understanding of the social determinants of health (SDOH) that will prompt health professionals to take pragmatic action.29,31,32 Using critical pedagogy29 and teaching about SDOH29–31 are strategies identified in literature for fostering critical consciousness. These strategies allow students to recognize and challenge the problematic structures in health care and medicine, in general,29 and were found to have potential impact on students' awareness, confidence, and reflexivity.31 In PT, teaching about SDOH is essential for learning how to address the array of social issues affecting patients' access to PT.39 Developing critical consciousness takes time as it involves transformation of perspectives and behaviors.29,31 Enabling such transformation would require changes not only in the curriculum but also in educators' teaching philosophy and institutional culture, such as adopting a social justice framework in practice and education.29 Evaluating student outcomes also needs to occur over time and would require not only students' self-reports of improvement but also observation of such changes.29,31
Suggestions for educating for SR reflect a more progressive view on curriculum development. A traditional curriculum uses a teaching plan to promote students' acquisition of universal truths or essential competencies for social efficiency.40,41 However, this can seem prescriptive in what and how to learn, with teachers regarded as authorities on the knowledge to be transferred to students. The more contemporary lenses, such as social reconstructionism and critical theory, view a curriculum as promoting students' more active learning often toward reforming societies. Students learning from reflection and action, rather than rote learning, is vital to this process.40,41 These contemporary lenses render a curriculum less prescriptive, allowing students to be more autonomous and responsible for their learning process.
Curriculum orientations, which correspond to the above lenses, are suggested. Table 1 lists the qualities of each orientation. Recommendations from reviewed literature and the results of a Philippine study on PT SR perspectives21 imply that a “curriculum as praxis” orientation is the preferred way to educate for SR because of its focus on transformation. Praxis involves recursive engagement in critical reflection and action that is situated in the real-world and geared toward societal change.42,43 The goal of “curriculum as praxis” is the development of a critical consciousness manifested by a transformation of self and the situation.43 Critical consciousness, as earlier discussed, is essential for becoming a socially responsible health professional.
Table 1. -
Orientations to Curriculum
37,38
| Curriculum as Product |
Curriculum as Process |
Curriculum as Praxis |
| Technical interest Emphasis on controlling the environment to achieve predefined outcomes Focus on content More traditional |
Practical interest
Emphasis on interaction between teachers, students, and knowledge
Focus on processes that enable learning
Framed within traditional parameters |
Emancipatory interest
Emphasis on active learning and knowledge creation through action and reflection (praxis)
Emphasis on transformation of self and the situation
More progressive and critical |
No study in the Philippine context has explored educating for SR. Aside from the service learning studies mentioned earlier, international literature is likewise lacking. Alongside other PT knowledge, skills, and attitudes, SR is an expected and equally important graduate outcome and is therefore essential to be included in entry-level PT curricula. The lack of studies on educating for SR hints at the inadequate attention given to this essential professional behavior. A scholarly discourse about it is therefore called for.
METHODOLOGY
This qualitative study followed a participatory-based methodology for its focus on participants' democratic participation in the inquiry process to co-construct with the researcher knowledge that will have meaningful impact on their practice.44 Participants' collaborative involvement encourages ownership of the results, empowering them to commit to the application of findings in practice.44,45 This study was approved for implementation by the University of the Philippines Research Ethics Board (UPMREB 2020-411-01) and the University of Liverpool Doctor of Education Virtual Programme Research Ethics Committee.
Subjects
Participants were the first author's faculty colleagues at a Philippine university, who were chosen because of their unique context as academics in an institution with a distinct leadership mandate in contributing to national development.46 Its students, whose tuition fees are state-subsidized, are also obligated to render service back to the country after graduation. They are therefore expected by the public to embody SR and be part of the solution to the issues the country faces. This makes educating for SR all the more important.
Participants were purposively invited via email based on their key involvements in the institution (eg, curriculum development and management roles). Their roles and insights from these involvements were crucial in understanding various aspects of educating for SR and for applying the results in practice. As democratic participation is central to the participatory paradigm, an equal number of senior (with at least 10 years of experience) and junior (with less than 10 years of experience) faculty members were invited to ensure inclusion of diverse perspectives in the collaborative inquiry. Written institutional permission to do the study with the participants and written informed consent were obtained from institutional authorities and the participants, respectively, before study implementation.
Methods
The participants collaborated with the first author in identifying questions to be explored. This process was informed by the results of a related study that explored Filipino PT leaders' and practitioners' views on Filipino physical therapists' SR, which were shared with the participants before data collection.21 The process was also informed by what participants perceived as necessary to understand their practice and the research objectives. This collaboration resulted in 7 questions explored through focus group discussions (FGDs), with the first author serving also as moderator. The participatory study design required a moderator who had both etic and emic perspectives about the topic,47 which the first author exhibited given her knowledge from the literature and a related study with Filipino PT leaders and practitioners, and insider knowledge as member of the university.
Group discussions are frequent methods of data collection in participatory-based research allowing collaborative exchange of knowledge.47 The identified questions included: “how can we attract applicants who are genuinely interested in becoming physical therapists and serving in the Philippines; how does the faculty feel about being socially responsible, and how is SR shown to students; in what extracurricular activities are students being encouraged to participate; what specific strategies are being done to foster SR; how should SR be assessed; how are institutional-level programs utilized to help foster SR; and what is the extent to which our educational strategies facilitate students' development of SR?” Participants' collaboration with the researcher also allowed them to perform supplemental data collection (ie, review of syllabi and curriculum map) to address some of these questions.
Three FGDs were conducted via a secure online platform over 3 separate days in January 2021. Discussions were transcribed verbatim then translated to English. Transcriptions were analyzed by the first author using thematic analysis, wherein textual data were coded and then sorted into potential themes that captured shared meanings within the collated codes.48 Data analysis was done iteratively as new discussion transcriptions became available. This allowed previously formed codes to be reviewed and refined based on newly acquired data. Final themes were assigned labels to reflect their overall essence.
To address issues of bias arising from the participatory study design, the first author remained reflexive about her actions and thoughts throughout the research. She shared her reflections with the participants to introduce another viewpoint to the discussion as part of the collaborative process. She also debriefed and collaborated with her co-authors to discuss ideas, opening herself up to their critique and alternative views. Although the first author was not the most senior colleague, there was still potential influence of power difference between the participants and the first author. This was addressed by openly acknowledging its existence and by verbally expressing their commitment to a respectful and truthful discussion. This was achieved as each member brought important perspectives to the discussion. The study's trustworthiness was further ensured through member checking, wherein participants evaluated and confirmed the accuracy of the transcripts and themes. This procedure also reinforced the co-creation of knowledge as the group agreed with how the results were interpreted. A memo of researchers' interpretations, reflections, and decisions was also kept, allowing retracing and appraisal of procedures implemented.
RESULTS
Subjects
Six of the 15 eligible on-duty full-time BSPT faculty members were invited and they agreed to participate. This number of participants was suggested to be optimal for generating and managing responses in an FGD without undermining any of the members.49 All 6 had teaching duties and were also involved in key roles in the institution, including department management, curriculum development, college service programs, and student organizations. The participants' and first author's years of experience teaching BSPT students ranged from 3 to 30 years. Three of the participants had at least 10 years of experience teaching in the institution, whereas the rest had less than 10 years, including the first author with 9 years of experience.
Themes
The thematic analysis resulted in 3 themes that highlight the areas perceived by the group to be important for improving their SR education. Themes are defined by 1 to 2 levels of subthemes depending on the range of codes these encompass. The themes are treated as equally important. Table 2 shows the resulting themes, subthemes, and sample codes.
Table 2. -
Thematic Analysis Results
| Themes |
Subthemes |
Sample Codes |
| Tier 1 Subthemes |
Tier 2 Subthemes |
| Stronger curricular focus on SR |
Curricular improvements needed |
More deliberate teaching of SR |
Purposeful SR inclusion in syllabi |
| Developing students' awareness about societal roles |
Learning from professionals of different roles |
| Focus on Philippine social health issues |
Reflective dialogues about social issues |
| Use of learning portfolio |
Reflecting on SR experiences |
| Maximizing institutional programs for further SR experiences |
Capitalizing on institutional service programs |
|
Encouraging volunteering in school's service programs |
| Honing opportunities from student organizations |
|
Guiding planning of socially responsible programs |
| Providing opportunities for SR experiences |
|
Allowing time for extracurricular activities |
| Ensuring faculty role fit |
Mixed perception about being socially responsible |
|
Expression of SR mainly through being an educator
Lacking engagement in social issues |
| Crucial roles of faculty members in fostering SR |
|
Mentoring toward SR development
Role modeling SR |
| Faculty challenges |
|
Balancing teaching technical and affective components
Mentoring time demands |
| Need for capacity-building |
|
Upskilling for mentoring |
Abbreviation: SR = social responsibility.
The theme stronger curricular focus on social responsibility outlines the group's views about their work in engendering SR through the curriculum and the potential improvements needed. A participant summed up the group's view as: “I think this is something that we are still in the process of making more tangible or felt by the students or even by the teachers” (FGD03). This was attributed to a perceived tendency to focus more on helping students learn about the technical over the affective aspects of the profession, including SR. As participant FGD01 remarked, “students were constantly reminded to be mindful of their grades, and this most often meant being knowledgeable of the technical aspects of PT.”
The group discussed the need to be more deliberate in teaching SR and related concepts and issues through strategies such as purposeful and gradually progressed inclusion of SR in courses across the curriculum. This includes, for example, teaching about SDOH and the health care system and using problem cases illustrating prevailing Philippine health issues. Discussed also was helping students develop awareness and appreciation for what they can do for Philippine society, especially given the university's commitment to contributing to national development. Also mentioned were engaging students in reflective dialogues about active learning experiences on social issues to increase critical awareness, and using a learning portfolio for documenting and reflecting on SR experiences and mentoring them in transformational learning toward fulfillment of learning goals.
The theme maximizing institutional programs for further social responsibility experiences includes the group's thoughts about the institutional structures' contribution to student development. They agreed that their institution's service programs and student organization activities have a significant role in reinforcing the curriculum in student SR development, especially because these are also driven by SR as an institutional core value. Because these service programs (eg, school's therapy service program) were also being used as settings for clinical training, they were concerned that these were not being appreciated as opportunities to develop SR and were instead being perceived more as venues for gaining PT knowledge and skills. To better take advantage of these programs, the group suggested re-emphasizing the programs' SR focus to students, encouraging students to volunteer for these programs, guiding student organizations toward implementing more socially relevant activities, and ensuring reasonable student load to allow time for self-directed and reflective participation in these activities. As participant FGD04 argued, “maybe we also have a responsibility as a faculty—we need to ensure that their workload is reasonable because that is the usual reason being raised [for not participating in such activities].”
The last theme ensuring faculty role fit pertains to the group's insights about their roles and the demands of educating for SR. The group shared mixed feelings about being socially responsible themselves. Some expressed guilt for their lack of engagement in social issues, whereas others already considered their functions as educators as socially responsible endeavors. However, they all believed that their predisposition toward being socially responsible contributes to their ability to engender the same to their students. They acknowledged that it is important for them to take on more roles and tasks as educators. Aside from teaching about SR, they also noted the need to provide students opportunities to reflect on social issues, mentor them toward achieving SR outcomes, and step up as role models by being engaged in social issues themselves. They also identified possible challenges such as finding a balance between technical aspects of PT and SR when teaching, performing these additional tasks on top of their existing functions as academics, and working with limited resources (ie, time and staffing). They acknowledged the necessity for capacity-building to support them through these roles and challenges. As participant FGD04 shared, “having this discussion made me realize more that I am lacking a lot in [educating for SR], but I also do not know what to do.”
DISCUSSION AND CONCLUSION
The participants' collaborative exploration of their practice was an important first step toward realizing the improvements necessary for better SR education. Their reflections suggest developing a transformative praxis-based curriculum, together with maximizing the influence of institutional structures and ensuring educators' capability to implement it.
The first theme alludes to ensuring deliberate and adequate opportunities for developing social awareness and learning SR within the curriculum, including engaging in reflective dialogues on social issues, self-reflecting on active learning experiences, and planning for self-change. This is consistent with adopting a more progressive view on curriculum development such as “curriculum as praxis” owing to its transformative purpose toward students becoming more socially aware and responsive through recursive critical reflection and action.41–43,50 The curriculum could then become a means for developing critical consciousness through autonomous and critical understanding of the world,50 informing action toward transforming situations.32,42 Aside from the group's suggestions, literature emphasizes that fostering critical consciousness needs to be action-oriented so that informed committed action becomes part of professional practice.29–31,51 A possible solution is for educators to provide opportunities for students to develop “equity-focused” skill set31 (eg, problem-solving and advocacy) and humanistic values such as empathy.30 A specific example is providing learning opportunities around PT fundamental interventions, which address social issues affecting access and equity in PT.39
Taking a curricular approach could also facilitate a more comprehensive SR education, which literature also suggests would benefit student development.10,29 The focus group's idea of a purposeful and gradually progressing inclusion of SR as a graduate outcome across the curriculum aligns with this. This requires revisiting the curriculum map to identify courses for SR learning and development, creating SR learning outcomes as appropriate, and designing teaching–learning and assessment strategies to achieve the outcomes.52 However, this would seem prescriptive and would contradict the autonomous learning espoused by “curriculum as praxis.” In a PT curriculum with predetermined outcomes, balancing outcome-based and constructive learning approaches in the curriculum could be essential for a more holistic student development.53 The strategies identified by the participants (eg, teaching about SR-related concepts, and providing opportunities to reflect on real-world experiences and to plan for action) illustrate this. These strategies align not only with suggestions from literature on developing critical consciousness,30,31,51 but also with learning requirements for designing interventions aimed at addressing patients' SDOH-related issues.39 Most of these strategies are already being implemented in the focus groups' academic program after results dissemination to the rest of the program faculty. Specifically, the faculty has revisited the mapping of SR across the curriculum. The next steps are including well-defined learning outcomes and mapping educational strategies and opportunities for praxis in relevant course syllabi.
Part of the broader curricular approach is designing assessment procedures. The focus group's suggestion of using a learning portfolio could be useful not only for facilitating development of critical consciousness through self-reflection and reflective dialogues with mentors, but also for assessing students' autonomous learning and development of SR. However, achievement of SR outcomes in relevant courses will also need other forms of formal assessment. An example could be evaluating knowledge gained about SR-related concepts and their application in actual and practice cases.
The second theme suggests furthering students' experience of SR by maximizing the influence of institutional structures and programs, which are considered part of the hidden curriculum, on student development. This is supported by literature,54 suggesting that the hidden curriculum, including institutional programs, norms, and culture, has rich potential to complement the formal curriculum in accomplishing its learning goals for students.50,54 Given the university's commitment to SR, its culture and service programs are readily available resources that can be capitalized on to further embed this explicit value in student experience. Although these culture and service programs already support formal training, educators could also help students more clearly recognize them as opportunities to support their autonomous learning and achievement of SR outcomes beyond their courses. Literature argues that students need to self-directedly engage in developing their graduate attributes and professional identities.55 Participating in co-curricular/extra-curricular activities plays an important role here.55 Educators could help students by mapping extra-curricular opportunities against course learning outcomes to promote understanding of how such activities can support their learning.
Results pertaining to the theme “ensuring faculty role fit” are also crucial for implementing a curriculum that engenders SR. The participants' ideas on their role in SR education concurred with the literature. These roles include being critically conscious on social issues in health, knowledgeable on SR-related concepts, and able to mentor toward praxis.29,31 Literature likewise supports the participants' remarks that educators also have a role beyond the formal curriculum to model SR to students as doing so also significantly contributes to their development.9,54,56 Ensuring faculty fit to the role of educating for SR is therefore fundamental. This could start from faculty recruitment by inquiring into how their values, teaching approaches, and educational perspectives align with institutional and professional SR agenda as those will serve as framework for their teaching practices.57 Employed educators' continued socialization into the institution's culture of SR and strategic professional development could further support working with students on developing SR. For example, some participants recognized the need for upskilling on mentoring students toward becoming socially responsible. Educators may also need support in implementing a curriculum that balances achievement of graduate outcomes with autonomous, transformative learning through praxis. Aside from targeted trainings, mentoring or coaching less-experienced educators by those with in-depth understanding of curriculum of praxis could support these professional development needs.58
The focus group and the first author aim to improve their practice of educating for SR by using the practical knowledge gained from this study. The discussions highlighted the need to strengthen the transformative function of their curriculum to support students' SR development. With the rest of the program faculty, they are taking a broader curricular approach in integrating SR more purposefully across the curriculum, providing appropriate educational strategies and adequate opportunities for acting and reflecting on social issues affecting PT access. Such curricular changes will be difficult to achieve and will require persistent review and reiteration of its importance. A comprehensive curriculum evaluation and revision plan, supported by leadership aligned with the SR agenda, may be needed to inform succeeding actions and achievement of desired outcomes.
Limitations
The study design limits the generalizability of its results to other contexts. The results and conclusions drawn from this research are based on the perceptions of a small number of university educators about their teaching context. The study's participatory design also poses potential biases. However, procedures (eg, member checking, reflexivity, and peer debriefing) were used to ensure that the results are accurate representations of the participants' actual experiences and perspectives (ie, credibility and confirmability).
Despite its limitations, transferability is still possible as this study offers a case on which reflections could be based for other contexts. The study enjoins PT educators to reflect on the SR agenda of their PT programs, whether they be BSPT or DPT, because all physical therapists must embody SR, and doing so requires lifelong development. Physical therapy educators and curriculum developers are encouraged to evaluate their curricula's ability to transform students into socially responsible physical therapists. Taking a whole-of-curriculum approach is potentially the ideal way going forward to ensure gradual and holistic student development. A promising solution is adopting a curriculum orientation allowing adequate opportunities to develop critical consciousness through recurring reflection and action on social issues affecting PT access. For DPT and other postgraduate PT programs, emphasis could additionally be placed on theoretical underpinnings of SR to understand the necessary shift to a societal approach for ensuring universal access to PT. Potentially important as well is placing emphasis on developing leaders in the profession to take this SR agenda forward at a program, institutional, or community level.
The study also offers insights on the need for PT educators to explore how their institutional structures influence student development and how these could be maximized to complement the curriculum. Findings also indicate the need to understand educators' perspectives about SR education and the support they need for this task given their key role in effective curriculum implementation and student development. Overall, educating for SR implies systemic changes in educational culture and perspectives to integrate SR widely into students' academic experience and ensure SR development. This study provides important foothold on viable solutions for this. With the advancements in PT education and the increasing importance of physical therapists in the Philippines and globally to respond to unmet rehabilitation needs, now is the opportune time to strengthen SR in the PT curriculum. The social issues that affect people's overall attainment of health especially during this time of ever-changing health and sociodemographic profiles amplify this urgent need.
This study is the first to engage in the topic of educating Filipino PT students for SR. Although much still needs to be done to advance this concept in the local practice, this study offers insights on what SR education may require. Future studies in the wider PT education field could include inquiry on the effectiveness of the aforementioned strategies in fostering SR and evaluating students' learning experiences.
FUNDING
This work was supported by a doctoral fellowship granted to the first author from the Faculty, REPS, and Administrative Staff Development Program of the University of the Philippines.
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