Background
Recent environmental changes and pandemics have precipitated a health and development crisis for approximately 250 million children under the age of five [1], emphasizing the critical role of pediatric healthcare. Nurses are pivotal in addressing diverse needs in these challenging environments, necessitating interdisciplinary collaboration to optimize patient care. Bally et al. [2] demonstrated that integrating interprofessional education into pediatric nursing courses significantly improved nursing students’ collaborative practice skills. This intervention included pediatric endocrinologists and palliative care specialists, highlighting its potential to enhance patient care [2]. Similarly, Straub et al. [3] underscored the importance of early, structured interprofessional education in nursing curricula. Their study revealed that nurses gain essential competencies during undergraduate studies, crucial for effective pediatric care collaboration [3]. Integrating these findings highlights how interdisciplinary education not only enhances healthcare providers’ collaborative skills but also improves pediatric health outcomes amid current healthcare challenges.
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 nursing 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.
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Integration of interdisciplinary learning is defined as an educational approach where instructors from different disciplines collaborate to integrate their knowledge and methods, addressing common themes or issues to enhance the learning experience [4, 5]. This method goes beyond merely presenting multiple perspectives; it synthesizes insights from various fields into a cohesive framework, fostering critical thinking, problem-solving, and the ability to navigate complex real-world problems [6]. In the context of our study, integration of interdisciplinary learning involved educators from different fields integrating their knowledge and methods to address common themes or issues. This approach provided nursing students with a richer and more comprehensive educational experience, better preparing them for the multifaceted challenges of healthcare practice.
Using the integration of interdisciplinary learning in the nursing curriculum, nursing students can benefit from a wide range of learning experiences that foster connections and associations across diverse academic and clinical domains. This approach empowers nursing students to expand their understanding beyond the confines of conventional classroom learning and apply their knowledge in real-world contexts [7]. Consequently, nursing students are equipped with effective strategies for enhancing the health outcomes of children facing environmental health challenges. This interdisciplinary approach not only enhances nursing students’ competencies in holistic patient care and collaborative practice but also effectively 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 [8]. Nursing students are therefore increasingly using therapeutic games to communicate with children [9‐11]. While research has mainly focused on the effectiveness of therapeutic play in reducing postoperative pain, improving symptoms, and reducing anxiety during hospital stays [9‐11], 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 nursing students’ competence in providing healthcare for children’s well-being. In contrast, early childhood education emphasizes the use of interactive strategies by faculties, such as facial expressions, gestures, and body movements, to enhance children’s engagement and facilitate their learning [12]. Integrating teachings from pediatric nursing and early childhood care can guide nursing 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.
Integration of interdisciplinary learning 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 nursing students with the ability to address complex societal issues. 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 [13]. Interdisciplinary education can stimulate creativity and expose learners to new ideas and perspectives [14].
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The integration of interdisciplinary learning projects implemented by the Departments of Nursing and Childcare Education is grounded in constructivist learning theory. It emphasizes nursing students’ active participation in knowledge construction and understanding. By integrating multiple disciplines, students develop a robust knowledge base, fostering profound learning and critical thinking [15, 16]. 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 [17]. 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 [14, 18]. Alongside group discussions, this course incorporates group practices involving clinical nurses and kindergarten faculties. 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 [15, 16]. The joint teaching of both departments allows for the arrangement of professional instructors who can provide guidance and counseling and address any questions or doubts the nursing 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 [19]. Liao and Wang [20] developed teaching plans that incorporate methods such as case discussions and narrative medical teaching, which allow medical 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 integration of interdisciplinary learning has been shown to enhance nursing students’ cognition and interdisciplinary interaction skills, limited literature exists on how it can improve their childcare abilities, specifically within the context of nursing education.
In the integration of interdisciplinary learning projects between the Department of Childcare and Education and the Department of Nursing, assessing student learning is crucial. We use the Instructional Evaluation Scale by Lin et al. [21], which is designed to gauge Teachers’ Instructional Input and Students’ Learning Outcome, reflecting the dynamics between teaching, learning, and curriculum. It incorporates Bloom’s taxonomy to evaluate cognitive, ability, and affective domains, including facts, concepts, procedural and metacognitive knowledge, psychomotor abilities, and affective values. This scale aligns with the principles of the American Association for Higher Education and the educational reform goals set by the European Commission. Additionally, in line with the emphasis on real-world applications in the integration of interdisciplinary learning, we have chosen the Service-Learning Abilities Scale by Chao et al. [22], based on experiential learning theory. Centered on students, this scale assesses developments in self-knowledge, communication, problem-solving, citizenship, teamwork, self-reflection, knowledge application, caring for others, and cross-cultural competence through practice and reflection.
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 nursing students’ abilities to use therapeutic games to enhance their clinical practice and care quality. We assessed the effect of integration of interdisciplinary learning on nursing students’ knowledge, abilities, 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) nursing students would outperform their pre-test outcomes in the post-test learning outcomes concerning knowledge, abilities, and attitudes; (2) nursing 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 direct correlation between nursing students’ course learning and social service outcomes.
Methods
This study employed a mixed methods design with two phases, utilizing qualitative findings from the second phase to interpret the quantitative data and enrich the research outcomes. Quantitative methods were used to evaluate students’ learning outcomes, while their reflective journals were qualitatively analyzed using content analysis to gain a comprehensive view of their learning outcomes.
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.
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 nursing students’ learning efficiencies. For the second phase, qualitative data were collected and analyzed from nursing students’ reflective journals to qualitatively evaluate student learning outcomes.
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 [23]. At least 90 nursing students were required, and as the attrition rate was 20%, 108 nursing students were selected for the study. After we applied purposive sampling and explained the project, 119 nursing students enrolled, and 108 nursing students completed the course activities.
Measurement tools
Interdisciplinary therapeutic play curriculum
Drawing from relevant literature, the principle of integration is articulated in the following statements [17, 24]:
(1) The curriculum is presented in a series that guides nursing 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 [25]. 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 [25, 26]. Meanwhile, the Department of Nursing divides therapeutic play into functions such as emotional outlet, instructional, and physiological health-promoting play [27]. 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.
Integration of subjects in course unit
The Department of Childcare and Education and the Department of Nursing at Northern Taiwan University collaboratively designed an 18-week therapeutic play course to integrate various subjects and approaches. The curriculum integrates content by adhering to established interdisciplinary collaborative teaching principles, which include setting common goals, employing dynamic teaching methods such as case discussions and role-playing, fostering a collaborative team environment, and providing support to navigate interdisciplinary challenges [14‐18]. These principles were crucial in developing and validating the curriculum through discussions with primary faculties from both involved departments, ensuring alignment with the university’s standards.
Interdisciplinary Courses:
1.
Development of Play in Early Childhood - Explores fundamental play aspects using insights from early childhood education and pediatric nursing to understand play’s role in child development.
2.
Therapeutic Play for Infants - Designs activities to shift attention and soothe, incorporating emotional and physical play concepts.
3.
Therapeutic Play for Toddlers - Focuses on lung expansion activities to enhance toddlers’ respiratory health through physical play.
4.
Therapeutic and Developmental Play for Preschoolers - Combines guided play with storybooks to foster self-care and developmental skills.
Additional Modules include field expert guidance and practical implementations where nursing students apply learned concepts in real-world settings, receiving feedback to refine their skills.
Each course and module follows these principles, detailed further in Table 1, ensuring effective integration of theoretical knowledge with practical application.
Table 1
Program for interdisciplinary teaching interventions
Weeks | Course Title and Focus | Common Content | Pediatric Nursing | The Department of Childcare and Education |
|---|---|---|---|---|
1–2 4 h | Interdisciplinary Course 1: The Development of Play in Early Childhood | Based on Piaget’s theory and early childhood education perspectives, young children’s play development can be summarized as: 1. Sensorimotor/Exploratory Play (0–2 years): Sensory and motor activities, simple imitation, repetitive actions. 2. Preoperational/Symbolic Play (2–7 years): Symbolic thinking, role-playing, imaginative play, building activities. | ● Sensorimotor Stage (0–2 years): Simple exploration and imitation. ● Preoperational Stage (2–7 years): Symbolic play, role-playing, and construction. ● Concrete Operational Stage (7–11 years): Structured play like board games and team activities. ● Formal Operational Stage (11 + years): Strategic play such as complex board games and video games. ● Introduction to Play Therapy | ● Exploratory Play (0–1 year): Sensory and motor activities, simple imitation. ● Functional Play (1–2 years): Repeating actions, such as shaking toys. ● Constructive Play (2–3 years): Building activities with blocks. ● Symbolic Play (3–5 years): Role-playing and imaginative play. |
3–4 4 h | Interdisciplinary Course 2: Therapeutic Play for Infants - Designing Attention-Shifting and Soothing Play Activities | 1. Piaget’s Sensorimotor Stage: 1. Key milestones (0–2 years). 2. Sensory and motor play importance. 2. Emotional Outlet Play: 1. Emotional expression. 2. Benefits for regulation. 3. Attention-Shifting and Soothing Play: 1. Divert attention and soothe. 2. Enhance comfort and reduce discomfort. | ● Piaget’s Sensorimotor Stage: ∎ Key milestones (0–2 years). ∎ Importance of therapeutic play. ● Emotional Outlet Play: ∎ Techniques for emotional expression (e.g., soft toys, gentle music). ∎ Benefits for infant emotional regulation. ● Attention-Shifting Physical Play: ∎ Activities to divert attention from discomfort (e.g., gentle rocking, interactive toys). ∎ Enhancing comfort and reducing pain through play. | ● Stages of Play Development (0–2 years): ∎ Overview of sensory and motor play. ∎ Importance of exploration and imitation. ● Designing Effective Play Activities: ∎ Incorporating sensory stimuli (textures, sounds). ∎ Simple, repetitive actions for engagement (e.g., shaking toys, peek-a-boo). ● Creating a Nurturing Play Environment: ∎ Safe, calming spaces. ∎ Age-appropriate toys and materials. |
5–6 4 h | Interdisciplinary Course 3: Therapeutic and Developmental Play Design for Toddlers - Designing Physical Enhancement Play - Lung Expansion Activities | 1. Piaget’s Preoperational Stage: 1. Key developmental milestones (2–7 years). 2. Importance of physical and imaginative play. 2. Physical Enhancement Play: 1. Activities for lung expansion (blowing bubbles, pinwheels). 2. Encouraging deep breathing through play. 3. Designing Effective Play Environments: 1. Safe and stimulating settings. 2. Age-appropriate toys and activities. | ● Piaget’s Preoperational Stage: ∎ Key milestones (2–7 years). ∎ Importance of physical play. ● Lung Expansion Activities: ∎ Breathing exercises (blowing bubbles, pinwheels). ∎ Techniques to promote lung health. ● Integrating Play with Therapy: ∎ Fun activities to encourage deep breathing. ∎ Benefits of combining play with physical therapy. | ● Piaget’s Preoperational Stage (2–7 years): ∎ Key milestones. ∎ Importance of physical function play. ● Physical Function Play: ∎ Activities for lung expansion (blowing bubbles, pinwheels). ∎ Encouraging deep breathing through play. ● Designing Play Environments: ∎ Safe and stimulating settings. ∎ Selecting age-appropriate toys and activities. |
7–9 6 h | Interdisciplinary Course 4: Therapeutic and Developmental Play Design for Preschoolers | 1. Health Maintenance Self-Care Play: • Teaching health maintenance skills through storybooks. • Activities for daily routines (e.g., brushing teeth, handwashing). 2. Cognitive and Language Play: • Enhancing cognitive skills with problem-solving stories. • Promoting language development through interactive reading. 3. Affective Play: • Guiding emotional expression and understanding. • Using stories to teach empathy and emotional awareness. | ● Piaget’s Preoperational Stage: ∎ Key milestones (2–7 years). ∎ Importance of instructional play. ● Instructional Play Activities: ∎ Structured play using storybooks. ∎ Interactive activities promoting health and development. ● Health Education through Storybooks: ∎ Teaching health concepts via engaging stories. ∎ Examples of story-based instructional play. | ● Self-Care Play: ∎ Activities promoting daily self-care skills. ∎ Using storybooks to teach routines (e.g., brushing teeth, dressing). ● Cognitive and Language Play: ∎ Enhancing cognitive abilities through problem-solving stories. ∎ Language development through interactive reading and storytelling. ● Affective Play: ∎ Activities to express and understand emotions. ∎ Using storybooks to guide emotional awareness and empathy. |
Additional Modules | ||||
Week(s) | Course Title and Focus | Content | ||
14–15 4 h | Field Expert Guidance | ● Industry experts share experiences, discuss the design of therapeutic games for social service, and brainstorm therapeutic play program designs. | ||
16–17 4 h | Caring Practice Activities | ● Implementation of therapeutic play activities to promote health, with industry expert assistance and feedback, understanding effectiveness through practical application. | ||
18 2 h | Group Presentations and Feedback | ● Activities in kindergartens, hospital playrooms, etc., with group presentations and feedback from nursing and early childhood education students. | ||
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 0.71 to 0.92, and the average variance extracted ranged from 0.59 to 0.75, 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 0.87 and 0.89; while the internal consistency reliability of the three dimensions of “students’ learning outcome” was between 0.88 and 0.89, 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 0.89 and 0.94. The internal consistency reliability of the three dimensions of “students’ learning outcome” was between 0.87 and 0.95.
(2) Service-learning Abilities Scale. Chao et al. [28] 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 0.86 to 0.93 [28]. In this study, Cronbach’s α ranged from 0.77 to 0.96 for the subscales.
(3) Qualitative questions. What are the perceived impacts of this course on the utilization of therapeutic play in pediatric care, particularly in knowledge acquisition, nursing skills, and competencies?
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 nursing students were required to complete the instructional evaluation scale and the service-learning abilities scale at the beginning and end of the semester. Apart from attending classes, they were divided into 10 groups of 10–11 nursing students and provided social services for four hours in hospitals and kindergartens, with guidance from two pediatric nurses and three kindergarten faculties. In week 18, the nursing students presented their learning results to the nursing faculty through a 15-minute video or photo presentation per group. During and at the end of the semester, the nursing 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 nursing faculty also required the nursing students to submit anonymous reflection sheets.
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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 scale. The Pearson correlation coefficient was used to compare the correlation between the two scales. Significance was set at p < .05. Predictor variables were explored using multiple linear regression analysis. Using the study by Lindgren et al. [29] as a guide for collecting qualitative data, we labeled and coded content relevant to the research process and linked them to the nursing 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 [29]. The analysis followed the outline of Lincoln and Guba [30] on the credibility, dependability, transferability, and confirmability principles for qualitative data analysis. For credibility, the first author employed peer debriefing: colleagues who were not directly involved in the research reviewed the findings and provided feedback to challenge and refine the interpretations. Dependability was ensured through the code-recode strategy: the first author coded the data, took a break, and then re-coded the same data to check for consistency in their interpretations. Transferability was achieved by purposive sampling: participants were selected based on specific criteria relevant to the research question, ensuring that the findings were pertinent to similar contexts or populations. Confirmability was established through reflexivity: the first author engaged in ongoing self-reflection to recognize and mitigate potential biases and assumptions that could influence the study [30].
Integrating mixed methods
In this mixed methods study, we integrated quantitative and qualitative findings to comprehensively understand the research problem. Quantitative data provided a broad statistical base, allowing us to measure and analyze trends, patterns, and relationships among variables using scales such as the Instructional Evaluation Scale and the Service-Learning Abilities Scale to quantify nursing students’ learning outcomes.
Qualitative data, gathered from the nursing students’ reflective journals, offered detailed insights into their learning experiences, providing rich narrative data that explored the context and deeper meanings behind the quantitative results.
Using a sequential explanatory approach, we first evaluated students’ learning outcomes quantitatively, then analyzed their journals qualitatively. This integration of mixed methods capitalized on the quantitative rigor and qualitative depth, yielding a nuanced and reliable response to our research questions [31].
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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 nursing students comprehensively, before the class. The nursing 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.
Results
Participant characteristics
A total of 119 nursing students were enrolled in the course. Among them, 11 nursing 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 scale. Although the average score of the 11 nursing students in the post-test was lower than that of all students who participated in the whole process, their results ranged from moderate to good. Overall, 108 nursing students completed the course activities, and five incomplete questionnaires were deleted; hence, 103 nursing students participated (89 = female, 86.4%). The participants were aged 19–27, with an average age of 19.66 years.
Quantitative outcome
The post-test mean scores for the Instructional Evaluation Scale and its subscales, Students’ Learning Outcome and Teachers’ Instructional Input, and the Service-Learning Abilities Scale were significantly higher than the pre-test scores (p < .001; Table 2). 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’ Instructional Input: 17.71–22.51, Students’ Learning Outcome: 16.80–22.30, and Service-Learning Abilities Scale: 95.15 to 125.81. Moreover, there is a significant improvement in the Students’ Learning Outcome and Service-Learning Abilities Scale scores from pre-test to post-test, indicating that the integrated curriculum effectively enhances students’ social service skills (Table 3). The mean of both subscales of the Instructional Evaluation Scale was as high as 85%. In the Service-Learning Abilities Scale, scores for the Citizenship and Social Responsibility items were lower than the pre-test, while all other subscales showed a significant increase compared to the pre-test. The overall improvement in Students’ Learning Outcome and the scores for Citizenship and Social Responsibility from pre-test to post-test were positively correlated (r = .635, p < .001). The three items with the highest scores (Team Skills, Self-Knowledge and Self-Confidence, and Knowledge Application) reached more than 85%. The Cross-Cultural Competence score was less than 80% of the total score. Multiple regression analyses were conducted to examine the effects the scores for Team Skills, Self-Knowledge and Self-Confidence, and Knowledge Application and Problem-Solving Skills on the Students’ Learning Outcomes score. The results showed that the scores for Knowledge Application and Problem-Solving Skills were significant predictors of the Students’ Learning Outcomescore (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 the Students’ Learning Outcomescore (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 = 0.44, adjusted R2 = 0.42).
Table 2
Pre- and post-test scores for participants on the Instructional Evaluation Scale and Service-learning Abilities Scale
Scale | Pre-test (n = 103) Mean (SD) | Post-test (n = 103) Mean (SD) | Paired t test | ||
|---|---|---|---|---|---|
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 Scale | 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*** |
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Table 3
Correlations between the mean difference in pre-and post-test subscale scores on the Service-learning Abilities Scale and Instructional Evaluation Scale
Subscales of the Instructional Evaluation Scale | ||
|---|---|---|
Service-learning Abilities Scale | Teachers’ Instructional Input | Students’ Learning Outcome |
Subscales of the SLAS | r (p) | r (p) |
Service-Learning Abilities Scale | 0.675 (< 0.001) | 0.666 (< 0.001) |
Self-Knowledge and Self-Confidence | 0.454 (< 0.001) | 0.468 (< 0.001) |
Communication Skills | 0.657 (< 0.001) | 0.650 (< 0.001) |
Problem-Solving Skills | 0.653 (< 0.001) | 0.617 (< 0.001) |
Citizenship and Social Responsibility | 0.673 (< 0.001) | 0.635 (< 0.001) |
Team Skills | 0.451 (< 0.001) | 0.441 (< 0.001) |
Self-Reflection | 0.668 (< 0.001) | 0.666 (< 0.001) |
Knowledge Application | 0.635 (< 0.001) | 0.632 (< 0.001) |
Caring for Others | 0.608 (< 0.001) | 0.616 (< 0.001) |
Cross-Cultural Competence | 0.626 (< 0.001) | 0.567 (< 0.001) |
Qualitative feedback
Nursing 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 4 explains how the themes were discovered through content analysis.
Table 4
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. |
Integrating different learning areas to promote children’s health. Nursing 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 faculties 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 nursing 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 nursing students mentioned that integration of interdisciplinary learning 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)
Discussion
This study found that integration of interdisciplinary learning improved student learning outcomes 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 the “teachers’ instructional input” scale indicated that students recognized the effectiveness of the integrated course teaching approach employed by their faculties to assist them in integrating multidisciplinary thinking. Furthermore, consistent with findings from other studies [32], our results show that positive teacher-student interactions enhance student participation, critical thinking, and teamwork in interdisciplinary learning, ultimately improving learning outcomes.
The “students’ learning outcome” revealed that the integration of interdisciplinary learning could improve students’ professional knowledge, which was consistent with the findings of Liao and Wang [20] and Liu [33]. Knowledge is enhanced when students can identify multiple facets of a problem, critique expertise framework, incorporate creative thinking, and develop innovative problem-solving skills [24, 33]. 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. Additionally, our findings showed that the integration of interdisciplinary learning can significantly enhance students’ communication, teamwork, theory-to-practice skills, and problem-solving abilities, essential for nursing practice. Regarding their attitude, qualitative and quantitative results indicated that students thought the content and practice of this course stimulated their interest in learning.
Based on the results from the ability subscale of the “students’ learning outcome”, we found that the post-test mean of nursing students reached 90.15%. Lin et al. [21], referencing related literature, categorized essential workplace competencies that university education should foster interpersonal communication, leadership skills, teamwork, and higher-order thinking (problem-solving, critical thinking, reasoning, and creativity). Consequently, the ability indicators defined in the learning outcome scale included self-directed learning, participation in discussions, teamwork, connecting theory with practice, problem-solving, and independent thinking.
Our study aligns with these findings, demonstrating that the interdisciplinary curriculum successfully enhanced these competencies among students. The significant improvement in the average post-test scores suggests that students were able to apply theoretical knowledge to practical scenarios more effectively, work collaboratively in teams, and engage in critical and creative thinking to solve complex problems. This comprehensive development is crucial for their future roles in healthcare, where such skills are indispensable.
Moreover, the course’s structure, which integrated perspectives from childcare and nursing education, provided a holistic approach to learning. This approach enabled students to see the interconnectedness of different disciplines and appreciate the value of a multifaceted educational experience. The positive correlation between improved learning outcomes and the integration of interdisciplinary learning approach underscores the effectiveness of this method in fostering a well-rounded skill set in students, preparing them for the diverse challenges they will face in their professional careers.
The findings of social service effectiveness were consistent with those of Chao and Yang [33]. Incorporating social service into the integration of interdisciplinary learning 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 faculties 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. [12] 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 [34]. 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. Integration of interdisciplinary learning 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. Some researches emphasized that students learn through the interdisciplinary integration of information and experiences [17, 19, 24]. This helps nursing students solve complex problems using critical thinking and make decisions by applying their worldviews [17, 24]. 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 integration of interdisciplinary learning, nursing students 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 integration of interdisciplinary learning for students were similar to those reported by Widmer et al. [35]. From a sociocultural perspective, diverse disciplines have unique cultural backgrounds that influence how individuals think and behave [35]. Through cultural exchange, nursing students learned how preschool faculties 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.
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 [36]. 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 [34]. Lastly, the integration of interdisciplinary learning course was taught only to nursing students by the faculties from the Department of Nursing and the Department of Childcare and Education at Northern Taiwan University. Future research could involve students from both departments to explore the effects of interdisciplinary learning to facilitate peer-to-peer learning.
Conclusions
The study found that integration of interdisciplinary learning can enhance students’ learning outcomes, leading to improvements in their knowledge, abilities, and attitudes in healthcare, particularly in therapeutic play. This includes enhanced communication, knowledge application, and problem-solving abilities. 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.
Acknowledgements
The authors appreciate all the participants for providing their time and data.
Declarations
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.
Competing interests
The authors declare no competing interests.
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