Service-Learning in a Clinical Curriculum:
A Case Study
Department of Physical Therapy
Western Carolina University
Cullowhee , North Carolina, USA
Physical therapy (PT) students participated in a service-learning project in which they provided clinical anatomyworkshops with prosected (previously dissected) cadavers for physical therapist assistant students from a nearby community college. Topics included the respiratory system, nerves of the arm, and shoulder rotator cuff muscles. Each workshop covered basic anatomic principles, selected pathologies and treatment options. Pre- and post-tests were used to determine whether curriculum objectives had been met. Workshop evaluations provided important feedback. PT students maintained reflection logs throughout the service-learning project. Responses from the workshop evaluations and the student reflections indicated that this was a valuable learning experience for both groups of students.
Service-learning is an educational strategy that is being incorporated into many disciplines in higher education. It is an instructional method that utilizes the concept of active learning by the acquisition of skills and knowledge through service to the community (Hatcher and Bringle, 1997). Service-learning involves community service activities based on educational goals. Proponents of service-learning are careful to point out that this type of learning strategy differs from community service or volunteerism in which service is at the center, rather than learning (Furco, 1996). Indeed, the hyphen in service-learning suggests a dependent relationship between the two components (Jacoby, 2001). The concept of service-learning has been around for a long time. In 1979 Robert Sigmon characterized service-learning as a kind of “reciprocal learning”. Students are not working for the community, but rather with the community. As a result community members also learn from the experience. Bringle and Hatcher (2002) stress that service-learning builds important campus-community partnerships that can have a positive impact on both the student and the community.
In addition to clinical experiences or internships many health care education programs are now incorporating service-learning into their curricula as a type of experiential learning. Siefer (1998) suggests that service-learning differs from traditional clinical experiences because the service component involves community partners and gives students an opportunity to meet community needs while also meeting curriculum goals. Service-learning activities help students in health care professions become an integral part of the community and foster relationships that will benefit these students in their clinical careers (Ferrari and Cather, 2002).
At Western Carolina University (WCU) service-learning has been a part of the Master’s in Physical Therapy (PT) curriculum for several years (Little, 2000; Starr, 2000a, 2000b). The primary mission of the PT department is to graduate physical therapists that can practice autonomously in a variety of settings. Upon graduation PT students will be involved in physical rehabilitation following injury or illness, trainingand education to restore and maintain health, and research to develop new therapies and techniques for rehabilitation. As part of the PT curriculum at WCU, PT students develop service-learning projects that meet one or more of the department’s educational goals.
An important component of the service-learning strategy is reflection on the process. Throughout the service-learning project PT students maintain a weekly reflection log. Student reflections address what they are doing, why they are doing it, and how they are benefiting from the experience. Hatcher and Bringle (1997) state that reflection connects the service activity to learning by forcing students to focus on the experience in relation to the educational goals. Community-based service-learning has been shown to develop critical thinking skills in nursing students as indicated by their written reflections (Sedlak, Doheny, Panthofer, and Anaya, 2003).
The purpose of this paper is to describe a service-learning project completed in 2004 by three PT students in which they organized clinical anatomy workshops with prosected cadavers (cadavers previously dissected by PT students) for physical therapist assistant (PTA) students from a local community college. In health care settings the PTA performs certain physical therapy procedures selected by and under the direct supervision of the PT. The PT, therefore, must have a firm understanding of the academic background of the PTA in order to provide the best quality of care for the patient. Robinson et al. (1994) distributed two surveys in 1986 and 1992 to evaluate the physical therapists’ perceptions of the role of the PTA in the health care setting. Although survey results indicated that the therapists’ perceptions of the PTA’s role were, in general, consistent with the published guidelines for practice, there were misconceptions about the role of the PTA in certain selected activities. To help PT students better understand the role and academic backgrounds of the PTA, this service-learning project was developed to provide an opportunity for PT and PTA students to interact with each other in a teaching/learning environment.
To determine the type of teaching/learning experience that would be most beneficial for PTA students it was important to understand the PTA curriculum and the needs of the practicing PTA. Two PT students from the class of 2000 gathered this information from surveys distributed to PTA programs and practicing PTAs in North Carolina. PTA faculty indicated a desire to enhance the anatomy content in their curricula using alternative teaching strategies, such as cadaver dissections. Practicing PTAs responded that access to cadavers would have improved their clinical knowledge. Their opinion is consistent with published survey data collected from occupational therapists, physician assistants, and physical therapists licensed in the state of Texas, in which the single most recommended teaching method involved the use of human cadavers (Latman and Lanier, 2001).
Developing a Project that Meets Curriculum Objectives
Based on the needs-assessment surveys the faculty advisor worked with PT students to develop a service-learning project in which clinical anatomy workshops with associated prosections would be provided for PTA students. Prosected materials were obtained from the cadaver dissections performed by first-year PT students as part of their two semester human gross anatomy course. While this service-learning project was first implemented in 2000, this paper will describe the project completed by three PT students in 2004. For the PT students, a key component of this project was an opportunity to develop their teaching skills. Thus, this project met two WCU PT program curriculum objectives: (a) communicating effectively with multiple audiences using appropriate strategies and technologies, and (b) employing effective educational strategies and technologies when teaching audiences with varied needs. Providing opportunities for PT students to improve their communication skills is vital to their becoming effective clinicians because a primary role of the PT is patient education (Chase, Elkins, Readinger, and Shepard, 1993).
Three PT students chose to participate in the service-learning project because of their desire to teach, to interact with PTA students, and to deepen their knowledge of clinical anatomy. The clinical instructor at the community college PTA program acted as the community liaison helping the PT students to develop the workshops. After reviewing the PTA program curriculum objectives with the community liaison, the PT students selected the respiratory system, the nerves of the arm (known as the brachial plexus) and the shoulder rotator cuff muscles as workshop topics. Each student was required to develop the content and lead one workshop. All the students, however, were involved in teaching the three workshops.
Learning Contract and Permission for Human Subject Research
Before beginning the service-learning project the PT students wrote a learning contract to outline the details of the project. Included in the learning contract were the purpose of the project, the learning objectives for the PT students, the methods used, a description of the literature review that would provide background information, and a timetable for completing all facets of the project. The PT students were also required to develop grading criteria by which their performance would be evaluated. The final contract was signed by the three students, the community liaison, and the faculty advisor.
Since each workshop included collection of data related to the PTA students’ performance on pre- and post-tests, the PT students were required to complete a Request for Review of Human Subjects Research form which was submitted for approval to the WCU Institutional Review Board. All PTA students who attended the workshops voluntarily gave informed consent to participate in the service-learning project.
Students’ Literature Review
The PT students developed a literature review to provide evidence that they had read the current literature as foundation material for each workshop. Using appropriate journal articles or other sources they defined service-learning and how it specifically related to their project. They also summarized the previous needs-assessment surveys and discussed how the findings supported their work. Since one aspect of
the project was to foster a better understanding of the PT/PTA relationship, the PT students researched the role of the PTA as it relates to the practice of a PT. To insure that their workshops addressed the needs of the PTA curriculum, the PT students described how this service-learning project met the course objectives of the PTA program at the participating community college. They also summarized several current journal articles on the clinical topics they had chosen and on the efficacy of using cadavers for human anatomy instruction.
Designing the Clinical Anatomy Workshops
The three workshops covered basic anatomic principles, selected pathologies and appropriate treatment options. For each workshop the PT students developed a list of learning objectives that were approved by both the community liaison and the faculty advisor. The workshops were approximately two hours in duration, beginning with classroom activities followed by a study of related cadaver dissections. PT students developed a detailed lesson plan, created presentations with handouts and overhead transparencies, and produced interactive laboratory exercises. Since the PTA students attending these workshops did not have previous experience working with cadavers, the PT students also discussed appropriate ethical behaviors when working with cadavers (Starr, 2003). Prior to conducting the workshops, the PT students did a mock presentation for other members of their own class. Using feedback from their peers, the PT students modified the workshops before their final presentation to the PTA students.
Assessment of the workshops
Ten to twelve first and second year PTA students attended the workshops. To determine whether the learning objectives had been met, PTA students were given pre- and post-tests at the beginning and end of each workshop. Knowledge of the same material was tested using a multiple-choice question format on the pre-tests and a fill-in-the-blank format on the post-tests. Test results were evaluated statistically and summarized to determine the effectiveness of the presentations. Mean test scores for the pos-tests were higher than those for the pre-tests in all three workshops. Using dependent t tests, scores were significantly
higher for the brachial plexus workshop (t = -5.511, df = 9, p < .001) and the shoulder rotator cuff workshop (t = -4.722, df = 11, p < .001). The PT students were asked to discuss how the data related to their teaching effectiveness as part of a comprehensive notebook of materials they submitted to the faculty advisor at the conclusion of the service-learning project.
PTA students provided feedback on the workshops by completing evaluation forms. They were asked to assess whether workshop information was helpful and appropriate in difficulty, whether instructional tools (handouts, diagrams and overhead transparencies) were adequate, whether the PT student instructors were well prepared, and whether cadaver dissections were useful for understanding the clinical topics. They were also asked to comment on the most beneficial and least effective aspects of the workshop and to provide suggestions for improvement. Responses on workshop evaluations were very positive. PTA students consistently expressed a desire to spend more time in the cadaver lab.
PT Student Reflections
As part of the service-learning protocol, PT students were asked to maintain a weekly reflection log of the service-learning experience. In their reflections they were to address what they had learned, how they felt about the learning experience, and how they would apply what they had learned. It was possible to see a progression in the students’ thoughts about the experience as the project moved forward.
One PT student, who had been a practicing PTA for 15 years prior to entering the PT program, wrote in her reflections “spring semester [the faculty advisor] planted the idea of my choosing this project. I am just now realizing how much of a complement it will be to my overall education. I am very excited to be participating in this partnership.” As the PT student developed her workshop she reflected, “I had initially been disappointed that I was to prepare and teach a lesson on the brachial plexus and related injuries. I felt that it was somewhat uncommon and I would rather do something that would be more
clinically relevant. But after reflecting on the issue, I have realized that this may not be something that the PTA students get much exposure to. That is the whole point of this project, to present them with information that they may not have gotten otherwise. I too will benefit from something that I don’t know a whole lot about.”
Another PT student, who was formerly a high school teacher, wrote in his reflections “I did know from my previous teaching experience that there is a lot of extra time required to be prepared for a lesson. It has been interesting to observe the newly gained respect my peers now have for teaching.” He also wrote, “I feel that this is a great opportunity for us as student PTs to share the wealth of knowledge we have acquired with our soon to be peers.” As the time approached for him to present his workshop, the PT student wrote “I am very excited to have the opportunity to teach once again. I will use my excitement to propel me through the rest of this project, while insuring that I am giving the students the best class possible.”
The third PT student, who was new to the health care profession with no previous teaching experience, wrote in her reflections “I have learned that our service-learning project will be a detailed and challenging assignment. Organization and time-management will be important goals.” As the PT student began to prepare for her workshop she noted “I was able to complete a broad outline [of the workshop] this morning, so that has encouraged me some, and I feel like I know what needs to go in the holes.” On the day of her workshop she wrote “the workshop itself was really fun, and it went by quickly! The cadaver lab went well and the students improved on their post-test scores with regards to knowledge about the muscles.”
It was apparent throughout their reflection logs that the PT students developed a greater understanding of the importance of planning and organizing in order to meet curriculum objectives. Their reflections also addressed the importance of good communication skills, not only in the presentation of their workshops, but in the teamwork necessary for developing the workshops. In addition to the weekly reflections the PT
students also shared their experiences in videotaped interviews for future PT students who may also be interested in this service-learning project.
Revision of Earlier Service-Learning Projects
This service-learning project was first implemented in 2000 with two second-year PT students developing and presenting three clinical anatomy workshops for PTA students. This project was briefly described in the HAPS EDucator, the official publication of the Human Anatomy and Physiology Society (Starr, 2000). In the current service-learning project implemented in 2004, several significant changes were made to enhance the learning experience for both the PT and PTA students. While in the initial project two PT students worked together to produce three workshops, in the current project three PT students were recruited so that each student would be personally responsible for creating a workshop. These PT students worked much more closely than previous students with the community liaison to develop workshops specifically tailored to the course objectives of the PTA program.
The literature review was expanded to include information from several current peer-reviewed journal articles about the latest physical therapy techniques related to the workshop topics (a form of evidence-based practice). More information was included from peer-reviewed journal articles relating to the use of cadavers as an instructional tool for teaching anatomy. A discussion on how the needs assessment related to the implementation of this project was also added to the literature review.
Students participating in the earlier service-learning projects asked for more feedback on their teaching. To provide greater feedback the PT students in the current project did a mock presentation for peers prior to implementing the workshops in order to help determine whether the presentations, handouts and tests were appropriate and meaningful. A formal written evaluation by the faculty advisor at the completion of each workshop also provided important feedback.
In earlier service-learning projects PT students compared performance on pre- and post-tests by determining whether the number of correct answers increased from pre- to post-test scores. No formal statistical analyses were done. Since students in the current service-learning project would be required to present their results in a poster session at a national conference, they were required to perform statistics on pre- and post-test results in order to analyze the test scores. They were also required to obtain approval from the WCU Institutional Review Board for a review of Human Subjects Research in order to publish these results.
In earlier service-learning projects PT students only wrote reflections at the end of each workshop summarizing their performance. In the current project students were required to maintain weekly reflections in order to think more about what they were learning during the process of developing the workshops rather than focusing solely on the results of the project.
Service-learning is an instructional strategy in which learning is accomplished through a community service activity. The learning experience must be directly tied to educational goals. In this service-learning project the educational goals for the PT students were to learn more effective communication skills and to be able to teach using multiple teaching strategies. The community service activity used to accomplish these goals involved having PT students implement clinical anatomy workshops for PTA students from a nearby community college. Using prosected materials to enhance the workshops provided a unique opportunity for PTA students to view anatomic structures discussed in the classroom portion of the workshop.
By bringing the PT and PTA students together, both groups gained a greater understanding of the PT/PTA relationship. These interactions will provide a basis for increased respect and cooperation when these students become practicing clinicians. The PT students had an opportunity to gain valuable teaching experience through the
development and presentation of the workshops. Their weekly reflections indicated that they now felt a greater appreciation for the time and effort involved in teaching at an educational level appropriate to the target audience. Their reflections also indicated that they had gained self confidence and a sense of accomplishment. After completing the project they presented their results in a poster session at a national meeting of the American Physical Therapy Association (Bunge, Brown, Mirovsky, and Starr, 2005).
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