RESEARCH REPORT

Attitudes of Healthcare Students on Gross AnatomyLaboratory Sessions

Yukiko Kawashiro,1 Reiko Anahara,2 Toshihiko Kohno,2 Chisato Mori,1,3 Yoshiharu Matsuno1,3*1Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan2Faculty of Health Sciences, Ryotokuji University, Chiba, Japan3Center for Environment, Health and Field Science, Chiba University, Chiba, Japan

At Chiba University, gross anatomy laboratory sessions (‘‘laboratories’’) are required forphysical therapy students. Though most physical therapy schools require their students toparticipate in laboratories so that they will better understand the structure of the humanbody, few data exist on the value of these laboratories specifically for physical therapystudents. We administered questionnaires to physical therapy undergraduate studentsboth before and after they participated in laboratories. Questionnaire items focused onstudent attitudes toward the laboratories and on human life and dignity. Data from 83students were analyzed, with the following results: (1) 74.7% of students had a positiveattitude about attending laboratories before doing so; (2) with few exceptions, students’attitudes about upcoming laboratories grew more positive after experiencing the labora-tory work (P < 0.001); (3) laboratories caused students to contemplate the topics ofhuman life and dignity; and (4) 83.1% of students hoped to participate in laboratories atleast four times. These results indicate that laboratories reinforce physical therapy stu-dents’ positive attitudes about laboratory learning and promote student reflection onhuman life and dignity. This study provides support for the implementation of multiplelaboratory sessions using cadavers into a uniform curriculum for physical therapystudents in Japan. Anat Sci Educ 2:273–279, 2009. © 2009 American Association of Anatomists.

Key words: physical therapy education; professionalism; human dignity; physical therapystudents; gross anatomy laboratories; cadavers; assessment

INTRODUCTION

Anatomy is a critical subject for all healthcare workers,including physical therapists. As much of physical therapytargets rehabilitation of musculoskeletal and other structuralbodily functions, physical therapists must have a thoroughunderstanding of human anatomy and physiology. Many ofthe medical schools in Japan, including Chiba University,offer gross anatomy laboratory sessions (‘‘laboratories’’) tophysical therapy students, with the intent of instilling in them

a three-dimensional understanding of the structure of thehuman body. Most physical therapy schools require that stu-dents participate in these laboratories, but few schools havestudents directly involved in cadaveric dissection. Often, thedifferent anatomy experiences depend on whether legal per-mission to dissect human cadavers is or is not clearly statedfor physical therapy students at their respective institutions.Accordingly, there is no uniform curriculum for physical ther-apy education in Japan.

The gross anatomy laboratory can be emotionally tryingfor medical students (Gustavson, 1988; Finkelstein and Math-ers, 1990; Horne et al., 1990; Dickinson et al., 1997;Dinsmore et al., 1999, 2001; Houwink et al., 2004), and atraumatic experience in the gross anatomy laboratory caninfluence future patient interactions (Gustavson, 1988; Finkel-stein and Mathers, 1990; Bourguet et al., 1997). We believethat these findings may apply not only to medical but also tophysical therapy students, but few data are available on thistopic. Similarly, few studies have investigated whether labora-tories help physical therapy students master anatomy. Webelieve that the time has come to critically examine the influ-ence of anatomy laboratories on physical therapy students.

Dr. Yukiko Kawashiro’s present address is: Department of Nursing,Chiba Prefectural University of Health Sciences, Chiba, Japan

*Correspondence to: Dr. Yoshiharu Matsuno, Department ofBioenvironmental Medicine, Graduate School of Medicine, ChibaUniversity, (A3) 1-8-1, Inohana, Chuoku, Chiba 260-8670, Japan.E-mail: ymatsuno@faculty.chiba-u.jp

Received 15 June 2009; Revised 24 September 2009; Accepted 2October 2009.

Published online 6 November 2009 in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ase.116

© 2009 American Association of Anatomists

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 Anat Sci Educ 2:273–279 (2009)

In our pilot study (Kohno et al., 2007), a questionnaire wasdistributed to physical therapy students at a vocational schoolboth before and after laboratory sessions in February 2006.Laboratory sessions occurred once per week for 4 weeks. Thatsurvey revealed that many students had uncomfortable emo-tions or images about anatomy laboratories before actuallyexperiencing them, using descriptions, such as ‘‘horror,’’‘‘death,’’ and ‘‘grotesque.’’ After four laboratories, however,most physical therapy students were more comfortable in learn-ing with cadavers, which is consistent with previous studiesthat have involved medical students (Evans and Fitzgibbon,1992; Dickinson et al., 1997; Arraez-Aybar et al., 2004a). Asstudents felt that their knowledge of human anatomy hadincreased after a certain amount of laboratory work, it wassuggested that laboratories might be effective learning environ-ments for physical therapy students. The effect of laboratorieson these students was somewhat unclear, however, because thepilot study did not compare students’ feelings before and afterthe laboratories. At least two important questions remained forfurther examination: (1) Would physical therapy students’ atti-tudes toward cadaver laboratories change after exposure to thelaboratories? and (2) Would laboratories affect physical therapystudents’ beliefs about human life and dignity? This studyaddresses questionnaire data and primarily explores physicaltherapy students’ attitudes about laboratories, both before andafter participating in laboratory work, and their beliefs abouthuman life and dignity.

MATERIALS AND METHODS

Subjects

The survey was administered to all second year undergradu-ate physical therapy students (88 students) at Ryotokuji Uni-versity, which participates in the laboratory education pro-gram at the Chiba University School of Medicine.

In the Department of Physical Therapy of Ryotokuji Univer-sity, both first- and second- year students take compulsory anat-omy courses. In the first year, students learn anatomy includingthe skeletal, muscular, and nervous systems, through lecture. In

the second year, students participate in laboratories four timesafter observing bone specimens eight times and internal organspecimens two times with a microscope. A sample physicaltherapy curriculum is shown in Figure 1.

Laboratory Program

Before the four laboratory sessions (90 minutes each, once perweek), all students attended a 30-minute orientation lecture byone of the anatomy staff. The lecture addressed how humanremains are donated to Chiba University, their preservativetreatment, the health effects of formaldehyde, how to dissect ahuman body, student behavior, and confidentiality.

Students from two classes were divided into four groups,each consisting of eleven students. The groups rotated amongfour cadavers (Fig. 2), with each cadaver displaying a differ-ent region of the human body. For approximately 20 minutes,students listened to a detailed narration from a member ofthe anatomy faculty about what they were viewing. The in-formation covered in the four laboratory sessions is presentedin Table 1. Students had the chance to directly observe andhandle human organs in the laboratories. They were also ableto return to their cadaver of choice for additional learningtime at the end of each session.

Questionnaires

All 88 students were asked to complete two questionnaires.The first questionnaire was conducted before the first labora-tory session (before June 2007), and the second was con-ducted one week after the fourth laboratory session (in July2007). The time interval between the two questionnaires wasfour weeks. Demographic characteristics, such as age andgender were included in the initial survey. The questionnairecontents are shown in Table 2. A seven-point Likert scalewas used to gauge students’ agreement with each statement,while a three-point Likert scale was used to judge students’understanding of human structure. Open-ended commentsand students’ opinions on the optimal frequency of laborato-ries were also solicited.

Figure 1.

Sample of typical curriculum for physical therapy students in Japan (from Ryotokuji University).

274 Kawashiro et al.

Ethical Issues

All students provided informed consent for participation inthis study. Students were fully informed of the purpose andmethods of the study and given assurance that cooperating inthe investigation was not compulsory and that questionnaireresponses would not affect their grades in any way. The studywas approved by the Ryotokuji University Research EthicsCommittee.

Data Analysis

All data for students who completed both questionnaireswere analyzed. Wilcoxon signed-ranks testing was used tocompare responses from before and after students’ laborato-ries experiences. The significance level for all statistical tests

was set at P < 0.05. Questionnaire data were analyzed usingSPSS 16.0 J (SPSS, Inc., Chicago, IL). Content analysis wasperformed for qualitative data (students’ free comments)from the follow-up survey.

RESULTS

Student Demographics

Eighty-seven students (98.9%) responded to both question-naires. Five students were excluded for having previously par-ticipated in laboratories. Data were therefore analyzed for 83students. The mean age of participants was 19.6 years (SD1.4 years; range 19–30 years). There were 56 men (67.5%)and 27 women (32.5%).

Figure 2.

Rotation pathway of student groups between four human cadavers each displaying different regions of the body.

Table 1.

Anatomy Content Presented During Each Laboratory Session

Cadaver Exposure Region of body Session Content

1 Anteriorview

Head, face, neck, andupper limb

1 Muscles of neck and upper limb

2 Blood vessels and peripheral nervous system of upper limb

3 Joints of upper limb

4 A total review

2 Anterior

view

Trunk 1 Muscles of trunk

2 Cardiovascular and respiratory system

3 Alimentary, urinary, and genital system, abdominoplevic cavity

4 A total review

3 Posterior

view

Back and lower limb 1 Muscles of back and lower limb

2 Blood vessels and peripheral nervous system of lower limb

3 Joints of lower limb

4 A total review

4 Posterior

view

Cranial cavity and

vertebral column

1 Cranial cavity, calvaria, cranial sutures, meninges

2 Brain and cranial nerves

3 Spinal cord and peripheral nervous system, sciatic nerve

4 A total review

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 275

Student Attitudes Toward Laboratories

In the initial survey, students were asked ‘‘How much are youlooking forward to learning in the laboratories?’’ Sixty-twostudents (74.7%) responded with a positive attitude; that is,a score of five, six, or seven on a seven-point Likert scale(mean score 5.52 6 1.28; Table 3). In the follow-up survey,students were asked, ‘‘If you had an opportunity to partici-pate in future laboratories, how much would you look for-ward to learning in the laboratories?’’ Eighty students(96.4%) responded with a positive attitude (mean score 6.486 0.90). This difference in student attitudes toward laborato-ries before and after laboratory work was statistically signifi-cant (P < 0.001; Table 3). Three students (3.6%) respondedwith scores of three or four on a seven-point Likert scale,indicating a neutral or slightly more negative attitude towardfuture laboratory sessions.

Understanding Anatomy Through Laboratories

In the follow-up survey students were asked, ‘‘Were you ableto understand the structures of the human body through thelaboratory experience?’’ Eighty-one students (97.6%)responded ‘‘yes,’’ and two students (2.4%) responded ‘‘noidea.’’ There was no student who responded ‘‘no.’’

Optimal Number of Laboratories

In the follow-up survey students were asked, ‘‘What do youthink would be the optimal number of times for physicaltherapy undergraduate students to attend these laboratories?’’Forty-six students (55.4%) responded that students shouldparticipate in the laboratories more than four times, 23(27.7%) replied that four times was sufficient, and 14

Table 2.

Questions in the Initial Survey (Items 1 and 2) and Follow-up Survey (Items 3–7)

Item Type of Response

1 How much are you looking forward to learning in the laboratories? Seven-point Likertscalea

2 How much have you thought about human life or dignity up until now? Seven-point Likert

scalea

3 Were you able to understand the structure of the human body through the laboratory experiences? Three opinionsb

4 If you have an opportunity to participate in future laboratories, how much would you look forward to

learning in the laboratories?

Seven-point Likert

scalea

5 How much did you think about human life and the dignity after the laboratories? Seven-point Likert

scalea

6 What do you think would be the optimal number of times for physical therapy undergraduate students to

attend these laboratories?

Frequency of

attendance

7 Please describe your opinion about the laboratories in your own words. Free comments

aScores were based on a seven-point Likert scale: 1 5 very little, 7 5 very much.bScores were based on a three options: 1 5 Yes, 2 5 No, 3 5 No idea.

Table 3.

Comparison of Students’ Attitudes About the Laboratories and Belief in Human Life and Dignity Before andAfter Attending the Laboratories

Meana SD Wilcoxon T P

Students’ attitudes Pre-laboratory 5.52 1.28 Z 5 25.357 P < 0.001

Post-laboratory 6.48 0.90

Belief in human life and dignity Pre-laboratory 5.13 1.42 Z 5 26.242 P < 0.001

Post-laboratory 6.25 0.85

aScores were based on a seven-point Likert scale: 1 5 very little, 7 5 very much.

276 Kawashiro et al.

(16.9%) indicated that two or three times would beadequate.

Human Life and Dignity

In the initial survey students were asked, ‘‘How much haveyou thought about human life and dignity up until now?’’Ten students (12.0%) responded with a low score (one, two,or three on a seven point Likert scale). In the follow-up sur-vey, they were asked, ‘‘How much did you think abouthuman life and dignity after the laboratories?’’ Only one stu-dent (1.2%) responded with a low score, the number wasdecreased by learning in the laboratories. This difference inpre- and post-laboratory survey answers was statistically sig-nificant (P < 0.001; Table 3).

Student Opinions After Laboratories

In the follow-up survey students’ opinions or feelings aboutthe laboratories were divided into two categories:‘‘knowledge’’ and ‘‘attitude’’ (Table 4).

Knowledge. A total of 28 students indicated that their‘‘understanding of the human body’’ had increased after thelaboratories. Five students noted that attending laboratorieshelped them recognize their ‘‘lack of knowledge of the humanbody.’’

Attitude. Several positive emotions were expressed by stu-dents. Twenty one students mentioned that laboratories were

a ‘‘valuable experience,’’ three students commented on ‘‘inter-esting anatomy,’’ two students identified the laboratories as a‘‘link to future learning,’’ 16 students requested to ‘‘take partin future laboratories,’’ four students noted their ‘‘respect fordonors,’’ and four students claimed that the laboratorieschanged their ‘‘belief about dignity’’ of donors. Three stu-dents expressed negative emotions, including ‘‘the smell ofthe formaldehyde was hard for me.’’ Six students were ambiv-alent, saying such things as, ‘‘I was resistant to touch thecadavers, but I was able to learn in the laboratories.’’

DISCUSSION

Anatomy laboratories have previously been shown to be valu-able educational environments for medical students (Gus-tavson, 1988; Finkelstein and Mathers, 1990; Horne et al.,1990; Dickinson et al., 1997; Dinsmore et al., 1999; Din-smore et al., 2001; Houwink et al., 2004). This study indi-cates that laboratories also represent significant learningexperiences for physical therapy students. In addition, ourfindings suggest that laboratories reinforce students’ positiveattitudes about laboratory work and promote students’ reflec-tive behavior with regards to human life and dignity.

Through attending laboratories, students significantlyincreased their positive attitudes about attending future labo-ratories. Almost all students felt that their understanding ofthe structure of the human body was greater after four labo-ratory sessions. Moreover, 80% of students expressed thedesire to attend at least four laboratory sessions. These resultssuggest that most student experiences in the laboratories werepositive and, perhaps, that laboratories are an effectivemethod for teaching anatomy to physical therapy students.There were a few students, however, who were less positiveabout laboratories after experiencing them as compared tobefore.

In previous studies of medical students, the gross anatomylaboratory has occasionally led to emotional problems (Gus-tavson, 1988; Finkelstein and Mathers, 1990; Horne et al.,1990; Dickinson et al., 1997; Dinsmore et al., 1999, 2001;Houwink et al., 2004). Our results are consistent with thesefindings. Although our physical therapy students did notactually participate in cadaveric dissection, the laboratory ex-perience was still seen to cause negative student emotions ina few. Unpleasant aspects of the dissection room includedsmell, seeing the face of the cadaver, and touching thecadaver (Arraez-Aybar et al., 2008), all of which could beavoided without dissecting the cadaver. Because a negativeexperience in gross anatomy might influence interactions withfuture patients (Gustavson, 1988; Finkelstein and Mathers,1990; Bourguet et al., 1997; Arraez-Aybar et al., 2004b),anatomy educators teaching physical therapy students need tobe sensitive to students’ reactions.

In gross anatomy education, senior students often serve asteaching assistants for first-year medical students (Ocel et al.,2003). Houwink et al. (2004) reported that having third-yearmedical students as assistants decreased first-year medical stu-dents’ negative psychological reactions. At Chiba University,medical students serve as teaching assistants who taughthuman body to healthcare students in laboratories, and mostmedical students who served as assistants reported that theact of teaching stimulated their own learning (Kawashiroet al., 2008). Healthcare students who received explanationsfrom medical students in the laboratories also felt that they

Table 4.

Students’ Comments After the Laboratory Experience

Identified categories No. of students

Knowledge

Understanding human body 28

Lack of knowledge about human body 5

Attitude

Positive emotion 50

Valuable experience 21

Interesting anatomy 3

Link to the future learning 2

Request to the laboratories 16

Respect for donors 4

Belief about dignity 4

Negative emotion 3

Ambivalent emotion 6

Total 92

Some students provided more than one comment.

Anatomical Sciences Education NOVEMBER/DECEMBER 2009 277

had a good understanding of the human body (Matsunoet al., 2004). Extrapolating from these studies with medicalstudents, one might expect the use of senior physical therapyor medical students as assistants to reduce physical therapystudents’ negative reactions and to promote learning.

The second major finding of our study was that laborato-ries provided physical therapy students an opportunity tocontemplate human life and dignity. We found that morethan 90% of students thought about human life and dignityduring or after participating in the laboratories. Gundermanand Wilson (2005) describe how medical students’ experien-ces with cadaveric dissection help them to develop a clearersense of what it means to be alive and an appreciation forthe vast chasm separating life from death. Our findings sug-gest that even four laboratory sessions may have a substantialimpact on physical therapy students.

Some students expressed feelings of gratitude and respectfor those who had donated their bodies. These feelings mayhave been precipitated by a 30-minute lecture about ChibaUniversity’s body donation program delivered to all studentsbefore their attending laboratories. Medical students havedescribed ‘‘respect for the body’’ as a covert learning outcome(Lempp, 2005) and have required preparation concerningbody donation (Cahill and Ettarh, 2008, 2009). The necessityof death education for medical students has previously beenhighlighted in the context of human anatomy teaching(Marks et al., 1997). Our results point to a hidden curricu-lum in such laboratories, one that transforms attitudes andtransmits values to students both by what is (and what isnot) taught and how such teaching features in the curriculum(Burton, 2003). In one study about medico-legal autopsyteaching, autopsies were found to carry a considerable hiddencurriculum concerning attitudes of respect, empathy, andcompassion (McNamee et al., 2009). Laboratories promotereflection (Lachman and Pawlina, 2006) and develop stu-dents’ humanity.

No student in our study explicitly described professionaldevelopment in comments on the follow-up survey. A phe-nomenological study of medical students, in contrast, foundthat future physicians felt it important for all medical practi-tioners to attend at least one autopsy in the course of theirprofessional training (McNamee et al., 2009). Physical ther-apy and medical students may have different opinions on thissubject because, compared to medical doctors, physical thera-pists seldom deal with human death in clinical practice. De-spite this, Rojas Alcantara et al. (2003) concluded that allfuture healthcare professionals, including physical therapists,require specific training in palliative care and bioethics.Moreover, the team approach to medical care requires thatphysical therapists also have a chance to contemplate humanlife and death as students, when their professional attitudesare forming. It is important that laboratory experiences beconnected explicitly with students’ professional developmentas medical healthcare workers.

In anatomy education, the use and effectiveness of e-learn-ing have been reported (Svirko and Mellanby, 2008). One ofthe study of medical students showed that only 60% of an e-learning group successfully passed a final examination com-pared to 82% of a cadaveric dissection group (Biasutto et al.,2006). Cadaveric dissection cannot therefore be replaced bye-learning. Professional anatomists further perceive cadavericdissection and prosection as necessary to understanding thethree-dimensionality of the human body (Patel and Moxham,

2008). Whereas previous work has shown the benefits ofusing cadavers to teach three-dimensional anatomy, our studyhighlights the value of these same experiences in developingphysical therapy students’ attitudes as future medicalprofessionals.

This study suggests that laboratories reinforce future phys-ical therapists’ positive attitudes toward laboratory learning.Laboratories also caused students to reflect on human lifeand dignity. We believe that multiple laboratory sessions thatinclude the viewing and handling of cadavers should beimplemented in a uniform curriculum for physical therapystudents. A larger study is necessary, however, because of thesmall sample size and inclusion of only a single school in ourstudy. Future work should also examine the acquisition ofknowledge of human anatomy among students with andwithout laboratory experiences.

ACKNOWLEDGMENTS

We would like to thank the physical therapy undergraduatestudents who participated in this study. We also wish tothank the members of the Chiba Shiragiku community whodonated their bodies to science.

NOTES ON CONTRIBUTORS

YUKIKO KAWASHIRO, Ph.D., is an associate professor inthe Department of Nursing at Chiba Prefectural University ofHealth Sciences, Chiba, Japan. She taught anatomy to medi-cal and medical healthcare students in the Graduate Schoolof Medicine, Chiba University, Chiba, Japan.

REIKO ANAHARA, Ph.D., is an associate professor inthe Faculty of Health Sciences at Ryotokuji University, Chiba,Japan. She teaches anatomy to first- and second-year physicaltherapy students.

TOSHIHIKO KOHNO, Ph.D., is a professor in the Fac-ulty of Health Sciences at Ryotokuji University, Chiba, Japan.He teaches anatomy to first- and second-year physical therapystudents.

CHISATO MORI, Ph.D., is a professor in the Departmentof Bioenvironmental Medicine at the Graduate School ofMedicine, Chiba University, Chiba, Japan. He teaches anat-omy and embryology to second- and third-year medical stu-dents.

YOSHIHARU MATSUNO, Ph.D., is a lecturer in theDepartment of Bioenvironmental Medicine at the GraduateSchool of Medicine, Chiba University, Chiba, Japan. Heteaches anatomy and embryology to second- and third-yearmedical students.

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