Does Participation in Physical Therapy Student-Run Free Clinics Relate to Altruism, Social Responsibility, and Cultural Competency Post-Graduation? A Pilot Study

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Introduction
Physical therapists, like other healthcare professionals, are required to abide by guidelines and practices established by their governing body.The House of Delegates of the American Physical Therapy Association (APTA) established the Code of Ethics as a core document in outlining ethical obligations of a physical therapist.The Code of Ethics is based upon the principles of the APTA core values, ethical action/obligation and the five roles of the physical therapist. 1][4][5][6] As a method to enhance health professions education, professional schools often establish student-run free clinics (SRFCs).][9][10][11][12][13][14][15] Physical therapy students benefit from SRFCs by demonstrating greater scores on the APTA Core Values Self-Assessment tool, improved clinical skills, and displaying professional growth compared to students who do not participate in SRFCs. 16hile there is research to support the benefits of SRFCs in the classroom setting, there is limited research to show the transition of skills and values to clinical practice.Participation in SRFCs as students may help improve value and demonstration of core values in practice.The purpose of this study is to identify if participation in SRFCs as student physical therapists correlates with greater values and demonstration of altruism, social responsibility, and cultural competency as practicing physical therapists.

Survey Development
An electronic survey (Online Appendix) was created using portions of the APTA Professionalism in Physical Therapy: Core Values Self-Assessment tool.The survey was intended to target practicing physical therapists that had the opportunity to participate in a SRFC as a Doctor of Physical Therapy (DPT) student, whether they volunteered or not.

Survey Dissemination
Universities were contacted through the Physical Therapy Pro Bono Network and were asked if they would participate in distributing the survey to their alumni.Researchers also reached out to three DPT programs within the state of Michigan for distribution of the survey.The survey link was distributed through email to 794 licensed physical therapists over the course of six weeks utilizing the Dillman Method. 17In an attempt to increase the number of respondents, two Facebook pages ("Doctors of Physical Therapy Students" and "Doctors of Physical Therapy Students: New Grads in the Real World") were also used as a means of distribution.

Data Analysis
Data were analyzed using IBM SPSS, version 24.0 (IBM Corp., Armonk, New York).Frequency tables and descriptive statistics were calculated for characteristics in the overall sample and within groupings of students.Spearman's rank correlation coefficient was used to determine the relationship between number of hours volunteered in a SRFC with leadership position held, participation in international service-learning, and values of providing pro bono services, altruism, social responsibility, and cultural competency.A significance level of p<0.05 was used for all tests.

Demographics
Eighty-five practicing physical therapists completed the survey.The majority of respondents were white (n=77, 90.6%), 61.2% (n=52) indicated they were female, and 80% (n=68) indicated they were between the ages of 25-29.Nearly all of the participants attended a public DPT program (n=82, 96.5%) and graduated between 2010 and 2017.Over half of the respondents (n=54, 63.5%) were APTA members and only 8.2% (n=7) of respondents were American Board of Physical Therapy Specialists.The majority of respondents reported that they work in a private outpatient facility or hospital-based outpatient facility (n=62, 72.9%) and indicated that they were not owners of their own practice (n=83, 97.6%).

SRFC Involvement
Seventy-three (85.9%) of the participants responded that they had volunteered in their universities' SRFC while 12 (14.1%)chose not to volunteer.Of the 73 that had volunteered, one-third of them (n=26, 35.6%) held leadership positions.A minority of respondents (n=4, 5.5%) indicated that the university mandated their volunteer work.Only 12% (n=9) of respondents indicated that they volunteered in an international service-learning trip.Forty-three (59%) of the participants volunteered 30 hours or fewer and the other 41% of participants volunteered 31 hours or more while in their DPT program.

Value on Providing Pro Bono Services
Participants who volunteered more hours as DPT students indicated that they place a greater value on providing pro bono services compared to those who volunteered fewer hours (rs=0.56,1).

Value on Altruism, Social Responsibility, and Cultural Competency
There was a small to moderate correlation between hours volunteered in a SRFC and valuing altruism (rs=0.32,p=0.003).The number of hours volunteered, leadership position held, and participation in service-learning trips weakly correlated with valuing social responsibility or cultural competency (Table 1).Regardless of participation in a SRFC, a majority of participants agreed or strongly agreed with each statement regarding cultural competency.

Value in Action
Despite indicating higher values on altruism, 86.3% (n=63) of participants who volunteered in SRFCs responded that they never to occasionally provide pro bono services in their current practice and 52.1% (n=38) indicated that they never to occasionally provide physical therapy services to underserved and underrepresented populations.A majority of respondents (86.3%, n=63) also indicated that they never to occasionally participate in political activism, 69.9% (n=51) indicated they never to occasionally participate in the achievement of societal health, and 53.4% (n=39) indicated they never to occasionally promote community volunteerism.

Barriers to Providing Pro Bono Services
Fifty-four people responded to the optional question regarding barriers to providing pro bono services.Of those, twenty-one (38.9%) reported time as a significant barrier to providing services.Other responses included: work requirements limiting pro bono services (n=16, 29.6%), financial obligations (n=6, 11.1%), access to pro bono clinics (n=5, 9.3%), and liability (n=3, 5.6%).Lack of community engagement and knowledge of resources in surrounding communities also impacted participants' ability to provide free services in their community (n=8, 14.8%).

Barriers to Participating in the Achievement of Societal Health Goals
Twenty-one people responded to the optional question regarding barriers to participating in the achievement of societal health goals.Of the twenty-one respondents, twelve (57.1%) reported time as a significant barrier to participating in the achievement of societal health goals.Four (19.0%) of the respondents indicated access to participation was limited in their communities.Two (9.5%) respondents indicated that financial obligations restricted them from participating in societal health goals.

Discussion
The purpose of the study was to explore the relationship between participation in a SRFC as a student physical therapist and demonstration of the physical therapy core values as a practicing clinician.Students who volunteer more hours in pro bono clinics or served on their leadership boards demonstrated greater valuing of altruism and providing pro bono services.Despite indicating higher value on these two characteristics, therapists are lacking demonstration of these values in current practice.Rarely are practicing physical therapists providing pro bono services, physical therapy services to underserved and underrepresented populations, promoting community volunteerism, participating in political activism or participating in societal health goals regardless of their involvement in pro bono work as doctoral students.Previous research by Guenter et al. and Denton et al. showed similar trends. 3,4mplementing multiple strategies may assist in decreasing the barriers that physical therapists report in providing pro bono services: lack of time, work requirements limiting pro bono services, limited access to pro bono clinics, financial obligations, and liability.In order to increase involvement in pro bono work and political activism beyond graduation, clinical sites may partner with university-led SRFCs to help serve their communities.Partnerships would help to eliminate many of the barriers that are keeping therapists from fulfilling Principle 8A of the APTA Code of Ethics: Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured. 1llowing physical therapists to participate in pro bono work could be beneficial for all parties involved: the community, the therapist, and the employer.Employers may choose to pay their employees to volunteer a certain number of hours a month at their local SRFCs which will eliminate the barriers of time, financial obligations, work restrictions, and limited access to free clinics.If an employer, however, chooses not to pay its employees to volunteer in an SRFC but gives them time to do so, therapists may still benefit from volunteering by gaining professional development requirements. 18Partnerships will not only benefit the employer-they will also benefit the employee and the physical therapy profession.
Some physical therapists view liability as a barrier to providing pro bono services and participating in the achievement of societal health goals; however, free clinics and universities are required to abide by legal and operational standards in order to provide care for under-and uninsured individuals in their community.In addition to the liability coverage provided by universities, laws are in place to protect health care professionals engaging in pro bono work.For example, in some states, the Good Samaritan statute may include immunity for licensed healthcare professionals rendering services at free clinics. 19,20Under the Volunteer Organization Protection Act of 2017, as long as the volunteer acts within their scope of practice, is properly licensed, and does not receive compensation for their services, no volunteer at a nonprofit organization should be held liable for harm caused with the intent to help. 21

Limitations
Due to the relatively small sample size of this study, findings are not generalizable to the physical therapy profession as a whole.However, the demographics of this study are similar to those of the APTA with regards to gender and race; almost all of the participants were less than 35 years of age which is different from the demographics of the APTA where only 37% or physical therapists are under the age of 35. 23Nearly 800 emails were distributed to DPT alumni at five universities, giving a response rate of 10.7% (n=85).Respondents were not identified as to whether they had received the email or followed the link on the Facebook pages.Of the eighty-five respondents who completed the survey, a majority (n=73) had participated in SRFCs.This made it challenging to make comparisons between those who had participated in SRFCs and those who had not.A survey response bias may have existed due to those completing the survey having an interest in pro bono work.Causative relationships cannot be inferred with our cross-sectional study design.However, regardless of having volunteered in a SRFC or not, practicing clinicians are still lacking demonstration of core values within the clinic.
Future studies may investigate practice models that facilitate provision of pro bono services and encourage continued development of altruism, social responsibility, and cultural competency.

Conclusion
Physical therapy student participation in SRFCs correlates with enhanced value on providing pro bono services and altruism post-graduation.Despite indicating higher value, practicing clinicians are lacking demonstration of these traits in their current practice.The physical therapy profession needs to work towards decreasing barriers at an individual, employer, and policy level to help increase the frequency at which physical therapists are able to provide pro bono services.Intentionally eliminating barriers to providing pro bono services may help assist the profession in meeting its new vision statement of "transforming society by optimizing movement to improve the human experience." 23

Table 1 .
Correlation between Hours Volunteered in SRFC, Leadership, Service Learning, and Valuing Altruism, Social Responsibility, and Cultural Competency