PTJ Author Interview: Advancing Sense of Belonging in Physical Therapist Students

Welcome to this APJA Podcast. Welcome to the PTJA Podcast, where you can get the story behind the research with insights into clinical application, study design, and future projects planned. Hello, and welcome to the PTJA Podcast. My name is Shauna Dudley-Jawarowski, and I'm a member of the PTJA Editorial Board and a faculty member at the University of Iowa Department of Physical Therapy and Rehabilitation. Today, we're highlighting an article entitled, "An Improvement Science Framework to Advance Sense of Belonging for Physical Therapist Students from Minoritized Backgrounds." Two authors are joining us today for the discussion, Dr. Keshri Nidu and Dr. Diane Jettie. Both authors are affiliated with the Department of Physical Therapy at MGH Institutes of Health Professions in Boston. Dr. Camille Powell from Northeastern University was also an author of this paper. So Keshri and Diane, a warm welcome to the podcast. Thanks for asking us. Thank you. To get things rolling, I'd just like to give the listeners a little bit of background about the work that preceded this perspective paper. In the past four or so years, your author group published a collection of articles that evaluated interventions that you developed to address a complex problem in your PT educational environment. So we'll talk about that more later. And each of those articles described an individual dimension of the work that your group has been doing. But this perspective paper ties all that work together and also kind of pulls back the curtain for the PT ed community on the specific approach that you used and that you're continuing to use to address the challenges that you identified in your environment. So I think that this paper really hits a sweet spot in PT education literature because it's simultaneously theoretical, but it's very, very practical. And so to set the stage for the listeners, I'm hoping we can begin by covering a couple of the more theoretical aspects of the paper that might be a little unfamiliar. So first, can you explain what is meant by a wicked problem? And then more specifically, how did that concept apply to the situation that your author team identified in your own educational environment? So I'm going to talk a little bit about the wicked problems and then Keshri can jump in at any time and add some information. But wicked problems are kind of the caused by this complex system with lots of different interacting components and poorly understood mechanisms. We just don't know what causes them. We don't know what information we need or maybe we have information that we don't understand. Or it's contradictory. There's lots of different opinions on the matter. There's lots of symptoms without solutions and kind of the way people explain it depends upon their point of view. So some of the big social problems that you might imagine are things like, let's say homelessness or health care disparities, thinking about those as wicked problems. But in education, we also have sets of wicked problems. You know, overall, for example, we don't even know how to sometimes define educational quality or how to measure it or how to improve it because we have a wicked problem. So belongingness is one of those wicked problems. We just don't have any complete notion and solutions to it. And I think as educators, we want nothing more than for the learners we interact with to have their best possible educational outcome. And when we are confronted with educational disparities just in the same way when we're confronted with disparate health outcomes, that's a wicked problem because it is so complex that we really don't know where to start. And that's why the model that we're going to be talking about today, improvement science was helpful in helping author teams and there were multiple author teams, the multiple improvement teams see the problem, see the system, and then decide where are we even going to start. And Diane, you mentioned belongingness. And that was really the focus of what you talked about in this perspective paper. So let's dive into there. What is sense of belonging within healthcare education and why is that so important to cultivate? Well, you know, a sense of belonging is part of Maslow's proposed hierarchy of needs. And so it's not new, this notion, but maybe applying it more to the educational setting has, I think, probably increased since 2020, probably. But it's really a sense of deep connection to a group of people or even individuals or an institution or a social gathering, but this sense of a shared identity with people that you're with being accepted and respected, valued and feeling secure. The important thing about education is that a sense of belonging is associated with well-being and we know our students' well-being has decreased over the past decade, shall we say, in five to 10 years. And sense of belonging is also associated with engagement and learning, which we know is important for educational outcomes. I think it's helpful to think about the fact that human beings are social creatures. And when we don't belong, feel as if we don't belong, we actually think of little else than belonging. And so when we think of learners in the educational system who feel as if they don't fit in, they don't belong, and you're dedicating so much of your cognitive resources to that, could you really be fully engaged in the learning experience? And this is why we see it associated with educational outcomes and why it was a priority for our team. Can you tell us a little bit about the specific population or subpopulation of students that you identified as this being a particular challenge? So when we examined the outcomes and what we spoke about, we want to see the best possible outcomes for all learners and we saw that for racially and ethnically minoritized students in our program, while we had this exceptional graduation rate, we noticed disparate outcomes in terms of time to graduation. And we noticed that students from minoritized backgrounds were taking longer to graduate. So the graduation rate looks good until you start to disaggregate data and look at it for different groups of students. And seeing this disparate outcome then led us to dig further into do we really understand the problem of why we are having this outcome in our program. And this is not how we define excellence for our program. We want everyone to have the same exceptional outcome. And this kind of leads us to then the approach that your group used. So you identified that this wicked problem was present in your educational environment of disparate outcomes for students from minoritized backgrounds. So can you tell us about the approach that you used, the improvement science framework, what that means, what are the basics of it, and what are its key steps, and why did it provide you with a helpful methodology for what you wanted to achieve in your program? Yeah, so improvement science, the framework is really learning by doing. So you have a series of these plan, do, study, act cycles, so PDSA cycles. And this is small scale change to test the efficacy of a change, and then you use feedback that you get from one of these cycles to make changes to your approach. And then you run the cycle again. So we're making small iterative thoughtful change. And before we decide to take something to scale, but in order to do that, you need to know what does success look like for you and for your program. So there's these principles that we describe in the paper. We talk about making the problem, making the work problem specific. So know what you are trying to fix, making it user centered. Do you understand the student experience? And then you want to address variations in performance. So some groups experiencing the change different than others. Did you have to make changes? How can you learn from changes? And then do we see the system that physical therapy education is not just happening in the classroom. It's not just in the academic environment. It's happening in the clinical setting, which in itself is an extremely complex system. So the improvement science framework helped us to appreciate two very complex systems and how they were interacting to contribute to the student experience. And then finally, we can't change what we cannot measure. So do we have good measurement tools? And in 2019, we didn't actually, it was challenging to measure belongingness among doctor of physical therapy students. And of course, since then, Dr. Poole at all, Dr. Omenroeder at all, they've been doing great work about these valid tools for assessing belonging. And we had to make due back in 2019. I think the alternative to that systematic process of improvement science is the notion of solutionitis, which we also addressed a little bit in our paper. And I think we're all subject to the desire sometimes, maybe, or maybe we're infected by the infection of solutionitis, but kind of picking a solution. We get in a room, we have all the faculty, there's 20 different opinions, we start narrowing it down and arguing about it. And then we leave the meeting after two hours and say, yep, that's what we're gonna do without really thorough consideration of the different perspectives and maybe even the perspective of the people who are gonna miss often the students. And often without valid data, you know, not understanding where the root cause is, right? Just seeing what the symptom is and jumping on the symptom. How did making the process user-centered, which is one of the pillars of this process, how did that look for your group? How did you focus your work on the user-centeredness, which would be the experiences of the DPT students? Yeah, so we used a mixed methods approach. So there was certain data that you could get from available measures at the time, but then we used focus group interviews to fill in the gaps. What were some of the things that we were noticing in the quantitative data and how to qualitative data help answer those questions? And in many ways, we're so well-situated to understand the user, because as education researchers, we're scholar practitioners, we're embedded with the users. So we want to make sure that we're not making changes without their perspective. I was wondering, as I was reading the paper, if also potentially participation in an improvement science process in itself could be an aid to the sense of belonging for participating students. Did you observe any? We did. Now, first year of our mentoring program, we matched first and second year students from minoritized backgrounds. And then the next improvement cycle, the mentees became mentors. And so they were involved in the process and they were training new mentors, and they were not shy to give us their opinion about things that worked and what didn't work. And we certainly have the opportunity to learn from variation, because the COVID-19 pandemic happened in the middle of one of the cycles, and we had to transition this program that we had envisioned with lots of in-person contact to virtual meeting groups. But in some ways, the participants told us, yeah, it was very freeing to meet with each other while wearing our pajamas, and we were very relaxed. We shared more information than we thought we would in school. That process of that iterative process where you examine the variation in one cycle and you use it to inform the next steps in the subsequent cycles. The final cycle, you actually broadened your scope quite a bit, and you looked further afield and you looked at clinical education. Can you tell us a little bit about how that evolved? Yeah, so that involved from one of the cycles where we started to get an appreciation for that. Sometimes the classroom can be a bubble of where students may be protected, and they were encountering these experiences in the clinical education environment with patient, caregiver bias, with maybe clinical instructors who didn't have the language to have conversations about race and culture and ethnicity in the clinical environment, and this provided this opportunity for, yeah, we were developing the faculty skills, but what about our clinical faculty? And so then this provided an opportunity to provide some professional development for clinical faculty as well. And that really emphasizes that there was no panacea to this problem. You had to continue to iterate, you had to continue to develop. And reading the paper, this wasn't the only dimension of the wicked problem that you identified within the educational environment. This wasn't the only source potentially, the root cause of why you were observing these disparate educational outcomes. So what are some other directions potentially in the future that your group may continue to work on to chip away at the problem? Yeah, so the the key driver diagram helped us to understand what could be the primary drivers that are causing these disparate outcomes. We decided to start with sense of belonging based on what we heard from the users. But one of the things we heard was that minoritized students were entering into the profession because they wanted to return to communities of color and effect change, and we weren't addressing this in the curriculum. And unless you spend this time understanding the user perspective, you may not get here on your own as as an educator. And so then this led to the development and the focus on social responsibility and health equity and social determinants of health and the development of a cross curricula thread in our program. And you know, in the spirit of thoughtful iterative change where we are in 2025, you know, many of those interventions may face barriers, and we require thoughtful change to be able to continue to do this good work of focusing on social responsibility and empowering the students to return to their communities and do good. The process is that, you know, what you describe in the paper was unique to your context, right? It was unique to your educational environment, right? But it has broad applicability. So what are some other ways that you see that the process could be replicated for other types of wicked problems in PT education? Because this is really the practical dimension of the paper is how readers might be able to leverage this for their own situations. Yeah, I'll let Diane go. I was just going to say one of the issues for many of our colleagues right now is kind of a drop in the first time pass rate for the MPTE. And I think in my experience anyway, faculty get together and do, oh my God, and then we have to do something. And then they say, oh, down the road at, you know, Northeastern University, here's what they did. And they saw an improvement. So let's do that. So they kind of jumped to solutions without really finding out from their students what some of the issues might have been. And without practicing that improvement science cycle to get to the best solution, even though it could be one of 10 solutions, what is the solution that's based on data? So that's just one problem I can think of. But I think in PT education, we tend to want to fix something right away because it's always a problem for our students. And as Keshree mentioned at the beginning of our conversation, we want to do the best for students. Every faculty member has their heart in that. And so how do we do that? Sometimes we don't do it well. I'm curious if you actually observed a change in culture or mindset among the faculty after they participated in this process, because as Diane described, the default is often the solutionitis approach, where we just flail, identify, let's try this. It seems like it could work. It's a good theory. And don't use data to inform it. Don't make it user centered. So we don't take key stakeholders into account. So in your educational environment after this process has been ongoing for multiple years, are things different somehow with the faculty mindset? Yeah. I think I hear very much now when somebody pitches the problem that somebody will say, let's do a needs assessment to make sure we understand the problem first. And so that's been very hardening how often I hear the word. Great. Yeah. Well, to wrap up, I'd just like to turn the floor over to you two for any final thoughts you might have. So is there anything that we haven't touched on today or that you'd like the listeners to know about this work? So I think one thing that has been really hardening is that I think we know that minoritized students express that they need a representative faculty body, because when they see faculty of color, it shows them that it's possible. There's persistence. It motivates them. However, at the same time, it's not just up to faculty of color to support minoritized students. And it's not even mathematically possible. But what came out in this work for us was how much the white faculty wanted to contribute to positive outcomes for minoritized students, how much they wanted to learn about, you know, cross-cultural communication, how much they ended up developing their cross-cultural psychological capital. And that's a big change that I've seen about this wanting to be allies and to support minoritized students. I think that's the biggest thing that comes out of this work for me is to engage our fellow faculty member who want to engage in this work with us. I mean, I think when I look at the process and you look at what we showed in the paper, how long it took, and what each step was, people have to be patient. And I sometimes think we're not patient enough. And we have to understand that in order to even come close to a good implementation of something that's going to work, that the systematic process is necessary. Yeah. And it's encouraging to me to read this paper because it's some good news in PT education. You know, it's really encouraging to hear that you are able to affect change and that you are gaining some traction on a problem that is, yeah, it was unique to your context. You identified it within your own educational environment. But I would also say that it's very widespread and that there's a lot of educational environments around the country that are similarly identifying this as a key problem for them. So well, thank you both for joining us on the podcast today. It's been really enjoyable talking with you and congratulations on this publication. And thank you for sharing your work with our profession through PTGA. Thanks for having us. Yeah. You can find more APTA podcasts like this one on Apple Podcasts, Google Play, and Spotify, or by visiting apta.org/podcast. Thanks for listening.