Abstract
Recent studies have suggested that occupational therapy fieldwork education, with its current emphasis on supervisory education, fails to maximize student learning and fails to adequately provide students with the skills and knowledge required to be competent and confident entry-level clinicians (Hodgetts et al., 2007; Lester, 1995; Toal-Sullivan, 2006). These research findings are a call to action to change the way fieldwork education is currently designed and delivered. Stefl-Mabry, Radlick, and Doane (2010) and Bransford, Brown, and Cocking (2004) are among a growing number of education theorists advocating for “the inclusion of student voice[s] in efforts toward educational reform” (Stefl-Mabry et al., 2010, p. 65). Stefl-Mabry and colleagues argued that students should not be considered as mere “passive consumers of information” (p. 65) but rather as collaborators in their own learning experience. To gain a greater understanding of occupational therapy students’ learning experience in fieldwork education, a literature search was conducted using several online databases (OTDBASE, OT Search, and Google Scholar) and relevant keywords (student perspectives, occupational therapy, fieldwork education, and learning). The following is a brief summary of the search results to help readers better situate this research study within the larger body of knowledge published on learning in occupational therapy fieldwork education.
A recent study by Doherty, Stagnitti, and Schoo (2009) suggested that students consider block placements (longer duration fieldwork experiences) to be more beneficial to their overall learning than nontraditional (shorter) placements. Hummell (1997), in a quest to gather student perspectives regarding effective fieldwork supervision, found that students prefer fieldwork educators (FWEs) who have well-developed interpersonal skills and use collaborative and facilitatory teaching strategies. This same researcher found that FWEs who lack time for supervision had a negative influence on student learning experiences. Mackenzie (2002) found that students prefer FWEs who are organized, understanding, and inclusive; have clear student expectations; encourage active student involvement in clinical activities; introduce students to other staff and clients; are approachable; make time to clearly explain concepts; and are flexible.
The literature has suggested that occupational therapy students find collaborative fieldwork education models more conducive to learning than traditional one-on-one models (one supervisor, one student; Martin, Morris, Moore, Sadlo, & Crouch, 2004; Mason, 1998). In a study by Mulholland, Derdall, and Roy (2006), students stressed that FWEs who create positive and inviting learning environments facilitate better fieldwork experiences. Rodger, Fitzgerald, Davila, Millar, and Allison (2011) found that students prefer a welcoming learning environment, a detailed orientation to fieldwork, clear expectations of the fieldwork experience, quality feedback, a graded program of learning, quality modeling and practice from FWEs, a consistent teaching approach, and educators who promote an open and honest relationship with their students.
Although the current literature on this topic is helpful in identifying some of the facilitators of and barriers to learning in fieldwork education, it has primarily focused on FWEs’ personal characteristics and placed little emphasis on the multitude of other factors that have the potential to influence learning. Current publications on this topic have not provided key stakeholders in the fieldwork education process (i.e., FWEs, fieldwork coordinators, curriculum design personnel, and students) with the information required to make effective, student-centered, and learning-centered educational reforms to occupational therapy fieldwork education. Therefore, a more comprehensive study examining the multifaceted and complex factors that influence learning within fieldwork education is warranted.
This study was designed to answer one key question: What are the facilitators of and barriers to learning in current occupational therapy fieldwork education? This question was explored by surveying a diverse group of occupational therapy students to gain a comprehensive understanding of these facilitators and barriers from the perspective of both Canadian and U.S. students, with the goal of generating new knowledge that can better inform the future design and implementation of fieldwork education and improve student learning outcomes. The design of fieldwork education differs between Canada and the United States: Canadian fieldwork education tends to favor block placements, whereas U.S. fieldwork education is more varied, offering students some block placements and some placements interspersed throughout the academic semester.
Method
Ethics approval to conduct this research was secured through Temple University’s institutional review board before the study commenced. To ensure a basic level of standardization, participation in this study was limited to Canadian and U.S. students enrolled in a clinical master’s degree program in occupational therapy who had already experienced some formal fieldwork education. To explore international student perspectives, an online survey was used to gather data. The survey was created using surveymonkey.com. Questions included in the survey (Figure 1) were mostly open ended and were structured to fill certain knowledge gaps identified during the initial literature search. Student responses were collected anonymously and stored via the surveymonkey.com website in a password-locked account accessible only to the study’s principal investigator (Grenier). Coding and analysis of gathered data were typical of a qualitative grounded theory inductive approach (Kielhofner, 2006).
Student survey.
Participants
In total, 29 students responded to the online survey. Of these, 27 were female and 2 were male. Seventeen respondents were attending a Canadian university (9 students from McGill University; 8 students from Queen’s University), and 12 respondents were attending a U.S. university (7 students from the University of the Sciences; 5 students from Alvernia University). To participate in the study, students had to have completed at least their first fieldwork education practicum.
Data Collection
Permission to disseminate the survey web link to the appropriate student cohorts was obtained from the program directors of two Canadian and two U.S. universities. A total of six universities were initially contacted to participate in the research study; however, two universities did not respond to requests for their participation in this study. Participation in the study was voluntary, which was explicitly stated in both emails sent to students and on the main page of the online survey. Possible risks associated with participation, including mild emotional or psychological discomfort, were disclosed in the email sent to students with the survey link. Completion of the online survey implied consent to participate in the study.
An initial email with the attached survey link, requesting student participation in the study, yielded a limited number of responses. A second, reminder email was sent to the students 2 wk later to elicit further responses. Student responses were gathered from October 1, 2013, through November 1, 2013. The online survey was closed November 1, 2013, after approximately 1 wk of inactivity on the survey website and to meet doctoral coursework time requirements.
Data Analysis
Data analyses were conducted from November 1, 2013, to December 31, 2013. Analyses were consistent with a qualitative grounded theory inductive approach, as originally described by Glaser and Strauss (1967). In addition to the meta-codes (barriers and facilitators), other subcodes emerged relating to fieldwork design and preferred student learning styles. A cross-sectional analysis of student responses was conducted to better identify recurring meta-codes and subcodes. Initially, Canadian and U.S. data were segregated so differences between the two could be more easily identified. Few significant differences were observed between the Canadian and U.S. data, so the data were aggregated in the final analysis.
Coding was completed by the author. Coding and themes were reviewed by the author’s research mentor, but no systematic coding or interpretation was undertaken by a second party. Relationships among codes were schematically mapped out to facilitate understanding of the dynamics involved in the student learning experience and to develop new theoretical conceptualizations of learning in occupational therapy fieldwork education. Student responses regarding facilitators and barriers to learning in occupational therapy fieldwork education were compared with current literature on the topic to ensure validity of responses. This data analysis technique was also used to ensure that questions included in the survey were valid and measured the concept of learning.
Results
Students’ occupational therapy fieldwork education was found to be a complex phenomenon, the result of numerous factors that influence the learning process. For the purpose of this study, these factors were divided into the following principal categories, based on the content analysis of the student data: individual, environmental, educational, and institutional. When appropriate, these principal categories were further divided into subcategories, in which the various facilitators of and barriers to learning were explored. Quotations were extracted from students’ survey responses.
Individual
The individual category encompasses the personal attributes of those people directly or indirectly involved in the fieldwork education process, whom students frequently mentioned as either facilitating or hindering learning in this context. These people include the FWE, the fieldwork site personnel, and the student him- or herself.
Fieldwork Educator.
The FWE was often cited as the principal influence on the student learning process. FWEs with well-developed interpersonal skills (i.e., “friendly,” “positive,” and “supportive”) and FWEs who demonstrated qualities of professionalism (i.e., “knowledgeable,” “committed/dedicated to the profession,” “strong work ethic”) were viewed as facilitating learning by creating positive learning spaces for students. FWEs who had realistic expectations of students and took into consideration individual knowledge and skill levels were repeatedly mentioned as contributing to positive learning outcomes. When reflecting on a past fieldwork experience, 1 student recognized that her FWE “knew when to give/how much responsibility to give me” and listed this quality as a facilitator of her overall learning. In addition, students argued that FWEs who were approachable (i.e., “patient,” “understanding,” “helpful,” “encouraging,” and “easygoing”) facilitated learning by “creating a safe learning environment.” Finally, students said that FWEs who demonstrated a passion for the occupational therapy profession enhanced their learning experience during fieldwork education. These particular FWEs were identified as being highly motivated and engaging people who infected students with their passion for the profession.
Characteristics of FWEs that negatively influenced the student learning experience included disengagement, a high need for control, closed-mindedness, lack of communication, lack of experience, and intimidation. Disengagement was discussed in terms of FWEs who were “distracted” and “complacent” and did not take the time to “explain concepts [or] clinical reasoning” and generally “[lacked] availability.” One student wrote,
They had more of a “hands-off” approach and would kind of throw me into things. I think I would have learned so much more if they [had] stayed with me longer and taught me their ways of doing things.
Another student reflected, “[The FWE] didn’t advocate for our profession, lacked leadership skills, didn’t speak up within the health team, [and] didn’t push to improve the status quo.” A high need for control on the part of the FWE was discussed as a significant barrier to learning, depriving students of opportunities to practice their newly developing skills. Students described FWEs with a high need for control as “lacking trust [and] confidence in student abilities,” “controlling,” and “micromanag[ers].” FWEs viewed as closed-minded were described as “defensive when it comes to receiving feedback and being open to suggestions or new ideas” and “condescending.” These FWEs created noncollaborative learning environments, which students viewed as a barrier to learning. Inexperienced FWEs, FWEs who were not up to date on current evidence or best practices, and FWEs who lacked communication skills were also viewed as creating poor learning environments. Finally, FWEs who were viewed as intimidating were considered negative influences on student learning. One student wrote, “My [FWE] from my first Level 2 [fieldwork site] would say things such as ‘I’m going to be meaner now’ that did not motivate me.”
Fieldwork Site Personnel.
Students identified various personal attributes of team members (exclusive of FWEs), including interdisciplinary team members, managers, and support personnel, as facilitators to learning in fieldwork education. “Friendly,” “welcoming,” “supportive,” and “inclusive” team members were mentioned as contributing positively to learning by encouraging students to practice real-world team interactions and creating a positive learning environment. Fieldwork sites at which occupational therapists were considered “respected member[s] of the team” were noted by students as also promoting a positive learning environment. Students acknowledged that FWEs and fieldwork staff who shared “similar values,” had “similar backgrounds,” and “[spoke] the same language” (i.e., French in the case of French-Canadian students) facilitated overall learning by creating a familiar and comfortable environment for learning and enabling quicker rapport. Fieldwork site personnel who were “uninvolved,” “unfriendly,” and “unwelcoming” were cited as barriers to learning by hindering team interactions and limiting potentially valuable learning opportunities for students.
Student.
Students identified self-confidence as a personal attribute that was both a facilitator of and a barrier to learning in fieldwork education. They viewed it as an important asset to have when they were asked to learn and then successfully complete a demanding or complicated task. However, when students were asked, “Please list any other facilitators and barriers to learning you have encountered during your past/current fieldwork experience(s),” 1 student identified “lack of confidence in my own knowledge and abilities” as a barrier. Another student wrote that his “willingness to get involved without preparation,” or overconfidence, was a barrier to learning.
Environmental
The environmental category, for the purpose of this study, refers to the physical environment in which the student is learning. It may include the site at which the fieldwork is being conducted and the site’s geographical location. Students frequently reported that access to a personal work space facilitated learning by providing them with a place to complete client documentation, read, and complete assignments. Students also listed easy access to resources (i.e., Internet, books, and journals) as contributing positively to their overall learning experience. Students preferred fieldwork sites that gave them the chance to shadow practitioners or work in multiple departments (e.g., geriatrics and outpatient rehabilitation departments) and with varied client populations. Such opportunities provided students with more exposure to varied learning opportunities within one fieldwork site. Students also preferred clean and organized fieldwork sites. Easily accessible fieldwork sites (i.e., within driving distance) were listed as contributing positively to the overall student learning experience by allowing students more time for coursework, part-time employment, and other extracurricular activities. With regard to barriers, students primarily listed lack of access to equipment and resources and outdated resources as negative contributors to learning that impeded their ability to treat clients within current best practices.
Educational
The educational category relates to individual teaching styles and methods, individual student learning styles, and fieldwork education models that can typically be seen in a fieldwork education setting.
Teaching Styles.
The teaching styles subcategory, for the purposes of this study, refers to any teaching method or technique used by FWEs, or other team members, to teach students new information or cultivate new clinical skills. Students referred to this category extensively in their survey responses, identifying several key teaching methods and techniques that facilitated learning for them. Educators who encouraged active student participation in treatment sessions, hospital rounds, and team meetings were viewed as facilitating the learning process. Students repeatedly cited regular and constructive feedback from FWEs as a key learning tool that allowed them to gain a better understanding of their strengths and weaknesses. Relevant tasks and assignments aimed at developing applicable occupational therapy skills were considered positive learning experiences by students.
Allotting students some degree of “independence,” “giving guidance,” and “modeling interventions” only when needed were among the preferred teaching techniques listed by students. Students also preferred FWEs who established “clear objectives and expectations” at the onset of the fieldwork experience and encouraged “frequent discussion” to give students a clear roadmap of the fieldwork education process. Finally, students said that educators who “[took] advantage of teachable moments” by teaching while they were treating patients positively influenced learning in the fieldwork setting.
Students considered being “[thrown] into a new situation with no prep time,” “frequent quizzing,” and “unbalanced pacing of student workload” to be detrimental to their learning experience. Students also said that an unstructured approach to teaching negatively influenced their learning. FWEs who did not explain the rationale behind interventions also negatively influenced learning.
Learning Styles.
The learning styles subcategory refers to students’ individual learning style and their preferences in a fieldwork education setting. Student respondents acknowledged that FWEs who adapt to student learning styles and present information in various forms facilitate learning by better tailoring the fieldwork experience to their individual learning needs. In addition, students appeared to prefer interest-based learning experiences as opposed to preassigned learning objectives. One student stated, “I learn much faster when I am learning something that I actually want to learn about!”
Students commented on their preferred individual learning styles at length, most often identifying a series of sequential steps required for the retention of new information and skills (e.g., see the intervention, do the intervention, teach the intervention; see Figure 2) rather than one all-encompassing learning style (i.e., visual learner, auditory learner, or kinesthetic learner). One student explained,
I like having a “see one, do one, teach one” style of learning. For example, I would like to see an assessment done by my preceptor, then I would like the opportunity to get hands on and do the assessment myself. Though there is not an opportunity to “teach one” in placement (usually), I would like to talk through the assessment that I did and figure out what worked and what didn’t so I can make changes the next time I do one.
Sequential learning steps preferred by students.
The varied nature of these preferred ways of learning further highlights the importance of getting to know each student’s preferred learning style.
Fieldwork Education Models.
Fieldwork education models are the systematic ways in which fieldwork education is designed and delivered. They may include collaborative, supervisory, didactic, explorative, and emerging fieldwork education models, among others. Students voiced a preference for collaborative education models, in which the FWE acts as a mentor rather than as a supervisor by providing guidance when necessary. Students also voiced a strong preference for interprofessional education models, in which they were given the opportunity to work within a multidisciplinary team. Students explained that they learned a great deal about the role of occupational therapists and about the role of other health care professionals when working within a multidisciplinary health care team.
Of the 29 students who responded to the survey, 12 indicated that they had experienced nontraditional fieldwork placements in which more than one FWE was assigned to them. Of those 12 students, 9 stated that the experience was overwhelmingly positive. One student wrote, “Having multiple fieldwork educators or working directly with a coworker gave me the opportunity to observe wheelchair fittings and take note of how two different hand therapists addressed the same diagnosis.” The other 3 students reported that although they did learn a great deal from each FWE, adjusting to different teaching styles was difficult at times. One student wrote, “[It] was complicated to adjust to their [different] style[s] of intervention and their style[s] of documentation. Also, they were in two different programs, which [resulted in] a lot of diverse diagnos[es] to deal with, too.” Another student reflected the same sentiment by stating, “It’s difficult to transition between one fieldwork educator and another because teaching styles and treatment note writing [are] different, and therefore [it is] hard to understand the ‘correct’ way of doing things.”
Ten students who responded to the survey indicated that they had experienced nontraditional fieldwork experiences in which more than 1 student was assigned to the same FWE. All of these students reported a positive experience. One student noted, “We were able to collaborate and learn to help each other with our strengths and weaknesses. We completed each other as a team.” Another student reflected on the benefits of being paired with another student:
There was a Level I student assigned to my fieldwork educator during my Level II rotation, which gave me an opportunity to be the teacher. A majority of the time, the Level I student shadowed me, which allowed me to explain [the] reasoning behind certain treatments and answer any questions. Sometimes I even learned from the Level I student because of questions she may have asked that I also did not know the answer to, therefore referring us back to our fieldwork educator.
Students discussed the duration of fieldwork experiences. Some considered longer duration fieldwork, which allowed for greater client continuity and observation of the entire spectrum of care from initial evaluation to discharge, better for learning. Others preferred shorter duration (but more frequent) fieldwork, which permitted more exposure to varied client populations and occupational therapy specialties.
Institutional
For the purposes of this study, the institutional category refers to any outside institutional structures, mechanisms, or governing bodies that may influence learning within the context of fieldwork education and may include laws, policies, budgetary constraints, and the economy. Students identified several institutional facilitators of and barriers to learning within fieldwork education. These facilitators and barriers were often the direct consequences of medical staff shortages, budgetary constraints, or the current unstable health care climate in Canada and the United States. One student argued that private clinics offered better learning opportunities for students because they had fewer workload pressures and provided greater opportunities for “patient continuity.”
The most frequently cited barriers to learning were high workload, which contributed to FWEs’ having “little time to devote to students,” and “high patient turnover” rates. Students argued that high workload pressures detracted from their overall learning experience by limiting one-on-one time with their FWE and preventing them from experiencing the full spectrum of client care. Alternatively, some students discussed how a low caseload and the lack of a meaningful occupational therapy role at some fieldwork sites negatively influenced learning by limiting their exposure to varied client populations and their understanding of the occupational therapy scope of practice. Lack of fieldwork site availability and variability was frequently mentioned as a barrier to learning because it restricted students’ choice of fieldwork site and limited exposure to diverse client populations.
Discussion
The personal attributes of FWEs that students listed as either facilitating or hindering their learning in fieldwork education were consistent with those found in the literature review. This finding suggests a basic FWE profile that is conducive to learning. Although many of these personal attributes are inherent to FWEs, some may be able to be cultivated through workshops or seminars aimed at training more effective FWEs. Increasing communication between universities and FWEs and raising awareness of the basic FWE profile will be vital to the successful delivery of future fieldwork education. These findings also suggest a need for the implementation of more standardized competencies for FWEs.
Students cited team members (exclusive of the FWE), including interdisciplinary team members, managers, and support personnel, as important influences on learning during fieldwork. Therefore, fieldwork coordinators and FWEs must be conscious of the team in which the student will be immersed. Students are not simply learning about diagnoses, documentation, and client interventions while on site; they are also learning valuable skills relating to teamwork, professional communication, and ethics. Learning is a team approach, and fieldwork sites with teams that are welcoming and supportive of student learning should be targeted as preferential fieldwork sites.
The fact that students identified themselves as facilitators of or barriers to their own learning was unexpected. Both overconfidence and underconfidence were cited as barriers to learning. Fieldwork is when students get to put their knowledge into action. It offers plenty of opportunities for students to gradually develop a sense of confidence and mastery with regard to clinical knowledge and skills. FWEs must be actively involved in the process by providing students with the “just-right” challenges that help them to develop confidence and a sense of mastery. Overconfidence, however, may jeopardize client safety. FWEs should be able to identify students who do not recognize their own limitations and be actively involved in the process of helping students gain the necessary knowledge and skills required to practice in a safe and proficient manner.
The studies reviewed in the literature search did not identify a personal workspace and access to resources during fieldwork as important factors. In an age in which practitioners frequently use computers and technology for documentation and provision of better client care (evidence-based practice), access to these resources will become increasingly important for students completing fieldwork education. Fieldwork sites would do well to create a space for students to complete documentation and research projects and provide them with access to services such as a wireless network to help them meet their learning objectives.
Regular and constructive feedback was a strong theme in survey responses, with nearly all students mentioning its importance in fieldwork education. Regular feedback requires a collaborative effort between the FWE and the student. Though providing regular feedback can be time-consuming, its importance in the fieldwork education process should not be underestimated. Heavy workloads often prevent regular face-to-face meetings between FWEs and students. Email and alternative modes of communication may be necessary in some instances to provide students with the essential feedback they require to maximize their learning experience. Regular feedback demands the participation of actively engaged and dedicated FWEs who are committed to successful student learning outcomes.
Students preferred FWEs who approached their role in fieldwork education as that of a facilitator, mentor, and collaborator rather than that of a supervisor. Again, these study findings reflect current and emerging education research, which suggests that collaborative education is more effective in facilitating learning than traditional supervisory education. Students also preferred nontraditional fieldwork education models (one student paired with two or more FWEs; multiple students paired with one FWE). Not only were these models preferred by students, but they could also help resolve the many frustrations encountered by students and fieldwork coordinators because of the limited availability of fieldwork sites. Canadian students in particular mentioned the lack of fieldwork site availability as a significant barrier in fieldwork education. In Canada, access to private health care facilities is limited because of Canada’s socialized health care system, thus restricting the number of fieldwork sites to a greater degree than in the United States. Students must often travel great distances, or temporarily relocate to another province, to complete required fieldwork. Remarkably, no other significant differences in student responses were found between Canadian and U.S. students. Nontraditional fieldwork education models could help resolve or minimize fieldwork site shortages by allowing multiple students to be paired with one FWE. These emerging fieldwork education models, therefore, should be strongly considered in the future design and implementation of fieldwork education.
The importance of understanding how each student learns best cannot be overemphasized. Although learning styles inventories are frequently used in both classroom and fieldwork settings, they do not capture the individualistic and dynamic nature of the student learning process. As illustrated in Figure 2, learning can occur in a variety of combinations of sequential steps. It is not sufficient for an FWE to simply present material in a visual manner to a student who identifies him- or herself as a visual learner. True learning occurs through a combination of sequential steps (e.g., material is presented visually, then discussed, and then put into practice). Understanding the individual learning process that works best for each student is critical to maximizing learning outcomes in fieldwork education. Again, collaboration and open communication between the FWE and the student is vital to this process.
The student survey responses clearly reflect that the process of learning is highly individual and dynamic and is influenced by numerous factors. Figure 3 highlights the dynamic relationship between the key factors influencing learning in occupational therapy fieldwork education identified by Canadian and U.S. students. Further research exploring student perspectives regarding learning in fieldwork education is necessary to better inform the future design and implementation of fieldwork education.
Key factors influencing learning in fieldwork education.
Study Limitations and Strengths
This study included Canadian and U.S. students who participated in occupational therapy fieldwork education at different levels. The characteristics that make learning experiences beneficial may vary at each fieldwork level. Therefore, future research should aim to identify more specifically those characteristics that facilitate and hinder learning at each level. The student response rate at the four schools that participated in the study was limited. Despite this, data saturation was reached. Student responses were consistent, even between Canadian and U.S. students. The inclusion of multiple university programs and international student perspectives increases the generalizability of these research findings.
Implications for Occupational Therapy Education
The results of this study have the following implications for occupational therapy education:
The inclusion of student perspectives in occupational therapy education reform is vital to future student learning outcomes.
Fieldwork experiences are a critical component of occupational therapy education and prepare students with the necessary skills and knowledge required to be competent and confident entry-level clinicians.
Student learning in fieldwork education is a highly individual and dynamic process, influenced by individual, environmental, educational, and institutional factors.
Conclusion
Findings from this study suggest that learning in fieldwork education is a highly individual and dynamic process, influenced by numerous factors. This study generated new information that has the potential to have a positive impact on future student learning outcomes in occupational therapy fieldwork education. Future design and implementation of fieldwork education will require a collaborative effort between all stakeholders, including students, to adapt to the evolving needs of students and of the profession. Further high-quality research exploring the learning experience of occupational therapy students in fieldwork education is therefore warranted. Future research should aim to identify more specifically the factors that facilitate and hinder learning at each fieldwork education level. In addition, future research should develop frameworks and models to help guide learning-centered fieldwork education in the field of occupational therapy.