Constructing and Evaluating an Intergenerational Academic Service-Learning Curriculum in Gerontology

Intergenerational Service-Learning has been documented to enhance student learning. Research indicates that students in healthcare professions view working with the geriatric population as a low priority due to negative stereotypes of the elderly. The purpose of this study was to develop a teaching model for establishing partnerships between academic programs and community services for students of gerontology and to evaluate the effect of an Intergeneration Service-Learning curriculum. This research adopted a qualitative approach to study the learning experiences of nursing students during an interdisciplinary community-based healthcare course. Data were collected by participant observation, students’ written journal reflections, verbal presentation of their reflections, instructors’ observations, and focus group discussion. It introduced the rationale, development process, content, and evaluation of the teaching model designed by the researcher. The effects of this curriculum not only were reported as a bridge across generations connecting youth and elders but also fostering positive attitude, improving the ability to care and enhancing commitment to elder people. This article provided an overview of Intergenerational ServiceLearning teaching model that involved students in learning outside the traditional classroom and provided a needed service in the community. Otherwise, an important element of this teaching model was to infuse “reflection” in learning process of the nursing students by faulty, which would be appropriate for improving the quality of education and the findings of this study provided direction for the course design for gerontology.


Introduction
Taiwan has a rapidly increasing population of older people, with 10.63% of the population over 65 years of age and predicted to increase to 14.4% by 2020 (Directorate-General of Budget, Accounting and Statistics, Executive Yuan, 2006).Older people tend to have multiple health problems and are the most likely to require health care.Thus, there is an increasing need for health care professionals to work with older adults.
Nurses play a significant role in meeting the care needs of the frail elderly.One of the goals of nursing education programs is to prepare students to care for the elderly in the community.Research indicates, however, that students in healthcare professions view working with the geriatric population as a low priority due to negative stereotypes of the elderly (Hernandez & Gonzalez, 2008).Research has also suggested that such negative attitudes are, in part, due to lack of personal contact with older people and experiences of intergenerational conflict at work (Briggs, Atkins, Playfer, & Carrado, 2006).
To create a more positive response to the elderly, nurse educators have recommended that positive attitudes be cultivated early in nursing education programs.In the last decade, several researchers have reported that attitudes toward the elderly can be improved by promoting contact with the elderly, which may reduce perceptual ambiguity and lessen psychological distance (Author, Wu, Chang, & Chen, 2007;Cohen, Hatchett, & Eastridge, 2006;Hernandez & Gonzalez, 2008;Lin, Yuan, & Kuo, 2005).Unfortunately, in traditional classes emphasis is on lecture and learning through memorizing, which limits students' experience of the real care world, resulting in disconnected teaching and practice and lack of reflective learning through community-based health care service (Cress, Collier, & Reitenauer, 2005).Educators are searching for effective pedagogy for healthcare students in this aging society.
Service-learning was proposed as a type of experiential learning that began to gain popularity in higher education at the end of 20th century (Eyler & Giles, 1999).It was considered an ideal instructional methodology to link the needs of stakeholders and benefit both students and community partners (Singleton, 2007).Through reflection on the process of participating in the program, students broaden and deepen their understanding of the health of individuals in communities and gain a more sophisticated understanding of risk factors associated with social determinants of health (Anstee, Harris, Pruitt, & Sugar, 2008;Ward et al., 2007) In recent decades, many service-learning programs have been conducted in Taiwan; however, it is little information on designing courses with a focus on community service for the elderly and evaluating what students learn from the service experience.Recognizing the increases in an aging population, the purpose of this study was to develop a teaching model for establishing partnerships between academic programs and community services for students of gerontology and to evaluate the effect of an Intergeneration Service-Learning curriculum.

An Intergenerational Service-Learning Teaching Model Development
Three aspects of the curriculum design will be discussed in this paper.These include the process of integrating community needs and applied research methods into an inclusive diversity education curriculum, building and implementing a service-learning project, and the outcome of the project on students' attitudes toward the elderly.

Philosophy of Service-Learning Programs
The idea of service-learning developed from an educational philosophy that encourages active learning to fulfill social responsibilities (Mueller & Norton, 1998).It promotes educational experiences in which students participate in organized service activities that meet identified community needs (Jacoby, 1996).Through servicelearning, educators can infuse experiential learning and reflective thinking in classroom and community settings (Dewey, 1933;Eyler & Giles, 1999;Scheuermann, 1996).
According to Kolb (1984), individuals learn in four stages or modes: concrete experience, reflective observation, abstract conceptualization, and active experimentation.He offered a more detailed view of experiential learning that includes reflection as an element of a more extensive learning cycle.Service-learning is very much founded on the concept of experiential learning which explores the cyclical pattern of learning from experience through reflection and conceptualization to action and on to new experience.The mechanism of knowledge transformation is depicted in Figure 1.
Service-learning provides a connection between the students' studies and the real world.Through students' active involvement, it is believed to foster the development of moral judgment, civic duty, cultural competence,  (Kolb, 1984).and global sensitivity.For health professional education, service-learning provides opportunities to develop core values of professional care, including altruism, autonomy, human dignity, integrity, and social justice (Fahrenwald, Bassett, Tschetter, Carson, White, & Winterboer, 2005).

Definition and Origin of Intergenerational Service-Learning
Intergenerational Service-Learning was defined as "an innovative method of teaching and learning that integrates community service activities focusing on the interactions of older adults and younger generations into academic curricula" (Newman & Tompkins, 2000: p. 4).Expected benefits of these programs include improved understanding of course concepts, dispelling myths about aging, and reinforcing career choices (Blieszner & Artale, 2001;Hernandez & Gonzalez, 2008).In addition, programs are expected to promote students' understanding of aging and issues related to aging in place as well as students' professional development and civic engagement (Horowitz, Wong, & Dechello, 2010).
One of the most important developments in Taiwan higher education in recent years is the emergence of service-learning, which has become increasingly popular among educational institutions.Fertman, White and White (1996) suggested four major elements of service-learning programs, preparation, service, reflection, and celebration.Although research on student effects of service-learning is becoming more plentiful, the processes of designing and implementing service-learning experiences have rarely been addressed (Anstee et al., 2008).In addition, students' perceptions of the influence of such programs have not been examined.

Course Design and Students
The service-learning experience was designed for sophomore students, enrolled in a multi-disciplinary gerontology course.The course included students in social welfare, health management, and nursing programs.
The course was a required course for nursing sophomore students.It was expected to identify the healthcare needs of the elderly and communicate with and provide basic care for the elderly.The course was founded on three core value: a) enhancing academic learning, b) ethics or social justice, and c) caring attitudes toward the elderly.The course included 16 hours of classroom instruction and discussion, 16 hours of community service, and 4 hours focused on evaluation.Relevant readings were recommended for the students.

Course Grading
In addition to the proposal and hours of service, 3 assignments were required for the Inter-generation Service-Learning teaching model: a reflective journal, an advocacy project, and a poster display.
During the year of carrying out the Intergeneration Service-Learning teaching model, the students were asked to keep personal reflective journals.The nature of reflection and its importance for service-learning were discussed during the introductory class.In their journals, students were encouraged to address how they were meeting the course objectives.An optional journal format that consisted of prompting questions (What?So what?Now what?) was presented for use if students were struggling with how to structure their journal entries.As the students completed their direct service, an advocacy project was also done.The advocacy project was designed to address course objectives and was completed individually or with a group of students completing similar projects.Students were encouraged to pursue advocacy projects related to legislative issues, although fund-raising and public education were also allowed.Students submitted a brief description of their advocacy project along with any materials (e.g.letters to legislators, brochures) that were developed.In addition, the designed a poster to display their learning experiences during the course.
Each course requirement was graded as satisfactory or unsatisfactory.The community partner administrator assessed the service aspect of the project through a one-page evaluation of the student's professional behavior, interaction with the community, and completion of the project as outlined in the proposal.The faculty member assessed the reflective journal, advocacy project, and the display poster.

The Process of Constructing an Intergenerational Service-Learning Teaching Model
The service-learning aspect of the course was designed based on a modified version of Fertman, White and White's model (1996).Their model included four stages: preparation, action, reflection and celebration.In our model, we infused reflection in each stage.The framework of this course is depicted in Figure 2. The preparation stage involved preparation for the community and students as well as pre-service reflection.Preparation activities for students included orientation to service-learning, knowledge related to older people, communication skills, elder care issues, and community resources.The pre-service reflection was important in providing students with the opportunity to examine their preconceptions and expectations before beginning the servicelearning experience.
Regarding community preparation, since conjunction with community care needs was one goal of this project; several avenues were used to establish relationships with potential community partners.First, the service-learning affairs department on campus sought potential community partner organizations.Organizations with varying service goals and target populations were selected.Initial contact was made via telephone or e-mail by faculty, and followed with a face-to-face meeting, if needed these calls and meetings served as a first step in developing a good relationship between a community agency and the faculty member and ensuring understanding of the mission and goals of each.Community partners were provided with a copy of the course syllabus and an overview of their responsibilities as community partners.The chief administrator of the agency functioned as the supervisor of student learning in this course, and contracts were completed between two institutions.Faculty and community partners then brainstormed potential activities and timing for student projects.Meanwhile, community partners also provided brochures or advertisements related to their organization to help students understand their missions or goals.Students were encouraged to work with community partners to identify projects that met the needs of both the community and the students.Students could work with an assigned community partner or initiate a community partnership on their own.
During the action phase, students got involved in contact with the elderly.After understanding the organizational missions and identifying the elder's care needs, the students were asked to select a task and complete an action proposal that included, a) how the task was health-related, b) how it contributed to meeting the needs of the elderly and the community, and c) how it served a population unfamiliar to the student.The proposal was reviewed and signed by the student, chief administrator of the cooperating agency, and the course instructor.Students were allowed to develop and complete the project individually or in small groups.Reflection was included in activities before, during, and after each interaction with elders.The students were asked to write down their reflections on a journal and to share verbally their experiences with their peers in class.
Celebration was the last stage of the project and included two parts.First, students presented their post-service reflections to their classmates and the representatives of the care center.All the students got awards provided by the agencies to affirm their contributions for the elders in community.Second, during the last class session, the administrators and older community residents were invited to provide their feedback to the students.

Method
The study used a qualitative description method to collect and analyze data, in order to identify the major themes reflected by the students and to evaluate the effect of participation on student's attitudes toward elders.

Data Collection and Analysis
Data were collected by several means, including students' written journal reflections, verbal presentation of their reflections, instructors' observations, and focus group discussion.
Journaling after each interaction in the community was intended to reflect the core value of this project.Journal guidelines included prompts such as "What have you done for the elderly, and what was their feedback?""How do you feel about their feedback?""What could individuals, government, or society do further for older people?" and so on.
Students' verbal class presentations were videotaped in order to review the tape for analysis.Five focus group discussions were conducted after the last class to provide a deep and comprehensive understanding of students' individual learning experiences.The interview guide for the focus groups was similar to that for the written journal, but led students to compare changes in their attitudes toward the elderly and academic achievement before and after the course.
All focus groups discussions were recorded, and were transcribed verbatim within 48 hours to develop a coding frame and conceptual categories from the bottom up within the data.Applying Miles & Huberman's (1994) method of content analysis, the researchers took the following steps in the analysis: a) reading through the set of transcripts to obtain a global understanding; b) systematically assigning codes to develop a number of meaningful conceptual units; c) gathering all data together, including the references from students' journals, verbal presentations in the class, and instructor's observation, then defining specific themes; d) classifying themes into groups of categories by examining their characteristics and attributes; and e) integrating all categorized themes to form a coding framework.In order to reach a consensus on the most appropriate categories, two researchers codified the same verbatim transcripts separately, and subsequently compared the categorizations derived by each.Discrepancies in codification were resolved through discussion and joint review of original accounts.Ultimately, the results were brought to participants to read and check to ensure that data analysis results accurately reflected their experiences.

Ethical Considerations
After examination by the Clinical Research Ethics Committee, potential participants were invited in a university in Taiwan.Before the focus interview, each participant confirmed their understanding of the research purpose and contents by signing a consents form and an agreement to participate.

Results and Discussion
A total of 23 males and 43 females participated in the study.The mean age of the students was 21.5 yrs, ranging from 18 to 22 years old.Qualitative results indicated that the Intergenerational Service-Learning experience had promising effects on the participating students.These effects are reported the central theme: a bridge across two generations.The process involved positive changes in the attitude of one generation toward another and reduction of stereotypical views towards older people.Six major themes were identified as the students engaged in learning experiences at various community sites: a) fostering positive attitudes toward older people; b) improving the ability to communicate with the elderly; c) increasing concern for the policy of elderly social welfare; (d) increasing the ability to solve the problems of elderly care; e) find self value via elder's feedback; and f) enhancing commitment for elderly care.

Fostering Positive Attitudes toward Older People
The journal written by the students presented the process of breaking down stereotypes involving cognitive dissonance.Building relationships with the elders challenged students' assumptions, perceptions, and stereotypes.Consistent with other service-learning research (Blieszner & Artale, 2001), we found that personal attachments between student and elder provided an opportunity to create such dissonance."I felt most of the elders in the institution were so lonely, they need others' concern and help" (#16; 34)."She touched my hair and face, and turned my body to see me.She was concerned whether I was cold, like her grandchild"… (#48).In addition, the students thought of themselves after being in contact with the elderly, "We'll become old like them, why don't we help them?We also hope others help us, don't we?" (#4) Some students demonstrated a change in their preconceived stereotypical images of the elderly, such as being "easily hot tempered", "stubborn", "garrulous" "solemn" "withdrawn" and "awful".Conversely, the students were surprised the older people were so optimistic and broad-minded (#30).Several students reflected that "they are so amiable and easy to communicate with.I felt fearless to take care of them" (#22, #30, #31, #32).Furthermore, the students found the elders were experts in some areas, and believed the elders should have their "splendid past": "It is unbelievable.The older person was expert in eight languages, Yo!He was so great; he was a Japanese teacher before" (#23, #63)."I was so surprised the elderly can do hand crafts so well" (#61).These quotes reflect the findings of Blieszner & Artale's study (2001) related to, "dispelling myths about aging".

Improving the Ability to Communicate with the Elderly
Some students expressed that they felt scared to contact the elderly because of stereotypes about the elderly.However, after the service-learning program, they found that there were a lot of memorable experiences in interacting with the elderly and that it was worth learning from them.Furthermore, they learned how to communicate with the elderly and how to get close to elderly people.
"Actually, communicating with older people is not too difficult…, you just have to be more patient, and speak slower..." (#15, #35).
"After participating in the service-learning activity, I know how to chat with the elderly, and how to make older people happy…" (#56) "During the early stage, I was scared to interact with the older people, but, gradually, I felt they are so easygoing, you can talk about anything you want with them…" (#21, #37).

Increasing Concern for Elderly Social Welfare Policy
The students stated that they pay more attention to the topic of the elderly in their daily life as a result of participating in the experience.They are more concerned with welfare issues and strategies related to the elderly.In addition, issues of living alone and long-term care for the elderly were mentioned in their reflection journals.Furthermore, they were willing to commit to elderly care because they were responsible for taking care of this population.One student shared: "The aged people are increasing, government should be more concerned about social welfare issues for the elderly…I am more interested in social problems after my experience in the service-learning activities.It is my responsibility to be concerned for society as a university student.Particularly the aged people who are alone should be paid more attention in the future" (#10, #24, #51) "Taiwan is an aging society, it is needed to education the child to understand older people and respect them…" (#11) Similar to Eyler and Giles's finding (1999), we found that developing ownership of an issue required that the students recognize the need for a change in the way the social problem is addressed by society and the need for change to better the lives of the people involved.The project provided the youth an opportunity of establishing a positive attitude toward society.

Increasing the Ability to Solve the Problems of Elder Care
The college students had few ideas about how to take care of older people in the beginning.As a result of their experience, however, they have developed concern for issues related to older people, criticized elder care strategies, and provided suggestions for related issues.One nursing student described the impact of the servicelearning experience during the focus group, saying, "I have learned to think about the problems of the elderly critically.For example, I felt staff fed the residents too fast; the attitude toward the elders should be more gentle..." (#17) The students also provided suggestions for staff for taking care of the elderly, such as providing more encouragement, respect for individual preference, concern for elders' privacy, and more attention to spiritual care.
"Older people should have more encouragement, if you gave more encouragement, they would like to do more… They do need more old friends…" (#24, #26, #27) "We should be concerned for each person's preference, somebody's characteristics tend to be active, some were quiet, so, we should consider and respect each person's habits .., if the elders don't want to tell you private things, you shouldn't ask further" (#23).
Further, the concern was not only to provide "material" but also "spiritual care" (#19).

Finding Self-Value through Elders' Feedback
One of the benefits of service-learning proposed by Blieszner & Artale (2001) is increased feelings of self-efficacy and self-esteem."Finding oneself to be useful" was reflected by student comments, such as, "I just provided a little concern to the older person, he was so happy.I found I was so great, and helpful for the elderly".(#69); and "when I saw them (the elderly) laugh, I felt my existence was worthwhile (smile)" (#25)."Actually, we learned from interacting with the older people.If they ask us about problems, we'll try to resolve them by searching for references, then we learn…" (#66)."I felt I was valuable when I provided care for the elders, especially when we saw them so happy due to our concern… In other words, as it is said 'giving is better than taking" (#9).
During the process of interacting with older people, several students "extended their love to their own parents or grandparents"."When I took care of them, I thought of my own parents…, it has been a long time since I went back home" (#11)."When I served the older people, I thought of my own grandma, she is 90 years old.I should visit her often..." (#20).Filial piety is a civic value in this society; the program achieved the goal of education.

Enhancing Commitment to Elder Care
Based on the changed positive attitudes toward older people and the enhanced ability for elder care, the students reflected their confidence and willingness to be involved in this field.
"I had never thought of elder nursing was a profession…, after I experienced the care for the aged , and learned how to solve the elder' s problems, I realized that elder nursing is one kind of profession and I would love to continue my studying in this field…" (#15).
In summary, the students demonstrated their willing and positive attitudes toward elder care, the findings support the research of Wells, Foreman, Gething, and Petralia's study ( 2004) that college students' stereotypes of the elderly can be changed through education.In addition, service-learning opportunities enhanced the ability of communication with the elderly, and lessened students' stress levels due to opportunities to interact with the aged.The results echo the findings of previous study (Author et al., 2007).Furthermore, after participating in this service-learning program, students not only started to voice their concerns about issues related to older people, but also paid more attention to the social welfare of the older generation.They questioned inequitable strategies for elder care and learned how to solve problems, provided suggestions related to elder care issues, and advocated for this frail population.The effects of the course on student abilities related to advocacy and social justice echoed O'Brien-Larivee's findings (2011).In addition, students in the present course also reported that they "found self-value" through providing care and became willing to devote effort to elder care, a defined goal for this course.The program provided an opportunity for the young students to become more involved in elderly care and created a bridge across generations connecting youth and elders.
The stage of "celebration" was seldom addressed in other studies; however, during the process of celebration in this course, students reflected on their satisfaction with what they had experienced and learned from the service-learning program.As one student stated "Each picture leads me into my memories during the service-learning program.I have changed and developed.I give a lot of thanks for learning from the aged people.I recognize that self-development happens after serving other people."Hunt (2007) indicated that the essences of a service-learning program were collaboration and reciprocity between the learner and recipient.Due to the process of sharing in the celebration party, college students not only shared their development and learning effects, but also confirmed their participation and contributions, and achieved the goals and expectations of the course.

Conclusion
This article provided an overview of Intergenerational Service-Learning pedagogy that involved students in learning outside the traditional classroom and provided a needed service in the community.The course was designed to incorporate three stages, preparation, action, and celebration.The preparation stage involved preparing the community and the students in order to coordinate students' learning needs with community health needs.In the action phase, service activity was implemented, and the celebration phase included evaluation and development of feelings of self-actualization.
An important element of this project was to infuse "reflection" in each stage.Reflective practice deepened students' feelings, observations, thoughts, and actions.The reflective experiences combined reflection on the learning process as well as summary reflection regarding outcomes.Process reflection involved individual journaling and group discussion, which allowed the students to connect themselves with the elders.Summary reflection encouraged students to pull together what they had learned.The reflection activities used in this course demonstrated the effectiveness of helping students deconstruct and reconstruct images, beliefs, and paradigms about older adults and enhancing the students' feelings of self-actualization.
The findings support the idea that service-learning is particularly salient for health care in gerontology.This Intergenerational Service-Learning teaching model will be appropriate for improving the quality of education and the findings of this study provide direction for course design for gerontology.

Figure 2 .
Figure 2. The framework of an Intergenerational Service-Learning teaching model.