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A Pediatric Service-Learning Program in Physical Therapy Education

Hou, Yu-Jen PT, MS; Liu, Wen-Yu PT, PhD; Lin, Yang-Hua PT, PhD; Lien, Hen-Yu PT, PhD; Wong, Alice M. K. MD; Chen, Chien-Min MD

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doi: 10.1097/PEP.0000000000000498
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INTRODUCTION

Service learning is “an effective method for students to garner real-world learning, enhance students' knowledge and attitudes related to professional issues, and foster commitment to service while offering meaningful service to their communities.”1 Service learning has been integrated into entry-level physical therapy (PT) education since 2003,2 and at least 28 studies have since shared service-learning experiences in relation to PT education (Table 1).2–29 The targeted population of 12 of these studies was at least partly pediatric, including school-aged children,25 high-school athletes,7,17,29 children in disadvantaged socioeconomic conditions,4,8,12,13,17,22 and children with obesity,10 hearing impairment,22 autism,14 cerebral palsy (CP),14 or general disabilities.3 Furthermore, at least 5 of these 12 programs involved interprofessional training. However, our review of these studies revealed a lack of reports on such service-learning experience in entry-level PT education in Asia, including pediatric PT. Therefore, the purpose of this report was to describe a service-learning program in entry-level PT education in Taiwan.

TABLE 1 - Previous Studies That Have Shared Service-Learning Experiences Related to Physical Therapy Education
Authors Year Country University Student Characteristics Service Recipients Mode of Service Prerequisite Duration of Service Credits
IPE PT Education PT/Total Children Others
Johnson & Howell 201715 USA University of Kentucky Y DPT 6/15 Y Direct Y 5 d N
Altenburger & Wilson 20173 USA Indiana University Y NS 22/37 Y Direct NR 2∼3 h NR
Hayward et al. 201614 USA Northeastern University Y DPT 3/5 Y Direct Y 9 d Y
Stemmons Mercer et al. 201428 USA University of North Carolina Y NS 28/149 Y Direct Y 1 d N
Seif et al. 201426 USA University of South Carolina, Charleston Y NS NR/232 Y Direct Y > 4 times/sem for 1 sem Y
Nowakowski et al. 201424 USA Springfield College DPT 126/126 Y Direct Y 20∼24 h over 4 sems Y
Mai et al. 201320 USA Clarke University DPT 61/61 X Direct NR 2 h/wk over 3 sems Y
Wise & Yuen 201329 USA Medical University of South Carolina DPT 42/22 Y Y Advocacy Y 10 wk NR
Black, Palombaro, & Dole 20136 USA Widener University DPT 18/18 Y Direct Y 1 y N
Hayward & Charrette 201213 USA Northeastern University DPT 28/28 Y Direct Y NS N
Lattanzi et al. 201119 USA Widener University DPT 78/78 Y Indirect Y 2 d NR
Furze et al. 201110 USA Creighton University DPT 47/47 Y Direct Y 1∼6 h Y
Buff et al. 20118 USA Medical University of South Carolina Y DPT 96/96a Y Advocacy Y NS N
Shrader, Thompson, & Gonsalves 201027 USA Medical University of South Carolina Y NS 10/113 NS NS Direct Y 20 h/sem Y
Gazsi & Oriel 201011 USA Lebanon Valley College DPT 17/17b X Direct Y 3 h Y
Flinn et al. 20099 USA Ohio State University Y NS 77/133 Y Direct and advocacy Y 8 h Y
Begley et al. 20094 USA Creighton University Y NS NR/52 Y Advocacy NR 3 times N
Kelly & Miller 200817 USA University of Indianapolis DPT 24/43 Y Y Direct and advocacy Y > 30 h NR
Romani & Holbert 200725 USA University of Maryland, School of Medicine DPT 32/32 Y Y Direct and/or advocacy Y 7-10 d NR
Neill et al. 200723 USA Idaho State University Y >BS 24c/114 Y Direct and advocacy NR 3 d/wk; 2∼15 wk NR
Krause 200718 South Africa University of the Free State BS NR/6 Y Direct and/or advocacy Y 1 × /2 wk for 2 × NR
Brown & Wise 20077 USA University of South Carolina NS 121/121 Y Direct Y NS NR
Michaels & Billek-Sawhney 200621 USA Slippery Rock University NS 38/38 Y Direct and advocacy NR 2 sems Y
Johnson, Maritz, & Lefever 200616 USA University of the Sciences Y NS >300/NR Y Direct NR 1 night/wk N → Y
Gupta 200612 USA College of St. Catherine Y NS NR/NS Y Y Direct Y 18 h Y
Musolino & Feehan 200422 USA Florida Gulf Coast University NR 24/24 Y Direct Y 1 sem Y
Belingd 2003, 20042,5 USA California university NS 40/40 Y Direct Y 2 h/wk NR
Totals 28 USA: 27 21 IPE:12 DPT: 13 1262/1667 12 19 22 Y: 12
Abbreviations: BS, bachelor of science; DPT, doctor of physical therapy; IPE, interprofessional training; NR, not reported; NS, not specified; sem, semester.
aNinety-six participants initially, but only 78 were included for data analyses.
bOne out of a total of 18 students did not participate due to illness.
cCount of PT and occupational therapy (OT) students.
dTwo studies conducted on the same group of PT students.

DESCRIPTION OF THE PROGRAM

The Department of Physical Therapy at Chang Gung University (CGU), Taiwan, offers a 4-year baccalaureate degree for entry-level PT students, as well as advanced graduate programs in rehabilitation science. Like other entry-level programs in Taiwan, students participate in didactic lectures and laboratories for the first 3 years of their degree, and complete a clinical practicum in their final year.30 In order to take the PT license examination in Taiwan, PT students have to complete at least 240 hours in pediatric and/or cardiopulmonary clinical internships at teaching hospitals. Prior to their preclinical practice, Taiwanese PT students tend to have limited relevant experience in interacting with children, especially children with special health care needs (CSHCN), and their families. For example, prior to their final-year clinical practicum, PT students at CGU only participate in formal clinical observations in a group setting for approximately 9 hours in their third year. Taiwanese PT students, including those from CGU, commonly report feeling anxious during their pediatric clinical practicum. A previous systematic review by Satchidanand et al also suggests that health care students who lack knowledge and service experience may feel fear and anxiety about caring for people with physical disabilities.31 Consequently, the faculty believed that alleviation of these fears and anxieties during the clinical practicum, especially when CSHCN were involved, appeared to be important. At the same time, the need to provide recreational experiences for children with CP was identified by the Cerebral Palsy Association of Taoyuan City, Taiwan. To meet the needs of the Taoyuan City community and provide preclinical experience with CSHCN to entry-level PT students, a 2-day camp-style service-learning program with children with CP has been run at CGU since 2012. The process of developing this innovative pediatric service-learning program is described.

DESCRIPTION OF THE SERVICE-LEARNING PROGRAM

Recruitment of Volunteer Students

The willingness of first-year entry-level PT students to participate in the service-learning program was surveyed at the end of their first semester. Once the students agreed to participate in the program, 2 student coordinators were identified. They recruited 20 students to be group leaders, divided into 2 task groups: the caring group and the activity group. The caring group was tasked with designing activities to promote the children's interaction with unfamiliar people in his or her subgroup, and to facilitate their participation in all activities during the 2-day program. The activity group designed scavenger games for the younger children and then worked with teenagers to serve as keepers for the scavenger games. In addition, the students in the activity group were asked to promote self-expression and independency in the teenagers. With help from faculty members and graduate students, the PT students planned their activities throughout the second semester. When they had completed the first draft of their activity plan, they tested the feasibility of their activities with 2 to 3 children with CP, and then modified the activities as required. In addition, the student coordinators recruited another 50 to 60 volunteer students for the 2-day camp. These students were recruited from the PT department, but also and other departments at CGU, to form an interprofessional team.

Training Program for Volunteer Students

To gain the basic knowledge and skills required for the program, the group leaders attended a 2-session training program in their second semester. The other volunteer students participated in the same training 3–4 days before commencement of the camp. The training consisted of 2 volunteer training sessions and 2 assigned readings related to communication and behavioral management, and emergency care for children. Topics covered in the training sessions included effective lifting, carrying, and transfer skills for preventing work-related injury (2 hours), followed by a brief introduction to children with CP (2 hours). This was in the form of didactic lectures and hands-on laboratory tests. To encourage peer mentorship, the instructors were postprofessional graduate students and/or young alumni who had recently passed the PT license examination. Upon completion of this training, the students had to pass an examination using a team-based learning approach,32 which included individual readiness assurance testing followed by immediate feedback assessment in small-group discussions.

Execution of the Service-Learning Program

The 2-day camp took place at the Chang Gung Health and Culture Village, Taiwan, which was designed as a least restrictive environment for the elderly. In this village, there were guest house, activity centers, and gymnasiums. The camp was attended by children with CP and their family members (usually their parents). Activity announcements were posted on the websites of the Cerebral Palsy Association of Taoyuan City and Chang Gung Memorial Hospital, Taiwan. Family members who were interested in the activities could send their information (such as diagnosis, Gross Motor Function Classification System,33 Functional Mobility Scale,34 Manual Ability Classification System,35 and Communication Function Classification System36) with the help of their service providers, such as physical therapists, to the Cerebral Palsy Association of Taoyuan City. The children and their families participated in this camp voluntarily, based on first come first served, unless there were health concerns such as uncontrolled seizure. The children and their families stayed at the camp for 2 days and 1 night at the guest house in the village. Chang Gung Memorial Hospital provided a budget for housing and food for the children and their families during the camp. CGU waived the dormitory fee for 1 week for volunteer students, as well as expenses for 5 meals and transportation for 2 days from the university to the camp. While the children participated in the activities run by the students, their family members attended parental empowerment seminars and leisure activities. For safety, children were divided into 5 small groups, and each group had at least 1 postprofessional graduate student from our departments or an alumni who had a licensed PT.

After the camp, the students were given certificates indicating the number of hours for which they had volunteered, which counted toward the service credits required for graduation from CGU. All the students and children were encouraged to complete and share reflective reports on the experience. In addition, the student coordinators were required to submit a final-outcome report to the Office of Student Affairs to obtain financial reimbursement from the university.

DESCRIPTION OF OUTCOMES

From 2012 to 2016, 356 volunteer students and 286 children participated in the service-learning program (Figure 1). Approximately half of the students were entry-level PT students (37%–62%). The requisite professional attributes identified by the World Confederation for Physical Therapy (WCPT)37 were apparent in the students' reflective reports (Table 2). Despite schedule conflicts for students who were unable to help with the training of the next group of volunteers during their entry-level PT education period, there were at least 4 students who became instructors for volunteer students after becoming postprofessional graduate students. Furthermore, at least 3 alumni per year volunteered again to be shepherds for safety.

Fig. 1.
Fig. 1.:
Volunteer students and child participants participated in this service learning program.
TABLE 2 - The Requisite Professional Attributes Identified From Students' Reflective Reports According to WCPT guidelinea
Professional Attributes Content of Reflective Reports From Participants Corresponding Behaviors
Altruism Participating in the Cerebral Palsy Camp activities is a meaningful and purposeful activity that benefits both others and oneself.... Incorporate free/voluntary/pro bono services (e.g. voluntary service overseas, riding programs for those with disabilities, free services to the homeless) into practice.
Compassion/caring Generally, most children already felt contented when they could participate in simple activities with someone in company. ... Promote active involvement of the patient/client in his or her care/intervention/treatment.
Cultural competency ...I would treat them with a different attitude, bearing no further grudges.... Manage patients/clients and interact with colleagues in a manner that is nondiscriminatory and nonoppressive.
Personal/professional development I reflected myself that I should try to solve the problem or to seek help from the teachers, rather than being affected by my own emotions.... Reflect and modify behavior in the light of experience and advice.
Professional duty The preparation of the activity had already started before the summer vacation. During the pre-camp training, we learned how to accompany the children with CP and learned the passwords of the children with CP; in this way, we got to know their conditions and provide the most appropriate assistance.... Participate in activities that support the development of the profession and patient/client services.
Social responsibility and advocacy ... Apart from liaising with the three parties, the Cerebral Palsy Association of Taoyuan City, Chang Gung Health and Culture Village, and Taoyuan Bus Company, the general and vice coordinator both took over the administrative matters of the school, including miscellaneous affairs, regardless if it were large or small.... Participate and show leadership in community organizations and volunteer service.
Teamwork Passionate volunteers are all around and each performed their duty, just like a production chain that can only be seen in a large enterprise.... Understand the roles of different health and social care professionals involved in the management of patients/clients.
aFrom World Confederation for Physical Therapy.37

DISCUSSION AND WHAT THIS ADDS TO EVIDENCE-BASED PRACTICE

Although we did not plan to measure changes in the students, we did observe positive preliminary outcomes. For example, there was a good turnout of both students and participants, and the reflective reports suggested that the program may have succeeded in nurturing some of the requisite professional attributes in the PT students. Previous studies have suggested that service-learning programs involving CSHCN may enhance students' core professional affective,17 psychomotor,14,17,22 and cognitive skills.14,17 The service-learning experience provides students with a rich opportunity to apply their new skills and knowledge in a range of contexts.2,5,6,20,22 The Academy of Pediatric Physical Therapy, American Physical Therapy Association, recommends using service-learning activities to nurture at least 2 essential core competencies for entry-level pediatric PT education,38 viz. to “implement age-appropriate and developmentally appropriate procedural interventions including play/recreational activities, natural environment, toys, and equipment” and to “educate caregivers about age-specific and developmentally appropriate environmental safety considerations.” It may be worthwhile to assess the immediate and long-term impact of our pediatric service-learning experience on the students' core professional attributes; indeed, we are currently working on a study that examines its immediate impact. Therefore, we can compare these service learning experiences to those in Table 1 in the future.

LIMITATIONS

We note that there were some barriers to participation in the service-learning program. First, participation was not mandatory for our entry-level PT students. Because the majority of the students participated in the program at the end of their first year, that is, before they had received any professional education, they received training in some requisite knowledge and clinical skills from their senior peers. Consequently, their experience and knowledge were not equivalent to those of a second- or third-year student who has received professional education. The effect of this on their motivation to learn, their performance, and their achievements might need to be further monitored. Furthermore, the effect of mentorship by their senior peers may also need to be investigated, especially since we observed different teaching styles among these senior students. In addition, in contrast to previous reports, the majority of students in our program were entry-level baccalaureate degree students, rather than entry-level doctoral degree students. Their comparative rate of acquisition of skills, experience, and knowledge may be worthy of future investigation.

Although feedback from students was collected by the student coordinators each year, as requested by the university, the usefulness of the feedback was relatively limited because it frequently focused on the playfulness of the scavenger games and the quality of the meals. In the future, the gathering of more useful information, such as students' impressions of the training, content and structure, and most importantly whether the students felt better prepared to work in a pediatric setting during their clinical practicum and/or after graduation is needed. Each year we receive feedback from the families and children. Their positive feedback has encouraged us to continue this service-learning program.

Finally, this service-learning program was delivered by an interprofessional team, which provided students from different disciplines with the opportunity to work together. Strategies for the promotion of interprofessional cooperation should be addressed in the future.

In conclusion, this report shares our experience in establishing a pediatric service-learning program in Taiwan. Our results suggest that this program has positive effects on fostering the development of professional attributes in entry-level PT students. Examination of the immediate and long-term effects of the experience on the students may be warranted.

ACKNOWLEDGMENTS

We are grateful for financial support from the Office of Student Affairs of Chang Gung University, Department of Physical Medicine and Rehabilitation of Chang Gung Memorial Hospital in Linkou, and the Cerebral Palsy Association of Taoyuan City, Taoyuan City, Taiwan. Finally, we thank the children, their families, and the students for their participation. We thank Uni-edit (www.uni-edit.net) for editing and proofreading this manuscript.

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Keywords:

education; pediatrics; physical therapy; service learning

© 2018 Academy of Pediatric Physical Therapy of the American Physical Therapy Association