Abstract
Introduction
Early career occupational therapists experience considerable learning. This research sought to develop a theory of how they learn once practising.
Method
The research employed a constructivist grounded theory methodology. Interviews were conducted with 20 participants who were either experienced (n = 8), early career occupational therapists (n = 10) or in supporting roles for early career occupational therapists (n = 2). Participants were asked their views about what early career occupational therapists find troublesome and how they respond. Data were collected and analysed concurrently. Open, focused and theoretical coding were used to develop a theory.
Findings
The theory of learning-to-practise occupational therapy included four learning thresholds: consolidating professional reasoning; navigating into the workplace; building competence and confidence; and developing a personal theory and practise style. There were 11 strategies identified that early career occupational therapists use to cross the learning thresholds.
Early career occupational therapists’ understanding and value of knowledge shifted, which culminated in them ‘realising’ their personal theory and practice style. They refined their values and beliefs and learned to be more deliberate and reflective in their thinking and actions.
Conclusion
Early career occupational therapists were challenged, which promoted learning. This research extends understanding of the learning needs, thinking and actions taken by early career occupational therapists to cross learning thresholds and to develop their personal theory and practice style.
Keywords
Introduction
There is growing interest in the learning needs of early career occupational therapists (ECOTs) (Fitzgerald et al., 2015). Previous research has considered the learning needs for preparedness for practice (Gray et al., 2012) and the development of personal paradigms during the transition to practitioner (Björklund and Svensson, 2006). However, much of the research explores broad experiences and challenges (Lee and Mackenzie, 2003; Morley, 2009; Murray et al., 2015; Toal-Sullivan, 2006; Tryssenaar and Perkins, 2001) and does not explore in detail the thinking done and actions taken by ECOTs to promote their learning and development. This research contributes to existing literature by developing a theory about ECOTs’ learning-to-practise. The research was underpinned by the educational theories of threshold concepts and troublesome knowledge (Meyer and Land, 2003; Perkins, 2006). Because learning often occurs in response to being troubled by something (Perkins, 2006), our research addressed the following two research questions:
What aspects of knowledge and practice are troublesome for ECOTs? How do ECOTs respond to troublesome aspects of knowledge and practice?
Literature review
The threshold concepts theory has been proposed in educational discourse as a means of supporting students with integrating and deconstructing knowledge for learning across multiple disciplines (Barradell and Peseta, 2017). Threshold concepts are said to be troublesome or unsettling and are transformative because they prompt critical reflection and require deep thinking for understanding (Meyer and Land, 2003; Rodger et al., 2013). This deep thinking enables the learner to see how bodies of knowledge can be applied together (knowledge integration). For example, in occupational therapy, client-centred practice has been considered a threshold concept by multiple authors, as learners develop understanding of the full scope of what this involves, the factors that influence it and how to be client-centred in different contexts (Nicola-Richmond et al., 2016; Rodger et al., 2013; Tanner, 2011). Threshold concepts are bound to disciplinary knowledge and discourse, cannot be unlearned (irreversible learning), and enable reconstitution of identity and building of expertise (Barradell and Peseta, 2017). An example of a bounded threshold concept in occupational therapy is the relationship between occupation and health (Fortune and Kennedy-Jones, 2014; Nicola-Richmond et al., 2016; Rodger et al., 2013). Even though the threshold concept theory is historically used to explore student learning, it is relevant to all learning.
Occupational therapy has existing literature identifying concepts that have threshold qualities for student learning and the transition to practice (Fortune and Kennedy-Jones, 2014; Nicola-Richmond et al., 2016; Rodger et al., 2013; Tanner, 2011). Rodger et al. (2013) were pioneers in this area and initiated action research to systematically identify five threshold concepts for curriculum reform. These were: ‘purposeful and meaningful occupation, client centred practice, the inseparable nature of theory and practice, integrated reasoning and professional identity’ (Rodger et al., 2013: 3). More recently, a Delphi survey by Nicola-Richmond et al. (2016) with occupational therapy students, practitioners and educators found consensus for 10 threshold concepts: understanding the models and theories of occupational therapy; evidence-based practice; clinical reasoning; discipline-specific skills and knowledge; practising in context; a client-centred approach; occupation; the occupational therapy role; reflective practice and a holistic approach. Similarly, transformed understanding of the concepts of health, self-determination and activity were viewed as pivotal for ECOTs’ learning-to-practise by Björklund and Svensson (2006).
The transformative nature of learning in threshold concept theory is described using a metaphor of crossing learning thresholds (Meyer and Land, 2003; Perkins, 2006). Learning thresholds are defined as the ‘point at which students [learners] experience difficulty’ (Meyer et al., 2010: ix–x). Consistently, the literature identifies confidence, critical thinking and being reflective as strategies for crossing learning thresholds (Creek and Lawson-Porter, 2007; Fortune et al., 2013; Robertson and Griffiths, 2009; Unsworth and Baker, 2016). Research and discourse about learning thresholds for occupational therapy students is useful for preparing students for the workforce (Gray et al., 2012) and for reaching the competency standards related to professionalism, communication, occupational therapy processes, knowledge and learning that are expected for practice in Australia (Occupational Therapy Board of Australia, 2018). However, little is known about learning thresholds for ECOTs and the strategies they employ to cross them.
The position of ECOTs differs from that of students because they become fully socialised into the workplace culture and are no longer in the protected space of being a student. Because of their inexperience, they may be vulnerable to clashes between their values and the workplace culture, which places them at risk of burnout and disillusionment (Poulsen et al., 2014). Supporting ECOTs through supervision and opportunities to ‘repackage knowledge’ (Robertson and Griffiths, 2009: 131; Sweeney et al., 2001) during this time of learning is important for retention in the profession and for work satisfaction (Roots and Li, 2013). To guide methods of providing appropriate support for ECOTs, we aimed to learn more about their learning processes by exploring the troublesome aspects of knowledge and practice for ECOTs, and the strategies they employ as they learn to practise. Given the dynamic nature of this aim, we will be using the term ‘learning thresholds’ rather than threshold concepts.
Method
Research design
A constructivist grounded theory approach within an interpretivist paradigm (Charmaz, 2014) was used. A premise of constructivism is that knowledge is constructed through contextual experience (Charmaz, 2014). Grounded theory uncovers the social processes that guide action and presents these processes in the form of a theory (Nayar, 2015). This methodology was appropriate as ECOT experience is contextually bound and includes action and processes.
Participants
Semi-structured interviews were conducted over 16 months with 20 occupational therapists. Consistent with grounded theory methodology, data were gathered from different participants to create triangulation of data (Charmaz, 2014). Eight experienced occupational therapists were interviewed first to share their observations of what ECOTs find troublesome and how they respond in the first years of practice. Gathering this data from seasoned occupational therapists was important for sensitising us to the ECOT experience and informed the next stage of data collection, which included interviews with 10 ECOTs. Finally, interviews occurred with two occupational therapists working in roles of supporting ECOTs (through new graduate programmes) to test the theory.
Sampling and recruitment
Purposeful criterion and theoretical sampling were used (Liamputtong, 2013). Recruitment occurred through advertising in Occupational Therapy Australia e-news and personal contacts. Volunteers were screened to ensure they met the inclusion criteria. There were different inclusion and exclusion criteria for each of the three participant groups.
The experienced occupational therapists were purposively sampled, with inclusion criteria of having over 10 years of experience, being involved in the supervision or education of graduates or students, self-identifying as leaders in the profession, holding senior roles and ideally having completed some postgraduate education. These criteria ensured recruitment of participants who could provide rich information about their observations of troublesome aspects of knowledge and practice for ECOTs. The criteria of having over 10 years’ experience was consistent with previous research recruiting ‘expert’ occupational therapists (Unsworth, 2001). These data sensitised us to the issues prior to interviewing the ECOTs.
The ECOT volunteers were purposively sampled according to being in their first four years of practising (2010 to 2013 inclusive). The timeframe of four years was selected to gain variation in trajectory across the learning thresholds and is consistent with previous grounded theory research involving ECOTs (Sweeney et al., 2001). ECOT volunteers were excluded if they had received their education at University of South Australia, because the possibility of having been taught by the first author could influence their honesty of responses. After the data from the first two participant groups were collected and analysed, theoretical sampling (Charmaz, 2014) was used for a final round of data collection. Occupational therapists in roles supporting new graduates were sought for interview through the same recruitment strategies as the first two participant groups.
The 20 participants ranged in age from 23 to 55 years, with 1–35 mean years of experience. Two of the experienced participants were male. Four of the experienced participants were known to the interviewer but there was no prior relationship with the remaining 16. The spread of practice areas and work settings of participants is detailed in Table 1. Participants were from all states/territories in Australia except Western Australia and Northern Territory.
Details for each participant group.
Because some participants worked across more than one practice area or work setting, these figures may be more than the number of participants.
Data collection
Prior to data collection, ethical approval was obtained from the University of South Australia ethics committee. Volunteers gave written informed consent before participating. A total of 20 semi-structured in-depth individual interviews (Liamputtong, 2013) were conducted. Fourteen interviews were via telephone, allowing for greater geographical diversity of participants. The mean length of the interviews was 62 minutes (range = 30–96 minutes). The interviews were conducted by the first author in a place the participant chose. All interviews were digitally recorded and transcribed verbatim. Example interview questions were: How prepared did you feel for practice? and What things do you think have fostered or hindered your development as an occupational therapist? As data collection in constructivist grounded theory is shaped by progressive theory development, the ethics protocol allowed for small iterations to be made to the interview guide as the research progressed within each stage. The ECOT interview guide was piloted with two ECOT volunteers who were known to the first author. Both pilot interviews were conducted over the telephone, were not recorded and did not contribute to the findings. They did result in some changes to the guide to ensure that questions were neutral and did not generate perceptions of the need to give ‘right’ answers. This change was made because it was observed that the ECOTs in the pilot interviews were less free in their responses if they thought that their knowledge was being tested in some way.
Data analysis
Data were analysed concurrently with collection, which accounts for the long period of data collection (March 2014–June 2015). To build the theory, deliberate decisions were made about the order of interviews in order to capture views across different practice areas and work settings. For example, after having interviewed an ECOT in an acute setting, we interviewed an ECOT in the community. The stages of coding and theoretical development are outlined in Figure 1. All four authors undertook independent initial coding of two transcripts (one transcript from each of the two main participant groups). Authors met to discuss differences in interpretation and reach consensus, thus enhancing credibility of the findings (Liamputtong, 2013). Each discussion was followed by the first author coding the remainder of the data. Theoretical saturation was ensured through collection of data from the last two participants, who were in roles of supporting new graduates. Member checking occurred by sending a summary of the findings to the participants to check and comment on. Ten participants responded (six experienced and four ECOTs). They found the findings relevant, enjoyed reading the quotes from other participants and some wanted more detail beyond the summary provided. This process resulted in no changes to the theory.
Flow chart of data analysis method (Murray, 2016).
Findings
A theory of learning-to-practise was developed that included four learning thresholds and 11 strategies for crossing the learning thresholds. An overview of the theory is provided in Figure 2. Findings are evidenced by quotes in text and longer quotes are provided in Table 2. Pseudonyms are used to differentiate between participants, and the different groups are identified by the abbreviations E (experienced), ECOT (early career occupational therapists) and S (supporter).
Overview of theory of learning-to-practise.
Interpretive quotes as examples of data supporting learning thresholds and strategies for crossing them.
ECOT: early career occupational therapists; E: experienced occupational therapists; S: supporters of early career occupational therapists.
The four learning thresholds were consolidating professional reasoning, navigating into the workplace, building competence and confidence, and the core threshold of developing a personal theory and practice style. Responding constructively to these learning thresholds involved 11 strategies. Strategies were methods raised by the participants for resolving troublesome aspects of knowledge and practice, and included changes in ways of thinking or perspective as well as action. Strategies were not specific to practice areas or work settings and were applied concurrently, thus influencing each other.
Consolidating professional reasoning (learning threshold 1)
This learning threshold involved integrating knowledge as well as challenging assumptions about knowledge and practice. Professional reasoning was underpinned by knowledge, incorporated thinking and decision-making. There were three main strategies employed to cross this learning threshold.
Respecting limitations on knowledge (strategy 1)
Reaching ‘an understanding [of their] limitations and … gaps in knowledge’ (Sally, E) was essential for ECOTs and we found that they ‘worked very hard’ (Nikki, S) to fill gaps in their knowledge. Consolidating professional reasoning took deliberate effort to integrate different bodies of knowledge (see quote from Liz (E) Table 2). Jody (S) explained that professional reasoning is ‘actually learnt and experienced and theory integrated into practice. It’s not common sense at all’. Joy (E) noticed that those ECOTs who ‘invest[ed] the time to come to grips with it [knowledge]’ and sought to name their limitations had breakthroughs in their understanding.
The breadth of the occupational therapy knowledge base was acknowledged as an issue by Liz (E), and Debbie (ECOT) agreed that ‘you can’t really cover everything’ at university and came to realise that transferable knowledge was the key to progressing in practice. ‘Transferable’ was a term coined by participants that we interpreted as knowledge that can be applied in many work settings or practice areas. Examples from the data included goal-setting, time-management, caseload-management, decision-making, working autonomously, communication, knowing about services, analysing occupational performance and applying the occupational therapy process (see quote from Susie (ECOT) in Table 2).
Recognising and accepting unpredictability (strategy 2)
Professional reasoning is situationally dependent, with different situations being unpredictable. Edna (ECOT) found the unpredictability of practice took her by surprise, and some ECOTs were dependant on procedural reasoning, which did not assist them in unexpected scenarios. ECOTs needed to relinquish a desire for ‘recipes’ or being directed by others and independently (with support) do the required thinking and problem-solving for each situation (see quote from Joy (E) in Table 2). Participants discussed integrating client expertise about their lives with application of evidence as part of their professional reasoning. Learning about different theories helped Angela (ECOT) to realise that ‘it’s not one-size-fits-all for each client’ and tailoring interventions as well some adaptability and flexibility was required. When unsure about how to proceed in unpredictable situations, Ann (ECOT) used theory including the occupational therapy process as her ‘fall back’ option (see quote in Table 2).
Gathering and synthesising information (strategy 3)
Occupational analysis and being client-centred were key methods for gathering and synthesising information. ECOTs learned to gather appropriate information about occupational performance and to avoid taking shortcuts and making assumptions about client goals. ECOTs needed to judge when they had enough information, avoid drawing conclusions too early and avoid taking information at face value, but also trust their intuition (see quote from Beth in Table 2). They initially found it difficult to listen to clients at the same time as remembering and processing information, attuning to clients and their emotions, and concurrently applying their knowledge. Debbie (ECOT) reflected that she used to forget three or four main points after client interactions because she had difficulty holding information in her memory, and Ann (ECOT) affirmed that thinking on her feet and processing information quickly was initially challenging. Ann (ECOT) found that she was able to ‘apply the OT [occupational therapy] process quite well’, but after assessment, found ‘the hard part’ was ‘knowing what to do’ next, which was supported by Jasmine (E) (see quote in Table 2). Paying attention to the psychosocial aspects of occupational performance (including spirituality and social relationships) during assessment and intervention were both identified by Sally (E) and Jasmine (E) as areas where ECOTs needed to explicitly develop in their professional reasoning.
Navigating into the workplace (learning threshold 2)
This learning threshold was about ECOTs finding their way amongst external forces and cultural/political factors. ECOTs were compelled to reconcile what they knew with workplace culture and norms, and for some this was disillusioning when it did not line up with their expectations. There were two main strategies to cross this learning threshold.
Trying to fit into workplace culture (strategy 4)
In some cases, ECOTs experienced a ‘culture shock’ as they were challenged by political workplace cultures that were largely tacit but highly influential over practice. They felt conflicted because they wanted to comply with workplace practices arising from culture and policy but believed they were compromising provision of fair and client-centred services. According to Jody (S), ECOTs were ‘not really aware of the politics and that’s something that comes as a shock’, particularly when they observed injustices that they felt powerless to change. Joy (E) had observed that responses to this conflict varied. She noticed that sometimes ECOTs accepted the workplace culture without question, sometimes they complied even if they didn’t agree, and sometimes they instigated change. Kate (ECOT) wanted to change workplace culture about client-centred practice and expressed frustration at the mismatch between policy and practice (see quote in Table 2). Louise (E) explained that learning to navigate the conflict between the biomedical model promoting the health professional as an ‘expert’ and the need to be collaborative and client-centred in occupational therapy practice was a tension for some ECOTs (see quote in Table 2).
Negotiating service delivery models and supervision (strategy 5)
Edna (ECOT) expressed powerlessness that her workplace made decisions about therapy on her behalf and she had to ‘pull the rug out from under’ clients and stop providing services because of policy decisions. Sometimes the ECOTs observed activity in the workplace that they didn’t agree with and needed to make sense of these circumstances, which invariably required conversations with others. Some ECOTs reported highly supportive workplaces and were satisfied. However, both Ann and Eliza (ECOTs) said they had been ‘thrown in the deep end’ with little support. Kim (ECOT) relied on her peer supervision group to debrief. Both Eliza (ECOT) and Kate (ECOT) experienced challenges with working with their supervisors and needed to work out how best to manage this because it was a sensitive and political topic to raise in workplaces (see quotes in Table 2).
Joy (E) expressed frustration about the high expectations placed on ECOTs in response to the demands of workplaces, and ECOTs reported feeling ostracised at times by colleagues who wanted them to contribute more. Support to manage these tensions was compromised by frequent changes in supervisors due to the transient workforce in occupational therapy and/or rotating positions. Having contact with other occupational therapists was viewed by both participant groups as essential for navigating the transition into the workforce. Consistently, all participants discussed the merits of an external mentor as an advisor in addition to their workplace supervisor and described the value of having supervision that matched their learning style (see quotes from Nicholas (E) and John (E) in Table 2): ‘I went to the two [supervisor and mentor] with very different questions … I could ask some of those big, broader questions [to a mentor] so it was helpful to have both’ (Susie, ECOT).
Building competence and confidence (learning threshold 3)
This learning threshold was the transition to becoming responsible and autonomous, which sometimes meant ECOTs second-guessed their decisions. There was, therefore, a need for heightened reflection and critical thinking about performance and management of stress. ECOTs wanted to do well but sometimes became overwhelmed due to the fast pace and dilemmas of being a health professional. Two main strategies were employed to cross this learning threshold.
Taking responsible action and trying new things (strategy 6)
ECOT confidence advanced by having opportunities to consolidate their learning through repeated practice, which was often procedural. However, some ECOTs found it ‘hard to step beyond that zone’ (Sally, E) and became uncomfortable when challenged. Susie (ECOT) realised that she needed to challenge herself to learn and had a habit of seeking help, but not always being ‘specific about what she was having trouble with’, and had to work to manage her supervision. Debbie (ECOT) pushed herself to develop confidence with prioritising referrals and managing her time. ECOTS learned to prioritise workload and be organised, as well as becoming flexible and adaptable to ‘think creatively and laterally’ (Joy, E) about alternative options. Taking responsibility also included learning to accept clients’ rights to take risks and the need to make difficult decisions that they felt could disadvantage clients (such as mandatory reporting for child protection – see quote from Liz (E) in Table 2). Angela (ECOT) explained that she ‘just wanted to keep them [clients] safe’ and had initial visions of this ‘utopia’ of being a health professional, but she realised that working with risk and enabling client choice was necessary (see quote in Table 2).
Evaluating performance and self-managing (strategy 7)
Most ECOTs seemed aware of the need for actively engaging in performance evaluation through reflection and supervision (see quote from Edna (ECOT) in Table 2). This strategy required continually asking, ‘how can I improve my practice?’ (Joy, E) and recognising when to change. However, it was also necessary to self-manage worry and any tendency to second-guess decisions, and to be okay with having to delay making decisions to ensure the situation had been fully thought through (see quote from Liz (E) in Table 2). Liz (E) described occupational therapy as ‘emotionally fraught’ and recommended that ‘good emotional self-management skills’ were essential for longevity in the workforce. Ann (ECOT) described herself as having ‘quite good personal coping skills’ but told a story of her friend who was ‘all forever incredibly stressed out and was ringing me … every week crying … I knew that I didn’t want to get to that point’. Despite acknowledging her emotional challenges, Eliza (ECOT) was reluctant to ask for ‘emotional support’ because she worried that she would appear ‘weak’, and yet Liz (E) validated that need. She identified one of the roles in a workplace as ‘look[ing] after the emotional welfare of the workers’, which can come from leaders or peers (or both).
Developing a personal theory and practice style (learning threshold 4)
Developing a personal theory and practice style was the core of the four learning thresholds in the theory of learning-to-practise. Personal theory and practice styles are developed when ECOTs refine what they value in their practice and hold beliefs about their conduct. At the point of developing their personal theory and practice style, ECOTs began to confidently express their views and to employ their own ways of thinking and working rather than modelling others’ methods. They were comfortable with their approach and able to articulate and defend this when challenged. There were four strategies that ECOTs employed to cross this learning threshold.
Adapting to discrepancies between university theory and practice (strategy 8)
ECOTs commented on a disconnect between the ‘text-book view of the world’ (Angela, ECOT) learned at university and the imperfections of practice. ECOTs expressed surprise, disappointment and frustration about the reality not necessarily matching the ideal (see quotes from Louise (E) and Nikki (S) in Table 2). This tension was particularly evident for the concepts of client-centred practice and occupation-based practice (see quotes from Angela (ECOT) and Claire (ECOT) in Table 2). They understood the need to ‘learn from something’ (Angela, ECOT) and didn’t disagree with the worldview taught at university, but the disconnect was troublesome nonetheless. They accepted that it was up to them to actively hold onto their ideals within the real world, instigate change if needed (see quote from Claire (ECOT) in Table 2) and instil these values in the students they were now supervising. This deliberate and constructive learning process supported ECOTs to establish their personal theory and practice style.
Knowing yourself and being secure in what you want (strategy 9)
ECOTs increased self-awareness as leverage for personal development. For example, Susie (ECOT) realised that her learning style of always needing to be prepared was holding her back and took steps to change her beliefs about how to approach practice. She began to be more spontaneous and flexible in her approach and sought her learning from reflecting afterwards rather than excessive planning beforehand. Eliza came to realise that she brings unexpected strengths into her practice that she learned outside of her degree and this insight boosted her confidence (see quote in Table 2). Once Angela’s (ECOT) supervisor, whom she held ‘on a pedestal’, went on leave, she ‘stepped out on her own’ and was able to develop her ‘own way of working and [her] own style’. Kate (ECOT) developed a style of ‘being open and transparent and realising that every day is a new day and whatever happened yesterday or the day before is in the past’. Kim (ECOT) had been exposed to adverse events such as client suicide and client drug relapse, and had learned to accept that sometimes occurrences were ‘unforeseeable’ and ‘you can only do what you can do’.
ECOTs needed to find their place within teams whilst establishing their role and identity. Sometimes their occupational therapy role within the team may conflict with the team values and beliefs, and ECOTs needed to be sufficiently secure and self-aware to manage this (see quote from Joy (E) about client-centredness in Table 2). Debbie (ECOT) had been uncertain about her career choice, but with new experiences she became increasingly aware her negative experiences as a student were to do with the workplace culture rather than her ability. She said: ‘Yes I did pick the right career and I am enjoying work, which was one thing I was a bit concerned about at the beginning’.
Believing in what occupational therapy offers (strategy 10)
ECOTs needed to work to further establish strong connections with their belief systems that inform their practice. To connect with their beliefs, Joy (E) recommended ECOTs understand and embrace them as ‘the total way that you go about your business; it’s not just something that you turn on and off at will’ [in reference to client-centred practice]. Professional beliefs can get lost if they are not explicitly recognised, and ECOTs needed to become comfortable with expounding their beliefs even without a lot of clear proof (see quote from Susie (ECOT) and John (E) in Table 2). ECOTs discussed how they felt a bit conflicted by the lack of strong evidence for some occupational therapy interventions, and Nicholas (E) expressed concerns about ECOTs becoming ‘blinkered by what the [empirical] evidence says’ rather than believing other forms of evidence, such as theory.
The vulnerability of ECOTs to being influenced by others with their own agenda was raised by participants who believed being able to stand their ground in such situations showed a strong connection to their beliefs and values (see quote from Edna (ECOT) and Sally (E) in Table 2). Being familiar with occupational therapy theory and confident in the professional foundations was key to beginning to establish a personal theory and practice style, but they often needed guidance to arrive at this place. ‘I think some people continue to engage with it [theory] and they have more “aha” moments and then they change their view … or they develop and refine their personal view of OT’ (Louise, E).
Transacting, defining and reconciling the occupational therapy role (strategy 11)
ECOTs were developing professional identity and learning to stand their ground. They needed to correct preconceptions about their role, present their ideas to other health professionals, speak up in meetings and show initiative (see quote from Claire (ECOT) in Table 2). Sometimes ECOTs held their own preconceptions about their role, which needed to be unpacked and explored further (see quote from Jane (E) in Table 2). ECOTs who were not confident in their role or found that their role was negotiable and ill-defined were initially unsettled and needed to make choices about what they were or were not willing to do (see quote from Nicholas (E) in Table 2). Liz (E) believed that the role of occupational therapists depended on the work setting, but was also dependent on history. She believed it was important for occupational therapists to reflect on ‘what they think would be the best contribution to the workplace’ (Liz, E). Validation about their contribution came from consumers of occupational therapy services and improved confidence for ECOTs about the value of their practice. For example, Beth (ECOT) was surprised at how grateful her clients were for her services (see quote in Table 2). ECOTs liked talking these breakthrough moments through with other occupational therapists with equal experience because ‘they knew exactly how I felt’ (Angela, ECOT).
Discussion
This research has led to a theory of learning-to-practise that addresses the research questions of ‘what aspects of knowledge and practice are troublesome for ECOTs?’ and ‘how do ECOTs respond to troublesome aspects of knowledge and practice?’ Troublesome aspects of knowledge and practice for ECOTs were explained in the form of four learning thresholds and 11 strategies employed to cross the learning thresholds.
The theory of learning-to-practise culminated in developing a personal theory and practice style. The notion of having a personal theory and practice style is not necessarily new, and similar concepts have been presented previously, such as having a worldview (Hooper and Wood, 2014), a professional paradigm (Björklund and Svensson, 2006), a personal frame of reference (Cusick, 2001) and a practice model (Higgs, 2016). We chose to use the term ‘personal theory and practice style’ as it seemed the best fit for the required integration of knowledge and transformation in thinking and acting that both the ECOTs and the experienced participants were describing.
When things were uncomfortable, ECOTs reflected, evaluated performance and made sense of their experience, leading to learning and recovery. This process supported establishment of their worldview (Hooper and Wood, 2014) in terms of being able to see the bigger picture and the ‘so what’ of their practice for their clients and for occupational therapy. Reflection was key in our research and was also identified as a threshold concept in Nicola-Richmond et al. (2016). Understanding of the inter-relationships between different knowledge and its value to understanding clients and informing management also shifted, which is consistent with Björklund and Svensson’s (2006) theory of paradigm transformation.
Workplaces are dynamic, there is role uncertainty, and there are competing conditions and political agendas that health professionals need to meet (Barradell and Peseta, 2017). For occupational therapists these circumstances are further complicated by being situated across both the health and social care sectors (Blair and Robertson, 2005), which can create a mismatch between their professional beliefs and the dominance of biomedical approaches in health (Wilding and Whiteford, 2009). Furthermore, almost every situation in occupational therapy practice is different, requiring ECOTs to adaptively adjust their professional reasoning.
To enable adaptability, it is necessary to have health professionals with a strong sense of their values, beliefs and purpose (Evans and Guile, 2012). Reconciling role confusion and confidently believing in what they were doing was key to ECOTs establishing their personal theory and practice style. Unfortunately, this issue of role insecurity is not new; it was coined ‘underground practice’ by Fleming and Mattingly (1994) and was explored further by Wilding and Whiteford in 2007. Drolet and Désormeaux-Moreau (2016) found that professional identity was linked to values and beliefs, which is supported by our findings of ECOTs’ growing self-awareness and consolidation of their values and beliefs to reach their personal theory and practice style.
ECOTs also needed to be willing to respond constructively to contextual challenges such as limited availability of supervision, a well-known issue for ECOTs (Roots and Li, 2013; Sweeney et al., 2001). It has been claimed that employers of ECOTs are placing increasing demands upon them to perform at levels beyond their readiness (Fortune et al., 2013; Gray et al., 2012; Morley, 2009). This pressure occurs due to high workloads and under-resourcing, and leaves limited time for the required guidance and support of ECOTs that our and previous research has identified as crucial.
The notion of developing a personal theory and practice style, and the strategies for crossing learning thresholds, provides a new contribution to occupational therapy discourse. Constructive responses to uncomfortable situations required effort (Meyer and Land, 2003) but were transformative (Brookfield, 2012; Mezirow, 2012). This effort was complemented by contextual and systemic political awareness, which has previously been identified as a learning threshold for health professionals (Barradell and Peseta, 2017). The idea of trying to cross the learning thresholds and being intentional in learning resonates with the work of Higgs (2016) about educating practitioners who become deliberate in realising their practice. She writes: [A] key area of choice for individual professional practitioners, is the practice model they adopt, pursue, embody, and are shaped by and consequently the practice model through which they shape their practice relationships and impact. Each of these choices is a reflection of the deliberateness involved in owning one’s practice model and realising one’s professional practice (Higgs, 2016: 196).
Implications for the occupational therapy profession
This research gives further evidence that when ECOTs encounter troublesome aspects of knowledge and practice it can be a challenging time for them but can lead to transformative learning. The implications of this theory of learning-to-practise are that ECOTs need support and supervision as well as opportunities to reflect, make sense of their experiences, be deliberate in their conduct as an occupational therapist and engage in collaborative sharing of both challenges and solutions (Binyamin, 2018). They would also benefit from having opportunities to name and frame the learning thresholds they are experiencing and being empowered with some of the strategies shared by the participants in this research. Although ECOTs cannot be prepared for everything, examples of how this research could inform pre-entry education include encouraging critical thinking, resilience and political awareness, and emphasising transferable knowledge across practice areas.
Limitations and strengths
It is possible that the ECOT participants were homogenous because they were motivated to participate and appeared to be connected to occupational therapy. While the sample size of 20 participants provided rich data, this is not intended to be fully representative of the profession (Charmaz, 2014). However, the breadth of practice areas and work settings from which the findings were drawn (see Table 1) gives the theory broad applicability. These findings are limited to the Australian context and the occupational therapy profession but may have some resonance with experience in other countries and disciplines. The findings are also limited to the health and social care environments and the models of service delivery during the period of data collection.
Recommendations for future research
A recommendation for future research is to determine the best way to prepare students for becoming ECOTs and to support ECOTs to ‘realise’ their personal theory and practice style. ECOTs told stories of colleagues who were not supported, had already left occupational therapy and were experiencing a sharp disconnect from occupational therapy knowledge, values and beliefs. The perspectives of these ECOTs were not captured in this research and this is a recommendation for future research. How to find a balance between nurturing ECOTs and giving them autonomy whilst accounting for varying levels of development and different learning styles is also worthy of research.
Conclusion
This research has developed a theory of learning-to-practise for ECOTs. The theory presents four learning thresholds and strategies for crossing them. The theory confirms that ECOTs experience troublesome aspects of knowledge and practice that can lead to learning if they respond constructively. ECOTs need to be equipped with knowledge, supervision and support to enable them to cross the learning thresholds. This includes learning to be deliberate and reflective in their thinking and actions towards developing their personal theory and practice style.
Key findings
Strategies for crossing the learning thresholds give early career occupational therapists direction for developing their personal theory and practice style. Early career occupational therapists need to be deliberate in their actions and reflective in their learning.
What the study has added
This study adds to knowledge about what early career occupational therapists find troublesome, strategies they can use to cross these learning thresholds and their transformation to establishing their personal theory and practice style.
Footnotes
Acknowledgements
The authors would like to thank the research participants for their involvement, and Occupational Therapy Australia for their assistance with recruitment. Thank you also to Susan Gilbert-Hunt for providing valuable feedback as the manuscript was in preparation.
Research ethics
Ethical approval was obtained from the University of South Australia Human Research Ethics Committee, ID No: 0000032359, 11th December 2013.
Consent
All participants provided written informed consent for the study.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research and/or publication of this article: Australian Postgraduate Award for PhD research by Carolyn Murray.
Contributorship
Carolyn Murray, Ian Edwards, Mark Jones and Merrill Turpin were all responsible for the development of the research. Carolyn Murray completed the ethics application, recruitment and data collection. For trustworthiness and rigour, all authors were involved in data analysis and provided input and feedback. Carolyn Murray wrote the first draft and all authors have reviewed, edited and approved the manuscript.