Effects of interdisciplinary teaching on student learning and healthcare-giving competence: A mixed methods study

doi:10.21203/rs.3.rs-3218987/v1

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Research Article

Effects of interdisciplinary teaching on student learning and healthcare-giving competence: A mixed methods study

https://doi.org/10.21203/rs.3.rs-3218987/v1

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published 23 Aug, 2024

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Background

Interdisciplinary collaboration is known to foster professional innovation and enhance student learning across different domains. However, the research on the effectiveness of interdisciplinary teaching in pediatric nursing education and its evaluation methods is limited. Therefore, this study aimed to examine the effectiveness of incorporating game-based learning from the Department of Childcare and Education into therapeutic play courses in pediatric nursing education for students’ learning and healthcare-giving competence.

Methods

We used a mixed methods study with pre-test/post-test quantitative analyses and a descriptive qualitative analysis of students’ reflection journals. Data were collected between August 2019 and July 2020 to gauge course effectiveness. Quantitative data obtained from the questionnaires were analyzed using a t-test, correlation, and regression analysis. Qualitative data were analyzed using content analysis. One hundred and three second-year students enrolled in a four-year nursing program. Students attended classes in university classrooms and served learning in a kindergarten or hospital in Northern Taiwan.

Results

Implementing interdisciplinary teaching in the therapeutic play course resulted in significant improvement in students’ knowledge, abilities, attitudes, and social service outcomes as measured by post-test scores. Furthermore, the scores on the Service-Learning Questionnaire indicated a significant increase in communication, problem-solving, knowledge application, and cross-cultural competence. Integrating instruction to improve problem-solving skills and knowledge application predicts student learning outcomes. Qualitatively, students reflected on integrating different learning areas, communication, problem-solving, and practical knowledge skills.

Conclusions

Interdisciplinary teaching effectively stimulates thinking among nursing students and enhances their knowledge, abilities, and attitudes toward therapeutic play, benefiting children’s health. Integrating social service with interdisciplinary instruction allows students to be physically exposed to each child's unique challenges and needs, enhancing their communication, knowledge application, and problem-solving. Students can blend knowledge and skills through integrated learning, which is crucial for career development.

Trial Registration:

N/A. It was a survey on educational activities.

Child

Education

Health

Learning

Nursing students

Recent environmental changes and pandemics have precipitated a health and development crisis for approximately 250 million children under the age of five^[1], highlighting the importance of this field of pediatrics. Nurses play a vital role in caring for children facing health crises and supporting their families; timely interventions in these cases can significantly improve their overall quality of life. However, conventional nursing education alone is insufficient in adequately preparing students to address the challenges associated with caring for children in such complex ecological environments. Nursing students require a comprehensive interdisciplinary approach that extends beyond traditional classroom education to effectively identify these health issues and initiate timely interventions.

By integrating interdisciplinary teaching into the nursing curriculum, students can benefit from a wide range of learning experiences that foster connections and associations across diverse academic domains. This approach empowers students to expand their understanding beyond the confines of conventional classroom learning and apply their knowledge in real-world contexts^[2]. Consequently, students are equipped with effective strategies for enhancing the health outcomes of children facing environmental health challenges. This interdisciplinary approach not only enhances students’ abilities but also addresses the urgent needs of the affected children, enabling them to thrive in the face of developmental health crises.

Therapeutic play in pediatric care can be an essential tool to encourage children to express their emotions and knowledge about illness and surgery^[3]. Nursing students are therefore increasingly using therapeutic games to communicate with children^[4–6]. While research has mainly focused on the effectiveness of therapeutic play in reducing postoperative pain, improving symptoms, and reducing anxiety during hospital stays, it is important to recognize that therapeutic play goes beyond addressing illness symptoms. It contributes to overall health promotion and growth in children. Furthermore, nursing education often provides a limited exploration of guidance methods that enhance students’ competence in providing healthcare for children’s well-being. In contrast, early childhood education emphasizes the use of interactive strategies by teachers, such as facial expressions, gestures, and body movements, to enhance children’s engagement and facilitate their learning^[7]. Integrating teachings from pediatric nursing and early childhood care can guide students in supporting holistic health promotion, encompassing both clinical nursing skills for managing childhood illnesses and assisting children in developing and practicing healthy habits to mitigate health and development crises.

Interdisciplinary research involves the integration of two or more disciplines to foster knowledge exchange and the establishment of a unified field, driven by the recognition of professional demands and the imperative to equip students with the ability to address complex societal issues or wicked problems. These problems constantly change and evolve, resulting in great uncertainty regarding their causes and effective solutions. In interdisciplinary research, scholars engage in collaborative interactions, fostering the growth of concepts, epistemologies, and methodologies across disciplines^[8]. Interdisciplinary education can stimulate creativity and expose learners to new ideas and perspectives^[9].

The interdisciplinary teaching project implemented by the Departments of Nursing and Childcare Education is grounded in constructivist learning theory. It emphasizes students’ active participation in knowledge construction and understanding. By integrating multiple disciplines, students develop a robust knowledge base, fostering profound learning and critical thinking^{[10, 11]}. Curriculum content integration also adheres to the following interdisciplinary collaborative teaching suggestions: (1) Design common course goals and learning outcomes to ensure that students have the same learning direction and goals, facilitating the integration of knowledge and skills from diverse disciplines^[12]. The overarching objective is to enable therapeutic play in supporting holistic health promotion for children. (2) Develop teaching plans, which can use methods such as case discussions, role-playing, and practical exercises for teaching. In addition to the joint teaching of both departments, this course offers opportunities for students to visit hospital playrooms and participate in practical visits to kindergartens. (3) Establish a collaborative team environment to encourage student communication and cooperation^{[9, 13]}. Alongside group discussions, this course incorporates group practices involving clinical nurses and kindergarten teachers. This enables students to collectively leverage their expertise and strengths to accomplish the course goals. (4) Provide support and guidance to help students overcome obstacles and challenges between disciplines^{[10, 11]}. The joint teaching of both departments allows for the arrangement of professional mentors or instructors who can provide guidance and counseling and address any questions or doubts the students may have. Some studies have proposed the establishment of a collaborative team environment to promote communication and cooperation among students from different fields. For instance, a collaboration between nursing and engineering students has been shown to foster industry–university cooperation^{[14, 15]}. Liao and Wang^[16] developed teaching plans that incorporate methods such as case discussions and narrative medical teaching, which allow students from medicine and healthcare to interact with each other and listen to patients’ stories to improve their reflective thinking, empathy, and narrative writing skills. While interdisciplinary teaching has been shown to enhance students’ cognition and interdisciplinary interaction skills, limited literature exists on how it can improve students’ childcare abilities.

Therefore, this study aimed to explore whether integrating the curriculum of the Department of Childcare and Education with therapeutic play in nursing courses can improve students’ abilities to use therapeutic games to enhance their clinical practice and care quality. We assessed the effect of interdisciplinary teaching on nursing students’ knowledge, skills, attitudes, cross-cultural competence, problem-solving, knowledge application, and social service-related communication in a therapeutic play curriculum. The study proposes three hypotheses: following the interdisciplinary lessons, (1) students would outperform their pre-test outcomes in the post-test learning outcomes with respect to knowledge, abilities, and attitudes; (2) students’ healthcare-giving competence, as measured by social service efficacy scores, are anticipated to improve in the post-test compared to the pre-test; and (3) there would be a correlation between students’ course learning and social service outcomes.

The study used quantitative research methods to evaluate students’ learning outcomes and analyzed the reasons for students’ feedback to obtain comprehensive information.

2.1. Aim

This study examined the effect on learning outcomes, including knowledge, abilities, and attitudes, of integrating the Department of Childcare and Education game-based learning approaches into therapeutic play courses for nursing students. Further, it explored the effect on communication, problem-solving, application of knowledge, and cross-cultural competence through social service activities.

2.2. Design

This study used two phases of a sequential explanatory approach with a mixed methods design. The first phase applied a pre-experimental, pre-test/post-test design to examine students’ learning efficiencies. For the second phase, qualitative data were collected from students’ reflections on their learning.

2.3. Participants

Sophomore nursing students were recruited to participate in this study and take the Therapeutic Play course. To calculate the sample size, we used G* Power 3.1 for t-testing and the calculation of means using the difference between two dependent means (matched pairs), a monitored effect size of 0.3, and a power of 0.8^[17]. At least 90 students were required, and as the attrition rate was 20%, 108 students were selected for the study. After we applied purposive sampling and explained the project, 119 students enrolled, and 108 students completed the course activities.

2.4. Measurement tools

2.4.1. Interdisciplinary therapeutic play curriculum. Drawing from relevant literature, the principle of integration is articulated in the following statements^[12,18]:

(1) The curriculum is presented in a series that guides students throughout children’s lifespans.

The curriculum revolves around lessons on life stages, from infancy to adolescence, and the corresponding cognitive and social development at each stage. Learners discern therapeutic play education and childhood stages and play games to enhance their interaction and health education skills.

(2) The curriculum focuses on children’s cognitive, play, and social development.

The curriculum is based on the stages of children’s play from Piaget’s theory of cognitive development and the social stages of play from Parten’s play theory^[19]. The Department of Childcare and Education divides play into six categories; namely, physical ability, self-care, cognitive ability, language ability, emotion recognition, and creative play. Meanwhile, the Department of Nursing divides therapeutic play into functions such as emotional outlet, instructional, and physiological health-promoting play^[20]. This study’s integrated curriculum is an application of therapeutic play focusing on child development and health. It enables nursing students to apply what they have learned and observed in kindergartens and hospital playrooms.

2.4.2. Integration of subjects in course unit. The Department of Childcare and Education and the Department of Nursing at Northern Taiwan University conducted an 18-week therapeutic play course to integrate various subjects and approaches. Weekly lessons lasted two hours. During weeks 1 and 2, the students gained an understanding of the majors of the two departments, curriculum structure, and teachers’ expectations for social service and group reporting. From weeks 3 to 11, the two departments confirmed the types of games to be developed for children between infancy and preschool age. In weeks 14 and 15, the students participated in discussion events led by industry experts that covered various topics such as game types and therapeutic play design. To enhance problem-solving abilities and achieve unified learning goals, the interdisciplinary integration process sought to identify commonalities and differences among the games (Figure 1).

2.4.3. Questionnaires. The data collection tools in this study comprised two questionnaires: the instructional evaluation scale and the service-learning abilities scale.

(1) Instructional evaluation scale. Lin et al.^[21] developed an instructional evaluation scale with 28 questions. Among them, 15 questions for “teachers’ instructional input” have three dimensions: course content and teaching arrangement (four items), teaching method and teacher–student interaction (seven items), and evaluation and feedback (four items). Thirteen questions for “students’ learning outcome” consist of three dimensions: knowledge (six items), ability (four items), and attitude (three items). Items were rated on a 5-point Likert scale, with higher scores indicating better student learning outcomes. The factor loadings ranged from .71 to .92, and the average variance extracted ranged from .59 to .75, thus showing good construct validity. In terms of reliability, Cronbach’s α of the internal consistency reliability of the three dimensions under “teachers’ instructional input” was between .87 and .89; while the internal consistency reliability of the three dimensions of “students’ learning outcome” was between .88 and .89, thereby revealing that all dimensions possess good evaluation criteria reliability^[21]. This scale helped us understand interdisciplinary curriculum implementation, student learning, and teaching effectiveness. In terms of internal consistency reliability, Cronbach’s α of the three dimensions of “teachers’ instructional input” was between .89 and .94. The internal consistency reliability of the three dimensions of “students’ learning outcome” was between .87 and .95.

(2) Service-learning abilities questionnaire. Chao et al.^[22] developed and validated a 36-item service-learning abilities questionnaire for use in Asia. The questionnaire evaluates nine components consisting of four items each: (1) self-knowledge and self-confidence, (2) communication skills, (3) problem-solving skills, (4) citizenship and social responsibility, (5) team skills, (6) self-reflection, (7) knowledge application, (8) caring for others, and (9) cross-cultural competence. Items are scored from 0 = completely disagree to 10 = completely agree. Higher scores indicate better service-learning skills. Cronbach’s α values for the nine subscales ranged from .86 to .93^[22]. In this study, Cronbach’s α ranged from .77 to .96 for the subscales.

(3) Qualitative questions: Please describe the effect of this course on your utilization of therapeutic play in caring for children: Is it knowledge? Nursing skills and competencies? What are your thoughts?

2.5. Data collection

The study period was from August 1, 2019, to July 31, 2020, and the course was conducted at a university in Northern Taiwan for 18 weeks, from September 18, 2019, to January 15, 2020. The students were required to complete the instructional evaluation scale and the service-learning abilities questionnaire at the beginning and end of the semester. Apart from attending classes, they were divided into 10 groups of 10–11 students and provided social services for a week in hospitals and kindergartens, with guidance from two pediatric nurses and three kindergarten teachers. In week 18, the students presented their learning results to teachers through a 15-minute video or photo presentation per group. During and at the end of the semester, the students shared their reflections in class regarding the teaching activities, learning experiences, and social service experiences to demonstrate their awareness of children’s health needs. The teachers also required the students to submit anonymous reflection sheets.

2.6. Data analysis

Data were analyzed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA). The demographic characteristics of the participants were determined using descriptive statistics. We used a paired t-test to evaluate the difference between pre- and post-test scores on the instructional evaluation scale and service-learning abilities questionnaire. The Pearson correlation coefficient was used to compare the correlation between the two scales. Significance was set at p < 0.05. Predictor variables were explored using multiple linear regression analysis. Using the study by Lindgren et al.^[23] as a guide for collecting qualitative data, we labeled and coded content relevant to the research process and linked them to the students’ reflections. During this analysis, the first author coded and analyzed the data, and other authors reviewed and made recommendations for all analyzed documentation and analysis results^[23]. The analysis followed the outline of Guba and Lincoln^[24] on the credibility, dependability, transferability, and confirmability principles for qualitative data analysis.

2.7. Ethical approval

The study was approved by Chang Gung Medical Foundation Institutional Review Board (Approval no. 201801939B0) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. We explained the research and course process to the students comprehensively, before the class. The students agreed to participate in the research freely. Participants were informed that their information would be kept private, all participants would be tagged anonymously and digitally, and any personal information that may be attributable to them would be deleted.

3.1. Participant characteristics

A total of 119 students were enrolled in the course. Among them, 11 students (two boys and nine girls) joined in the middle of the course and did not complete the pre-test. For these 11 students, the post-test mean ± SD of the two subscales, “teachers’ instructional input” and “students’ learning outcome,” of the instructional evaluation scale was 62.09±10.71 and 55.64±9.37, respectively. However, it was 257.45±34.15 for the service-learning abilities questionnaire. Although the average score of the 11 students in the post-test was lower than that of the students who participated in the whole process, their results ranged from moderate to good. Overall, 108 students completed the course activities, and five incomplete questionnaires were deleted; hence, 103 students participated (89 = female, 86.4%). The participants were aged 19–27, with an average age of 19.66 years.

3.2. Quantitative outcome

The post-test mean scores for the instructional evaluation scale and its subscales, “students’ learning outcomes” and “teachers’ instructional input,” and the service-learning abilities questionnaire were significantly higher than the pre-test scores (p < .001; Table 1). The Post hoc power of all scales was > 90%. The pre-test/post-test showed significant mean differences across all scales (95% confidence interval [CI]). Teachers' input: 17.71–22.51, student outcomes: 16.80–22.30, and service-learning abilities: 95.15 to -125.81 (0 not in the interval). Moreover, the instructional evaluation scale and the service-learning abilities questionnaire were significantly correlated (Table 2). The mean of both subscales of the instructional evaluation scale was as high as 85%. In the service-learning abilities questionnaire, scores were lower than the pre-test for the citizenship and social responsibility items, while all other subscales showed a significant increase compared to the pre-test. Students’ learning outcomes and citizenship and social responsibility were positively correlated (r=0.86, p<0.0001). The three items with the highest scores (team skills, self-knowledge and self-confidence, and knowledge application) reached more than 85%. Cross-cultural competence scores were less than 80%. Multiple regression analyses were conducted to examine the effects of team skills, self-knowledge and self-confidence, and knowledge application and problem-solving skills on students' learning outcome. The results showed that knowledge application and problem-solving skills were significant predictors of students’ learning outcome (β = 0.48, 95% C.I. [0.04, 0.92], p = .04; β = 0.44, 95% C.I. [0.02, 0.85], p = .039), while team skills and self-knowledge did not significantly predict students’ learning outcomes (β = 0.07, 95% C.I. [-0.04, 0.19], p = .22, β = 0.04, 95% C.I. [-0.07, 0.14], p = .48). The overall model was significant F (4, 98) = 19.11, p < .001, R² = .44, adjusted R² = .42).

3.3. Qualitative feedback

Students’ reflections presented four themes: (a) integrating different learning areas to promote children’s health, (b) strengthening communication skills, (c) developing multiple problem-solving abilities, and (d) practicing enhances learning effectiveness. Table 3 explains how the themes were discovered through content analysis.

Integrating different learning areas to promote children’s health. Students reported that interdisciplinary learning allowed them to gain more insight into therapeutic play and differentiate between game characteristics in nursing and early childhood care. Exposure to different fields helped them expand their thinking and move beyond designing games solely based on the concept of disease. They expressed the intent to consider child development and living environments when providing health-promoting care for children.

The teacher will provide us with more channels for reference, help us understand the use of games by the Department of Nursing and the Department of Childcare and Education, and teach the natural coping methods used in children’s lives. (S4)

Strengthening communication skills. The students applied their undergraduate knowledge to design game content that effectively communicated with children. They developed skills to communicate with children about topics beyond health, such as discussing their favorite animals or characters. They also learned to use lively verbal expressions and body language to encourage children to participate in therapeutic play and develop an interest in learning about health issues.

Entering kindergarten this time gave me a vastly distinct experience. I’ve learned a lot from making party flute toys with these kids, from how to chat with them, make them pay attention to me, and use the gesture “give me five” to encourage them to answer questions. This time, it made me aware that I should let the children speak generously and that I can encourage them with such simple gestures. (S56)

Developing multiple problem-solving abilities. The students mentioned that interdisciplinary teaching allowed them to anticipate the health needs of the subject; collaborate to develop appropriate materials; and deliver therapeutic play through role-playing, simulation activities, and trial teaching. They applied therapeutic play to enhance children’s rehabilitation post disease and address motor and social development issues. The students also acquired time management and emotional regulation skills, thereby improving their critical thinking ability during interactions with children.

We gradually understand how to face children in addition to understanding what they want, how to let children know the concept of health in the game...children playing with toys with their hands can also train their small muscles to work. … In the process, we have some areas that are worth improving, such as time control and being a little bit overwhelmed when the children do not want to play color-sorting games. This experience taught us how to handle children’s refusal to participate in activities. (S62)

Practicing enhances learning effectiveness. The students indicated that teaching should not only introduce professional knowledge but integrate it with the practical aspect. When they completed the work, they felt a sense of accomplishment. The students served children in the field, saw their smiles, and received their feedback. These activities enabled the students to affirm themselves and understand the meaning of learning. Additionally, they stated that they received assistance and comments from practitioners, which made them realize that knowledge is acquired through application.

The kids are happy to hear from and interact with us. We learned a lot in this short hour...and the feedback from our practitioners after the event was also helpful. They suggested that children should be guided more. Instead of doing it for them from the beginning, not with kids together..., it turns out that actually applying the knowledge is more valuable than listening to textbook theory all the time! (S69)

This study found that interdisciplinary teaching improved student learning and healthcare-giving competence. The effectiveness of student learning influenced their capacity to offer social services to children, thus confirming Hypotheses 1–3.

The findings of teachers’ instructional input in the instructional evaluation scale indicated that students recognized the effectiveness of the integrated course teaching approach employed by their teachers to assist them in integrating multidisciplinary thinking. Furthermore, in terms of teacher-student interaction, the results align with studies conducted in another country^[25], demonstrating that a positive teacher-student relationship promotes student participation, critical thinking, and teamwork in interdisciplinary teaching, ultimately enhancing learning outcomes.

The “students’ learning outcome” revealed that interdisciplinary teaching could improve students’ professional knowledge, which was consistent with the findings of Liao and Wang^[16] and Liu^[26]. Knowledge is enhanced when students can identify multiple facets of a problem, critique expertise framework, incorporate creative thinking, and develop innovative problem-solving skills^[18,26]. Therefore, students can critique the limitations of therapeutic play and develop new health-promoting games such as those that promote child development and teach children about their emotions. The subscale also suggested that interdisciplinary teaching resulted in a significant increase in students’ abilities. These abilities were communication, group cooperation, applying theory to practice, and problem-solving. Regarding their attitude, qualitative and quantitative results indicated that students thought the content and practice of this course stimulated their interest in learning.

The findings of social service effectiveness were consistent with those of Chao and Yang^[27]. Incorporating social service into interdisciplinary teaching enhances students’ application of knowledge, proficiency in skills, and development of positive attitudes. Furthermore, it improves their communication and problem-solving abilities, and their awareness of social responsibility toward children. The results of the multiple regression analyses further confirmed that interdisciplinary instruction enhances students' knowledge application and problem-solving skills, which, in turn, can positively impact their learning outcomes. The qualitative data showed that students communicated with teachers and experts in the Department of Childcare and Education and learned how to implement healthcare for a child. Students engaged with children using children’s natural verbal and non-verbal physical expressions to motivate their focus and participation. The students learned to incorporate play elements into a storybook or use body-action language to encourage less confident children to participate in activities together and allow children to assert their abilities. Xiao et al.^[7] found that storytellers used eye contact, gestures, voice modulation, and questioning to stimulate children’s emotional engagement and cooperation. However, the data indicated that “citizenship and social responsibility” did not improve, which was inconsistent with the findings of Chao and Yang^[27]. Some students felt uncertain about their ability to serve independently owing to a gap between their imagination and practical application. Nevertheless, there was a positive correlation between students’ learning outcomes and citizenship and social responsibility. Interdisciplinary teaching can enhance students’ identification with citizenship and social responsibility, thereby enhancing their learning and practical application skills.

Regarding problem-solving, nursing students often use therapeutic play in disease treatment. However, using therapeutic play to promote children’s emotional expression and motor development, among other health issues, is a challenging task for them. Different countries emphasized their research findings that students learn through the interdisciplinary integration of information and experiences. This helps them solve complex problems using critical thinking and make decisions by applying their worldviews^[12,18]. Teaching and practical activities by early childhood education professors enable them to understand the importance of making toys with children, grasp the health needs of service recipients, and aid children’s gross and fine motor development. Specifically, it allows them to fully focus on children’s developmental status beyond just disease observation. Therefore, through interdisciplinary teaching, they can play a greater role, particularly by using therapeutic play to promote children’s emotional expression and motor development.

We also found that the cross-cultural competence outcomes of interdisciplinary teaching for students were similar to those reported by Widmer et al.^[28]. From a sociocultural perspective, diverse disciplines have unique cultural backgrounds that influence how individuals think and behave^[26,28]. Through cultural exchange, nursing students learned how preschool teachers guide children in learning health issues rather than merely impart knowledge. They believed that children should be encouraged to speak more and that educators should learn how to provide support and guidance in teaching.

Through on-site participation, the students re-examined the approach used by the Department of Childcare and Education when communicating with children. The interactions with children also prompted them to reflect on themselves and improve their knowledge and abilities.

4.1. Limitations

This study assessed student learning outcomes in interdisciplinary education, revealing significant improvements in it. However, several limitations should be noted. First, the quantitative measurement relied on self-reported scores, which may not fully capture knowledge gained across domains. To address this, qualitative reflections from students were collected, which provided deeper insights into the effects of the integrated curriculum. Furthermore, the study’s use of a purposive sample restricts the generalizability of findings to the specific student population. Nevertheless, the research demonstrated some degree of generalizability as it presented qualitative results aligned with participants' experiences^[29]. Second, the low number of male nursing students (13.6%) limits the generalization of findings to only female students. Further research should include more male students to determine gender differences. Third, time and manpower constraints prevented the student group from interacting with children in both kindergarten and hospital playrooms simultaneously. However, students shared their experiences and learned from each other through reporting and reflection^[27]. Lastly, the interdisciplinary teaching course was taught only to nursing students by the faculty from the Department of Nursing and the Department of Childcare and Education. Future research could involve students from both departments to explore the effects of interdisciplinary learning.

The study found that interdisciplinary teaching can enhance students’ knowledge and healthcare skills in therapeutic play, including communication, knowledge application, and problem-solving abilities. Additionally, this teaching approach contributes to improving students' learning attitudes. The Department of Childcare and Education provides nursing students with valuable perspectives and strategies that allow them to view therapeutic play as extending beyond the treatment of illnesses. It expands their instructional abilities and empowers them to create games that better cater to children's daily lives, thereby improving the overall health of the children.

Ethics approval and consent to participate

The study was approved by the Ethics Committee of Chang Gung Medical Foundation Institutional Review Board (Approval no. 201801939B0). This study is conducted anonymously, and this course is a teaching activity that administrative units must implement, and no consent is required which approved by Chang Gung Medical Foundation IRB.

Consent for publication

Not applicable.

Funding source:

This work was supported by the Ministry of Education [grant number PSK1080241, 2019]. The funder had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

CRediT authorship contribution statement:

Bao-Huan Yang: Conceptualization, Methodology, Software, Data curation, Writing- Original draft preparation, Visualization, Investigation, Supervision, Writing- Reviewing & Editing. Kao-Wen Lo: Software, Validation, Writing- Reviewing & Editing. Yuh-Shiow Li: Software, Validation, Writing- Reviewing & Editing. Kuo-Yu Chao: Software, Validation,Writing- Reviewing & Editing.

Acknowledgements:

The authors appreciate all the participants for providing their time and data.

Conflicts of interest:

None.

Availability of data and materials

In light of the sensitive nature of the questions posed in this study, participants in the survey were guaranteed the confidentiality of their raw data and reassured that it would not be shared.

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Table 1. Paired t-test of the Questionnaires

Questionnaire		Pre-test Mean (SD) n=103		Post-test Mean (SD) n=103		t
Instructional evaluation scale
	Teachers’ instructional input	45.07	(10.84)	64.62	(8.65)	-14.10***
	Course content and teaching arrangement	11.86	(2.93)	17.16	(2.50)	-13.62***
	Teaching method and teacher–student	21.31	(5.12)	30.17	(4.14)	-13.80***
	Evaluation and feedback	11.89	(3.17)	17.29	(2.46)	-13.31***
	Students' learning outcome	36.97	(9.48)	57.08	(7.04)	-16.61***
	Knowledge	16.82	(4.49)	26.15	(3.35)	-16.23***
	Ability	11.43	(2.95)	18.03	(2.13)	-18.13***
	Attitude	8.72	(2.52)	12.90	(2.12)	-12.33***
Service-learning abilities questionnaire		184.57	(61.58)	295.05	(40.51)	-14.30***
	Self-knowledge and self-confidence	20.39	(6.96)	34.21	(11.00)	-10.08***
	Communication skills	20.54	(7.05)	32.51	(4.74)	-13.86***
	Problem-solving skills	20.32	(7.40)	32.39	(4.89)	-13.42***
	Citizenship and social responsibility	20.13	(7.64)	17.38	(2.31)	3.43**
	Team skills	21.30	(7.51)	34.60	(10.34)	-9.97***
	Self-reflection	20.91	(7.19)	33.16	(4.67)	-13.92***
	Knowledge application	21.59	(7.71)	34.03	(4.61)	-13.49***
	Caring for others	20.75	(8.09)	33.75	(4.79)	-14.60***
	Cross-cultural competence	18.64	(6.81)	27.51	(4.24)	-11.38***

Note: SD: standard deviation; **p<.01, ***p<.001

Table 2. Correlation of Post-test Instructional Evaluation and Service Learning

Outcome variable		Person correlation coefficients
Instructional evaluation scale		Instructional evaluation scale		SAR
Instructional evaluation scale		Teachers’ instructional input	Students’ learning outcome	SAR
	Teachers’ instructional input	1	.821^** (N=103)	.550^** (N=103)
	Students’ learning outcome	.821^** (N=103)	1	.636^** (N=103)
SAR		.550^** (N=103)	.636^** (N=103)	1

Note: SAR: Service-learning abilities questionnaire; **p<.01

Table 3. Identified Themes, Categories, and Codes from the Representative Quotes

Theme

Category: Code

Representative quotations

Integrating different learning areas to promote children’s health

Identify the characteristics of games based on a child’s developmental stage: different kinds of toys, snowman push, paper-tearing games, and guide games for storytelling.

Things that use the child’s living environment: stickers, balloons, stockings

S46: In this course, I learned a lot, such as different types of games and toys, and the suitable age groups for each. Although I had no clue at the beginning, I felt a sense of accomplishment upon completing the work.

S43: Teachers teach us to use familiar things in children’s lives to improve their health habits.… We prepared their favorite cartoon stickers in advance...Someone is also responsible for folding balloons for children on the spot to help them participate in activities.

Strengthening communication skills

Vivid verbal expressions: pretending to be an animal or cartoon character when speaking.

Simple body language: gestures that are familiar to children’s daily lives.

S70: We use what we teach in class...talking to children through animals or characters can capture their attention, which is effective.

S63: We use more sign language nursery rhymes to interact better with the children.

Developing multiple problem-solving abilities

Discuss jointly: jointly conceive the activity process, plan suitable games, and divide labor and cooperation.

Learn different aspects of the ability to address children’s health problems: development of children’s physical activities, fine motor development, time management, and children’s emotional problems.

S36: Demonstrate teaching first and allow group members to stimulate children to confirm that the teaching methods and sentences are understandable.

S54: Many children of this age do not know how to tear paper. When they started making masks, they felt impatient. When I helped them tear paper for the first time, they happily told me they would do it too! I find that we often overthink things and forget that they can be simple and lovely. Thank you for this course, which allowed us to have these experiences.

Practicing enhances learning effectiveness

Practical application: assisting children in making toys themselves, combining professional knowledge and practice.

Live feedback:

Child giving back - happy, child completing activity, child thanking

Teacher feedback - guide children’s ways, time control, children’s emotional comfort, and make toys together

S50: When we were putting together masks, everyone was inexperienced at first, so there was some hesitation. However, as time passed, everyone gradually started to help the children make their masks and understand their emotions.

S38: I found their snowman decorations with sick kids to be creative. It is important for sick children to have normal activities like other children. We received a lot of positive feedback from the children’s smiles.

S51: The teachers have suggested that there are ways to improve the process, such as controlling the time and providing more encouragement to the children. We should explain the approximate time to the child at the outset so that everyone can progress consistently. Encouraging children generously while interacting with them can motivate them to accomplish their tasks. Thanks to the teachers’ assistance, the event ran smoothly.

No competing interests reported.

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