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Service-Learning: Developing Community-Campus Partnerships for Physical Therapy Education.

Abstract

The purpose of this project is to describe how a developing physical therapy program utilizes service-learning activities to provide experiential learning opportunities for students and its impact on student learning. Service-learning, a form of credit-bearing experiential learning, is a method in which students learn and develop through thoughtfully-organized service that mutually benefits both the community partners and academia. The writer recommends service-learning activities to physical therapy educators as an adjunct to traditional classroom and clinical experiences to enhance personalized learning for students, to empower students as learners, teachers, achievers and leaders, to foster citizenship and encourage faculty creativity in teaching methods.

Introduction

Background

Physical therapy (PT) education is changing. Since 1988 the number of accredited PT schools has increased sixty-five percent, and the number of graduates has increased eighty-seven percent. Likewise, degrees offered today have expanded to include Bachelors, Masters, and the doctorate, with the majority of programs offering the Masters degrees. Also, fewer programs are associated with academic health science centers while clinical education time is increasing as a portion of the total curriculum (A decade of growth, 1998; Update on program growth, 1998). The health care delivery system environment is also changing and having an effect on PT education. Economically-driven changes include Medicare reimbursement for student-provided service in Skilled Nursing Facilities and Outpatient Rehabilitation Facilities, growth of managed care, restructuring of the clinical workforce with fewer managers and qualified clinical instructors, and increased demand for placements of internationally educated students (Government Affairs, 1999; Briggs, 1999). A combination of these, and other factors leads to physical therapy clinicians concerns about productivity and job security, which, in turn, leads to a reluctance to supervise students' clinical experiences.

With more physical therapy programs, with more students, with the trend toward non-academic health science center related programs, with increased time in clinical internships, with the increased number of physical therapist assistant programs (that also require clinical experiences), with economically-driven environmental factors--with all that, there is now a scarcity of available clinical placements for students and an intense competition for the clinical sites that are available (A decade of growth, 1998; Government affairs, 1999; Briggs, 1999). And with that comes legitimate concern about the quality of clinical learning experiences as well as opportunities to develop non-traditional methods to augment clinical experiential learning.

Service-Learning

Service-learning, a form of non-traditional experiential learning, combines community service with student learning; service-learning, therefore, meets community-identified needs and satisfies curricular goals. Credit-bearing service-learning "programs" emerged on college campuses in the 1960% and 1970's but failed because they were not integrated with the central mission of the schools and colleges (Jacoby, 1996). During the late 1970's and 1980's, the elements necessary for effective and successful service-learning programs were identified in the Principles of Good Practice for Combining Service and Learning. These principles included (1) structured opportunities for critical reflection; (2) clearly articulated service and learning goals; (3) needs defined by agencies who have needs; (4) clearly identified responsibility of each involved member; (5) organizations genuinely and actively committed; and (6) flexible, appropriate time allotted for service and learning goals (Honnet & Poulsen 1989).

Health professions educators have long recognized the value of experiential learning for both refining and developing new skills. Typically, the experiential components have been hospital-based clinical experiences or internships, both emphasizing mastery of professional skills. More recently, however, health professions educators have begun employing service-learning experiences as adjuncts to the traditional clinical internships, with equal emphasis given to both the learning component and to the service component. Outcomes of successful collaborations (between health professions schools and communities where the "service" is conducted) have included, among other things, (1) changes in the way faculty teach, (2) changes in the way health professions schools relate to communities (enabling community organizations and citizens to play significant roles in health professionals education), and (3) improvement in community health (Seifer, 1998).

Key concepts of contemporary service-learning are reciprocity and reflection (Jacoby 1996). Reciprocity involves collaborating with the community to build on the community's strengths and assets. Service-learning, therefore, avoids placing students in community agencies simply to accomplish student learning outcomes, and allows students to acquire a sense of belonging and responsibility as members of a larger community while confronting real-life situations. Reflection involves critical thinking the "transformative link between the action of serving and the ideas and understanding of learning" (Jacoby, 1996: 14) which helps students reach beyond the provision of service to learning from that service. Through reflection, students make connections with prior knowledge and acquire a greater understanding of the new experience (Stanton 1998).

Described here are service-learning projects that were actually implemented and their results in terms of impact on student learning.

Service-learning on a Rural Campus

Implementing service-learning processes requires planning, service, reflection, and reporting to community partners and peers (Burns 1998). The department of physical therapy used two service-learning projects, one each for first- and second-year students in academic courses. Initial preparation involved reviewing resources within the department of physical therapy and seeking methods to establish community partnerships. Faculty members willing to participate in service-learning activities were identified. Assessment of methods to establish community partnerships included (1) department-directed assessment of hospital training needs for physical therapy technicians, (2) inventory of existing university-based contacts with community service industries and programs for older adults, and (3) faculty relationships with community service providers. The first-year students' project was a physical therapy technician workshop. Physical therapy faculty contacted area hospitals' continuing education faculties and rehabilitation service directors to determine need and support for physical therapy technician educational workshops. The second-year student service-learning project involved a community service industry for adults with developmental disabilities and mental retardation and mental health problems.

Planning

Planning, an essential component of incorporating service-learning activities in a course, requires establishing community-campus partnerships, assessing community assets, identifying gaps, and developing plans for service-learning projects to fill those gaps. Planning also includes developing methods for evaluating student learning, quality of the service performed and benefit to the community. Students received satisfactory-unsatisfactory grades based on their evaluations of each other's performance, participant evaluations and satisfaction, and instructor evaluations of student learning.

For the physical therapy technician (PTT) service-learning project, faculty sent letters to seven facilities asking, "Would you be interested in and support an external continuing education program for your physical therapy technicians?" Five facilities responded in the affirmative and enrolled twelve physical therapy technicians in the workshops. Faculty also developed specific and measurable learning objectives to be addressed by this project including:

1. Develop an instructional unit in one of the basic care skills.

2. Employ effective educational strategies and technologies when teaching audiences with varied needs.

3. Present an instructional unit at an appropriate level to other health care professionals.

4. Reflect on service and professional development.

Implementing service: First-year student project

Implementing the PTT workshop involved collaboration with the dean of continuing education. The workshop met mutually identified needs for all stakeholders: (1) the community need to educate employed technicians; (2) academic needs to help physical therapy students develop management, communication, and teaching skills for varied audiences; and (3) academic needs for continuing education students to experience the business process of developing a continuing education program. To make the experience more informative for workshop participants, faculty decided to develop two workshops consisting of two sessions each. Materials presented at the fall workshop included range of motion exercises, assisted ambulation, and transfer activities. The spring workshop topics were therapeutic exercises and thermal agents.

Reflection on Value, Impact, Citizenship

Following the final session of each workshop, participants used reflection to assess the impact on student learning. PTT reflected on the value of the workshop to their work setting and made suggestions for expanding their learning experience. Comments from workshop participants concerning PT student instruction and workshop organization included the following. One participant suggested, "Explain a little better each motion such as sitting the patient back down especially about blocking the bad leg." Another said, "I liked that students did the instruction. It gives both them and us a chance to learn from each other." A third commented, "I liked the hands-on experience. It made me learn." Through this reflective process, physical therapy students and workshop participants identified methods for improving the workshops including teaching methodology and presentation. Additionally, workshop participants suggested areas for future training to help them to improve their care of patients, such as "basic anatomy of the extremities," "more lifts and transfers," "a session on terminology," and "wound care."

The theme of the student educators' reflection was to communicate using terminology compatible with the audience's understanding. One student stated, "I have become so accustomed to technical terms and PT jargon that I forget some people may not understand the meaning." Other comments related to the student educator's knowledge. One student observed, "Teaching a subject required a greater understanding of the subject than just being able to pass an examination." Another said, "Preparing to teach a subject requires much more knowledge than is actually presented." A third student stated, "This experience helped me to learn more about my particular topic; to teach it, I needed to know it thoroughly."

Another theme related to PT student teaching skills: One student remarked, "For future teaching I would consider the audience's level of knowledge, writing clearer objectives, having appropriate demonstrations and giving feedback during the presentation." Another student said, "I did not expect the PT technicians to have as much experience as some of them did." A third stated, "I realize how much preparation is necessary (to teach) and the pressures teachers are under."

Collaboration University Mission

The university community benefited from interdepartmental collaboration. PTT workshops provided PT students the opportunity to develop organizational, teaching, and communication skills; student interns in continuing education refined their techniques of working with clients, developing workshop budgets, and managing finances. One student reflected on collaboration saying, "I had to balance being an accommodator, compromiser, and collaborator. This experience taught me to observe my professionalism and to create a respectful and conducive environment for learning." Students and faculty from two university departments worked collaboratively on problems associated with developing and producing a workshop. The dean of continuing education commented on the value of collaboration, "These small workshops provide our students an opportunity to work in all phases of continuing education including budgets while they are still students." Thus, technician workshops benefited all partners-physical therapy students, continuing education students, physical therapy technicians, and community partners.

Implementation: Second-year Student Project

The director of a community service industry for adults with developmental disabilities, mental retardation, and mental health problems requested ergonomic assessments for selected employees. Second-year students evaluated the workplace and the working capacity of six clients during an ergonomic assessment unit in a PT science course. Course objectives for the ergonomic project included:

1. Develop an ergonomic assessment tool for clients with multiple disabilities using recognized sources.

2. Evaluate a client with multiple disabilities using the assessment tool.

3. Prepare a written report for the client, the supervisor, and the director of projects.

4. Teach the client and the supervisor proper body mechanics and how to improve working posture to reduce possible injury.

5. Provide suggestions for modifications of the workplace to the director of projects.

6. Assist community agent to make modifications to the workplace.

Students worked collaboratively in groups of five with a single client. For each ergonomic evaluation, students became familiar with industry requirements for personnel production and identified methods for adapting the workplace to the capabilities of individuals with specific disabilities. Physical therapy students developed tools for assessing patients in workplace settings using limited equipment and resources. For the final products, students (assisted by faculty) prepared written reports for both clients and the community partner. Students presented exercise and proper body mechanics training programs to the clients to help reduce workplace injury and provided suggestions to the community partner for reducing workplace injury with minimal cost to the agency.

Reflection

Physical Therapy Students: Themes related to cultural sensitivity and skills development were identified. One student reflected, "Seeing the client with disabilities in a work setting helps me to develop programs and assessment tools for this population. This (activity) requires additional study and thought." Another student observed, "I did not know the amount of research necessary to develop tools for evaluating people with multiple problems. I used the web as well as textbooks to find the latest information."

Community Partner and Faculty: Industry staff reported adopting some student-suggested workplace changes including "extending the length of work platforms and mats," "adding high-seat chairs to reduce standing-in-one-place for a long time," and "brief hourly rest periods of five minutes." The facility director stated, "The work your students did and their reports have been of great value to several patients, especially the lady with fibromyalgia." Students learned to work collaboratively with limited resources. They expressed confidence in their "abilities to work with people with varying abilities."

Clinical Instructors: Student competence in teaching demonstrates how service-learning impacts student learning. One clinical instructor stated, "Sam did an excellent job with in-service presentation on transverse myelitis to members of the PT department & other students. Teaching is one of his strengths, and he will do well with teaching groups, fellow therapists, etc." Another reported, "Mary presented an excellent arthritis of the foot review. She spoke clearly and did a good job of research." These statements demonstrate the value of service-learning to empower students as learners, teachers, and achievers.

Faculty: An essential aspect of service-learning is faculty involvement. Service-learning success depends largely on committed, continuous faculty involvement. Both service-learning projects described here required frequent faculty creativity and planning to develop learner-centered, interactive, experiential experiences. Faculty established course goals and grading criteria for each project, made initial contact with university agencies, scheduled workshop dates, and outlined a timeframe and subject matter for the workshops. For the ergonomic project, faculty provided the community partner with information concerning student capabilities and grading criteria, invited the partner to present an informational program to the students, videotaped clients at work, coordinated initial student evaluations with the community partner, and mentored student evaluations of clients. To ensure quality outcomes, faculty reviewed workshop presentations, ergonomic reports, and patient educational programs. Not only did these activities require additional preparation time, but also faculty had to constantly communicate with university and community partners to ensure client satisfaction. Communication between faculty members was essential for evaluation of student learning. Referring to heavy time commitments, faculty often complained of the need for additional colleague support, stating, "Additional assistance would permit more student-faculty-client interaction for analysis, evaluation, and critical reflection."

Another faculty concern was the amount of time students should devote to service-learning activities. Students devoted more than twenty hours of service during each project, but only one-fourth of that time was spent in direct contact with clients. In discussions, faculty recognized a need to "increase curricular time for planning and completing service-learning projects." Faculty recommended, "Students should have a full academic year to participate in a service-learning project to increase their abilities and to develop effective partnerships with community agencies."

An essential dimension of service-learning is critical reflection. Due to inexperience, faculty initially did not develop guidelines for critical reflection in the ergonomic project. Since then students have been required to maintain reflection journals using specific guideline criteria to answer: "What did you learn? How did you feel about it? And how can you apply it?"

Discussion

Student Learning Outcomes

Learning outcomes achieved through service-learning in physical therapy curricula include experiential learning outside of the hospital clinical setting and student opportunities to practice physical therapy as educators, counselors, and developers of wellness and prevention programs. "Through service-learning students' psychological investment in learning, understanding, or mastering knowledge and skills, comes from an internal commitment to address a concern or to enhance a valued relationship" (Cairn & Kielsmeir 1991: 23).

Service-learning as a collaborative experience also taught student physical therapists to work together and accept the contributions of community partners while striving to produce quality service outcomes. Interdisciplinary service-learning programs help new graduates overcome anxiety and develop a greater understanding of themselves, their communities, and the team process (Interdisciplinary collaboration, 1997).

Students in service-learning projects are involved in application and development of knowledge and critical reflection. Instructors must develop skills to accommodate this student-focused learning. The principles of reflection continuous, connected, challenging and contextualized provide guidance to instructors for developing critical inquiry techniques essential for provision of quality services (Eyler, Giles & Schmiede, 1996). Assisting the student to develop the ability to critically reflect on social issues and policies of the larger community requires the application of these principles of reflection.

An additional benefit of service-learning to students was the development of cultural sensitivity. Clients in the ergonomic project represented a diverse, minority population with special needs. Physical therapy students learned that this population can meet production demands and are dependable workers. Students learned how to interview and assess clients with multiple problems: physical, mental and emotional. With the dramatic demographic changes in the United States resulting from increases in ethnic and racial minority populations, the most up-to-date health care may be ineffective if the professional cannot communicate with the patient and the caregiver, or if the health care provided is not culturally acceptable to the patient. Cultural competence, an evolving process, has been described as having five components: (1) awareness and acceptance of cultural difference, (2) self-awareness, (3) understanding the dynamics of difference, (4) basic knowledge of the patient's culture, and (5) adaptation of skills (Cora-Bramble, 1997; Cohen & Kinsey, 1994). Service-learning strengthens partnerships between health professions schools and their communities. Through service-learning, students became more aware of issues involving language, culture, and ethnicity in the context of the communities they serve (Patterson, 1987). Service-learning projects augmented the process of developing sensitivity as students work with culturally different members in the community. Physical therapy students involved in the ergonomic project experienced cultural diversity and developed sensitivity to these concerns. Physical therapy students participating in the PTT workshops began to recognize the misconception of certain beliefs, such as their misperceptions regarding the knowledge level of workshop participants.

Faculty Issues

To assure the best possible outcomes from service-learning, faculty must rigorously assess the fit between community service and academic expectations. Howard (1993) provides the following guidelines: (1) academic credit should be awarded for quality of learning, not service; (2) academic rigor must not be compromised: faculty must establish structure and hold students accountable for previously established learning criteria; (3) faculty must establish criteria for the selection of community service placements; (4) course assignments and learning experiences must be carefully balanced to maximize benefits of both; (5) maximum student learning can be insured by minimizing differences between classroom learning environments and community learning environments; (6) faculty roles should be adjusted to include models of instruction that support inclusion of new learning from community and student reflection; (7) uncertainty and variation in student learning outcomes should be expected; and (8) community awareness can be maximized by encouraging student group responsibility through group projects and shared learning.

Service-learning also has inherent disadvantages. Students may not wish to participate in service-learning activities or may not see the service-learning experiences as being more valuable than a classroom experience (Patterson, 1987). Faculty must communicate to students that service-learning experiences are relevant to and can enhance classroom materials. Service-learning activities must allow students time to apply newly acquired knowledge and skills in real world situations. Adequate time working with the community agency is essential to expand skills and knowledge as well as for understanding community needs and developing citizenship. Research showed that service-learning projects where students spent less than twenty hours of service had little impact on student attitudes toward community service (Patterson, 1987).

Locating community agencies that are willing to share equally to ensure meshing of identified community needs with curriculum goals required faculty and community cooperation. To develop these partnerships, community partners were educated to the advantages of such a partnership and instructed in methods of assisting student learning and development. This process required faculty time and assistance in addition to regular classroom preparation and activities. Faculty must also be prepared to expect the unexpected, such as community partners that are less than actively involved, incomplete student projects due to loss of clients for follow-up, or too few workshop participants to proceed with a student-developed workshop. Even when faced with these limitations, student reflection can make the service-learning activity valuable.

Administrative support is vital to the development of service-learning as a program or as part of a course. Faculty must have release time to establish community partnerships and to develop partners that participate actively in educational processes. Also, recognizing and rewarding faculty involved in service-learning activities encourages faculty innovation and participation. Policies related to legal issues of liability may also be a concern. Since service-learning is part of academic courses, many institutions consider service-learning as a regular university activity. Most institutions consider these activities covered by university and student insurance, although these policies have not been challenged.

Conclusion

This paper describes two service-learning, credit-bearing, structured learning experiences and their impact on student learning. Students provide direct community service, learn about the context, and apply academic learning to work environments. Service-learning activities enhance student learning beyond the classroom, assist students with critical self-reflection, and teach sensitivity to ethnic and racial minority populations. Service-learning programs provide students with valuable tools to meet real world problems in a collaborative manner. Refinement of faculty experience with service-learning methodology resulted in increased student learning and confidence in their abilities. Service-learning experiences led the author to recommend service-learning activities to other physical therapy educators. Prior to developing service-learning programs, it is recommended that the planning team assess university and community resources, review information on service-learning, establish time for faculty planning, determine the impact of a semester-long service-learning course on student learning, and establish rigorous standards for assessing student learning. Additional study with service-learning is recommended to determine the long-term benefits and disadvantages to using service-learning as an adjunct to traditional experiential education methods.

References

Briggs, E. (1997). Medicare reimbursement for clinical education costs and services by students. PT Magazine of Physical Therapy, 7(9): 14-15.

Burns, L. T. (1998). Make sure it's service-learning not just community service. Educational Digest, 64(2):38-40.

Cairn, R. W. & Kielsmeir, J. C. (1991). Growing hope: a sourcebook on integrating youth service into the school curriculum. Roseville, MN: National Youth Leadership Council: 5-30.

Cohen, J. & Kinsey, D. (1994). Service experience and the moral development of college students. Journalism Educator, 48:4-14.

Cora-Bramble, D. (1997). Service-learning and cultural competence. In Seifer, S. D. & Connors, K. M. (eds.), Community-Campus Partners for Health: A Guide for Developing Community Responsive Models in Health Profession Education. 1st ed. San Francisco: USCF Center for the Health Professions: 41-44.

A decade of growth in US physical therapy education programs. (1998). Accreditation Update, 3: 3-4.

Eyler, J.; Giles, D. & Schmiede, A. (1996). A practitioner's guide to reflection in service-learning: Student voices and reflection. Nashville, TN: Vanderbilt University Press.

Government Affairs. (1999, May). All-payer graduate medical education act. READ.

Honnet, E. P. & Poulsen, S. J. (1989). Principles of good practice in combining service and learning (Wingspread Special Report). Racine, WI: The Johnson Foundation.

Howard, J. (1993). Community service in learning in the curriculum. In Howard, J. (ed.), Praxis I: A Faculty Casebook on Community Service Learning. Ann Arbor, MI: OCSL Press.

Interdisciplinary collaboration in service-learning: lessons from the health professions. (1997). In Seifer, S. D. & Connors, K. M. (eds.), Community-Campus Partners for Health: A Guide for Developing Community Responsive Models in Health Profession Education. 1st ed. San Francisco: USCF Center for the Health Professions: 33-40.

Jacoby, B. (1996). Service-learning in today's higher education. In Jacoby, B., et al. (eds.), Service-Learning in Higher Education: Concepts and Practices. San Francisco: Jossey-Bass Publishers: 3-25.

Patterson, E. W. (1987). The effects of participation in required and not required community service programs on the process of self-actualization in high school students. Gainesville, FL: University of Florida. Ph.D. dissertation.

Seifer, S. D. (1998). Service-learning: Community-Campus Partnerships for Health Professions Education. Academic Medicine, 73: 273-277.

Stanton, T. K. (1998). Institutionalizing service-learning within postsecondary education: Transformation or social adaptation? Partnership Perspectives, 1:9-18.

Update on program growth in physical therapy education. (1998, December). READ: 5-6.

Chloe D. Little, Ed.D., PT, is Assistant Professor of Physical Therapy. She received her education at Emory University, Duke University, and The University of Georgia. <littlec@wcu.edu>.

Chloe D. Little, Western Carolina University, NC
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Author:Little, Chloe D.
Publication:Academic Exchange Quarterly
Geographic Code:1USA
Date:Dec 22, 2000
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