Abstract
Keywords
Pediatric occupational therapy practitioners have historically valued the involvement of parents in assessment and intervention (Hanna & Rodger, 2002; Øien, Fallang, & Østensjø, 2010). However, some practitioners find it difficult to adopt a family-centered perspective, which is inclusive of parents’ goals and desires for their children (Hanft, Shepherd, & Read, 2012). Shared decision making between the practitioner and the parent is evident in practice settings such as early intervention and the school systems and is further supported by federal legislation in these two contexts (Hanna & Rodger, 2002). However, collaboration between parents and practitioners in other practice settings, specifically rehabilitation, is also needed (Øien et al., 2010; Wiart, Ray, Darrah, & Magill-Evans, 2010).
Simulation experiences may be used to teach collaboration skills to occupational therapy students. Simulation experiences are often well received by students and are being adopted more and more by occupational therapy education programs (Bethea, Castillo, & Harvison, 2014; Giles, Carson, Breland, Coker-Bolt, & Bowman, 2014). However, there is a lack of literature related to using simulation experiences in pediatric occupational therapy courses. Preservice educational experiences that emphasize therapist–parent collaboration may help ensure that practitioners are meeting the occupational needs of children and families. This article describes a standardized parent experience that was included in a master’s-level occupational therapy program and the outcomes associated with the experience (i.e., the perspectives gained from the occupational therapy students about the assignment).
Instructors who value constructivism believe that learning takes place when students actively engage in, reflect on, and attach meaning to experiences (Merriam & Bierema, 2014). Each experience that a student encounters has the opportunity to cause a shift in his or her cognitive schemes, or the way in which he or she mentally organizes and uses information (Rutherford-Hemming, 2012). Transformative learning theory is based on constructivism and presupposes that learning takes place after a person has the opportunity to examine his or her own practice or behaviors in light of new experiences (Cranton, 2006). Intense experiences or events are used by the instructor as catalysts that cause students to reflect on their habits of mind, or their personal beliefs and well-established ways of viewing the world and making judgments (Cranton, 2006). Patient simulations are an example of one such experience that has the potential to ignite this reflection and, ultimately, a shift in thinking (Giles et al., 2014).
Occupational therapy students are novices and are often in the early phases of reflective judgment. Sometimes these students, like other novices, readily assume the role of “expert” and discount parents’ insights regarding their children’s strengths and rehabilitation potential. The adoption of a family-focused model, or one in which professionals collaborate with families to mutually agree on the child’s needs, can be challenging (Hanft et al., 2012). Such partnership models require professionals to ensure that families are well informed while supporting them to make decisions (Hanft et al., 2012). Framing the family as equal team members is easier said than done in practice and often requires a shift in thinking. This shift may happen more efficiently and effectively if students are given an opportunity to practice and develop these new habits of mind during their training programs.
Health profession education programs are becoming increasingly reliant on patient simulation experiences to integrate students’ knowledge and skills into practice (Cant & Cooper, 2010). These experiences offer students the opportunity to practice new skills; work toward competence in a safe, low-stakes environment (Cant & Cooper, 2010); and potentially establish new habits of mind. The use of patient simulation is supported by various adult learning theories and often viewed as the gold standard in terms of allowing students to demonstrate their clinical reasoning before entering the field (Rutherford-Hemming, 2012). Therefore, students may benefit from opportunities to trade the abstract principles acquired through textbooks and didactic practices for a collection of insights gained through experiences.
In occupational therapy education programs, the primary method of patient simulation includes the use of standardized patients (Bethea et al., 2014). Typically, standardized patients are actors who are trained to adopt the persona of a person with a certain medical condition or disability or are people with a medical condition or disability who are trained to present their case story and medical history in a standardized way (Liu, Schneider, & Miyazaki, 1997). There is a paucity of research in the field of occupational therapy that addresses how patient simulation can be used to enhance training in pediatrics.
To provide an opportunity for occupational therapy students to gain an awareness of the complexities involved in collaborating with parents in a rehabilitation setting, the instructor (author Cahill) developed a standardized parent experience that was embedded into a pediatric practice course. The focus of the course was on the application of occupational therapy evaluation and intervention techniques with infants and children with a variety of diagnoses (e.g., cognitive, physical, social–emotional, developmental, and acquired) and across different settings (e.g., early intervention, school systems, rehabilitation, outpatient clinics). The occupational therapy students take this course in the 2nd year of their 27-mo curriculum.
The impetus for including a parent simulation experience in the pediatric practice course came from formal and informal course evaluations and discussions with other occupational therapy program faculty members who were using patient simulation in their classes (i.e., adult rehabilitation and psychosocial groups). Initially, the instructor hoped to design a patient simulation experience using standardized child patients; however, the literature has questioned the reliability of child actors for this purpose (Hubal, Deterding, Frank, Schwetzke, & Kizakevich, 2003). Therefore, a simulation experience that used standardized adult actors was developed. The context for the experience was based on course evaluations and a review of the assignments and experiences included in the pediatric course sequence, which were, at the time, heavily focused on early intervention, school systems practice, and outpatient clinics. Consequently, it was determined that the occupational therapy students would benefit from a simulation experience that took place in a pediatric rehabilitation setting.
Two scenarios from Cases in Pediatric Occupational Therapy: Assessment and Intervention (Cahill & Bowyer, 2015) were used as the foundation for the standardized parent experience. Each case was modified so that the occupational therapy students were provided with basic background information, similar to information in a medical chart, about a child who had experienced a traumatic injury (i.e., either a spinal cord injury or a brain injury). After the cases were modified, the instructor met with the adult actors from the university’s simulation center to plan out logistics of the experience. The instructor also participated in two training sessions for the standardized actors so they could learn the specifics of each of the cases. Finally, the instructor presented the occupational therapy students with information related to the standardized parent experience and the specifics associated with the corresponding reflection assignment.
Students were informed that they would be randomly assigned one of the two cases and that they were to prepare for both of them. The use of two cases and the random assignment was done in an effort to simulate practice on a pediatric rehabilitation unit, where practitioners need to be prepared to treat whomever is on the unit. Students were made aware that they would be responsible for completing a chart review, locating and reviewing information identified in the chart review before the interview, conducting a 15-min interview with a standardized parent (i.e., actor) using the Canadian Occupational Performance Measure (Law et al., 2005) as a guide, and reviewing a videotape of themselves performing the interview.
During the interview, students focused on establishing at least one collaborative intervention goal with the parent and offering a recommendation associated with this goal. In addition, students learned that they would also receive feedback regarding their interpersonal skills from the standardized parents and feedback related to occupational therapy knowledge and skills from their instructor. To receive a grade for the standardized parent experience, the students were asked to review the videotape of their experience and the feedback from the standardized parents and the instructor in class and then complete a reflection paper. The questions that guided the reflection paper are included in Figure 1.
Reflection paper questions.
Method
Outcome data were collected to better understand the master’s-level occupational therapy students’ perspectives regarding the standardized parent experience. The data were collected after approval was received from the university’s institutional review board.
Focus groups and reflection papers served as the means for collecting the outcome data. A semistructured interview guide was used to structure the focus groups (Figure 2). Focus groups were selected as a method of data collection because meanings and perceptions are often constructed on the basis of discussions among multiple people (Creswell, 2007). Participation in the focus groups was voluntary. The focus groups took place in a private conference room on campus and were audiorecorded and transcribed verbatim. A document review of the students’ reflection papers (see Figure 1 for reflection prompts) was also conducted in an attempt to gain varied viewpoints, particularly from students who did not want to attend the focus groups.
Focus group questions.
Participants
Occupational therapy students from two cohorts (44 students per cohort) in 2 successive years were invited to share their perspectives once they received their final grades for the pediatric practice course. At the time they offered their perspectives, the students were currently enrolled in the occupational therapy program and in the process of studying for midterm exams. The focus groups took place between 4 and 5 wk after the pediatric class ended. Nine students volunteered to participate in a total of three focus groups (i.e., 3 participants in each group), and 12 students gave consent for their reflection papers to be included in the analysis. Students were assigned to focus groups according to their availability.
Analysis
When all the data were collected, they were analyzed using a three-step process that involved (1) data reduction (which includes the coding process), (2) data display (i.e., organization of the data in a systematic way that allows the investigator to begin to draw conclusions), and (3) conclusion drawing and verification (Miles & Huberman, 1994). The analysis process started with line-by-line open coding. Transcripts from the focus groups and reflection papers were reviewed one at a time, and key quotes from each type of document were grouped together in data displays by related concepts. Initially, the instructor coded the first transcript for main themes. The themes and corresponding quotes were entered into a data display. Then, the instructor further reduced the data and refined the themes. Next, the instructor reviewed the second transcript for general themes.
After the second transcript was completed, the instructor reviewed it for the initial themes found in the first transcript. Key quotes from the second transcript were added to the data display, and the first transcript was recoded line by line for the new themes that were identified in the second transcript. This process continued for the third transcript. The same process that was used for the focus group transcripts was used for the 12 reflection papers.
When all of the data were coded, the instructor analyzed the initial themes separately and then compared them across documents. The themes were further refined using axial coding. Field notes were also examined, and the influence of the group process was interpreted.
Results
Two main themes emerged regarding the occupational therapy students’ perspectives related to the standardized parent assignment. The themes were It felt real and It helped me to think deeper.
It Felt Real
The occupational therapy students discussed how the standardized parent experience was realistic and helpful in terms of assisting them to gain a sense of what practice is “really like”:
I feel like the experience was . . . a snapshot of what [practice] is really like. So if I hadn’t had it, and say I was on a fieldwork and [my fieldwork supervisor said] “you are going to go talk to this parent,” . . . I would not be sure exactly what to say or where to start. It was a big skill builder for me. Now I know how to prepare for something like [a parent interview], and I feel like I could apply that to pretty much any other setting.
The students repeatedly described the standardized parent experience as being close to what happens outside of school:
It’s helpful anytime you can incorporate something that is not so “classroom” or “textbook.” Even though some of those things are based on real kids, it keeps us in the little school bubble, and then we aren’t in contact with the real stuff that is happening out there.
The students repeatedly discussed the importance of using a standardized parent with whom they were not familiar:
I think that putting us face to face with an actual person that we don’t know, that’s not part of this program, and that we never met before and having her act as a parent put us more in a realistic situation . . . like one we will find ourselves in in the future. I just think there are too many interpersonal dynamics that are happening if it is someone that we really know [like an instructor]. Because at that point, it would just be role-playing, and I’m not a fan of role plays.
It Helped Me to Think Deeper
Students talked about how the specific case scenarios combined with the time they spent with the standardized parent changed how they thought about collaborating with a parent. They repeatedly described the need for prioritization and positively framing a child’s strengths:
It has been overwhelming for me in the past to imagine reading a chart like this child’s and then think about speaking with a parent at such a sensitive time. But that is the reality of the work that we do as occupational therapists. After completing this assignment, I feel more at ease and confident in my ability to prioritize and synthesize information. It helped me to think deeper into how I can frame strengths and needs in a positive light while still being empathetic and caring when speaking with a parent seeking occupational therapy services for their child.
Students also repeatedly described the need to think about the parents’ perspective and to approach parents empathetically:
Working with a kid and working with a parent are totally different. We learned about the client constellation. This [experience] was so helpful in realizing that how you act with the child is so different from how you act with the parent. The parent is going through something totally different than the child, especially in this case because they are just starting with their child’s diagnosis. I never really thought about it before. I’m going to be going into someone’s life for the first time after something tragic. It might be so hard to meet someone who has just experienced such a significant life change. What I say to the parent that first time and how I say it is really important.
Students repeatedly described how they had to think about working together with the standardized parent:
When I asked [the parent] questions, I feel like her responses actually limited me. I had things I could see us working on, and she just wouldn’t bite on any of them. I had to think about being collaborative. She has an idea in her head of what she wants me to be coming in and doing. I had my own ideas, too. It really forced me to collaborate with her . . . to work together. I wanted to work on play or something, but she was way more concerned with going back to school. I think that would happen in real life all the time.
Finally, students repeatedly described the need to view the parent as an expert:
I was going into it probably a little overconfident. I went in on this pedestal, like I’m the great OT. The parent is actually probably the real expert on her child. That is more realistic, and I’m glad I had this [experience] before going into my first real experience and completely stumbling.
Discussion
Occupational therapy practitioners working in pediatric settings value family-focused models of practice, which provide authentic opportunities for collaboration between themselves and the parents of their clients (Hanft et al., 2012). Therapist–parent collaboration can be difficult to teach, despite being a well-entrenched value of many pediatric rehabilitation professionals (Øien et al., 2010). A standardized parent experience was developed to provide occupational therapy students with an opportunity to gain an awareness of the complexities involved in collaborating with parents in a rehabilitation setting.
The results from this study suggest that these occupational therapy students value the use of standardized parents to practice interview skills and collaborative goal setting. Participants described how the standardized parent assignment helped them gain a better understanding of what they would typically encounter during regular practice. They also described how this experience helped them try out new skills before they were required to perform them during fieldwork. These findings are consistent with the literature as occupational therapy education programs are increasingly integrating patient simulation (including standardized patient) experiences into the curriculum to allow students to practice skills in safe, low-stakes environments (Bethea et al., 2014; Giles et al., 2014). Moreover, the students emphasized the value of using actors with whom they were unfamiliar. The use of unfamiliar people, compared with role-playing with an instructor, speaks to the value of simulation experiences that are as authentic as possible (Giles et al., 2014).
Participants also stated that this standardized parent experience caused them to think more deeply about working with parents. For example, they commented on the need to be empathetic, present the children’s strengths, focus on collaboration, and view the parent as the expert on the child. It is possible that this standardized parent experience afforded the students an opportunity to shift their thinking and led to the development of new habits of mind. Student feedback from similar experiences in the literature supports this finding and suggests that the use of simulated encounters can activate transformation (Giles et al., 2014).
Implications for Occupational Therapy Education
Occupational therapy educators are charged with preparing occupational therapy students for success in fieldwork and entry-level practice (Giles et al., 2014). Many occupational therapy educators seek to create learning experiences for students to actively engage in, reflect on, and attach meaning to occupational therapy practice. Occupational therapy educators who adopt such a constructivist view (Merriam & Bierema, 2014) may benefit their students by designing patient simulation experiences. Moreover, occupational therapy educators who teach pediatric content should consider framing the use of simulation as a means to expose occupational therapy students to the complexities associated with effectively collaborating with parents and other caregivers.
The results of this study have the following implications for occupational therapy education:
Intense standardized parent experiences, such as the one described in this study, allow occupational therapy students to understand the viewpoints held by parents about their children when establishing rehabilitation goals and developing intervention plans.
Standardized parent experiences may also help students reflect on and ultimately adopt a family-focused model (Hanft et al., 2012) when providing services to children in various practice arenas.
The use of a standardized parent experience appears to be useful, at least to some extent, in providing occupational therapy students with an opportunity to practice and reflect on the way they might collaborate with parents in a pediatric rehabilitation setting.
Because it is challenging to guarantee standardized experiences using child actors (Hubal et al., 2003), occupational therapy educators should consider the use of adult actors who assume the role of clients’ parents.
Occupational therapy educators should continue to research the use of actors to address the unique concerns of various patient populations in different practice settings.
Limitations
This study has several limitations. First, the outcomes associated with this pedagogical approach were collected and analyzed solely by the instructor (the author) who developed the standardized parent experience. Second, the instructor attempted to address the power dynamic in the instructor–student relationship by offering focus group participation after the students’ last pediatric class, which was the last class for each cohort taught by the instructor in the curriculum sequence. In addition, recruitment for the focus groups did not take place until after the students’ final pediatric course grades were posted and they had begun a new quarter. Despite these efforts, it is possible that some students were hesitant to participate in the focus groups because of their relationship with the instructor. Such hesitation may have limited the number of focus group volunteers. Moreover, the existing relationship between the instructor and the students could have influenced the students’ level of comfort and their willingness to be completely open during the focus groups. Third, focus groups typically include more than the 3 participants per group in this study. Therefore, interviews may have provided more robust perspectives.
Fourth, two standardized parent cases were used in this study, and efforts were made to ensure that all the students, regardless of the case to which they were assigned, had a consistent experience. For example, both cases were set in a pediatric rehabilitation unit, and both involved a child who had experienced a traumatic injury. However, it is possible that students may have perceived one case to be more difficult than the other. These perceptions could have influenced how they prepared for the cases and ultimately how they interacted with the standardized parent.
Finally, the use of focus groups may not have facilitated prolonged participant engagement, thus potentially affecting the quality of data. More research is needed to determine whether the use of focus groups and document review are adequate for studying students’ perspectives related to assignments. Research is also needed to determine whether standardized parent experiences are effective in other occupational therapy programs.