‘You actually see what occupational therapists do in real life’: Outcomes and critical features of first-year practice education placements

Abstract

Introduction

First-year practice education placements have numerous benefits for occupational therapy students but are resource intensive. In considering alternatives, it is critical to consider students’ voices to ensure that planned experiences enable students to achieve the outcomes they value and need. This study examined undergraduate occupational therapy students’ views about important outcomes and characteristics of first-year placements.

Methods

Focus groups were conducted with 18 occupational therapy students and analysed using constant comparative analysis.

Findings

Two overarching outcomes were valued: confirmation of occupational therapy as a career choice and experience to draw on for future learning and practice. These outcomes were achievable through four proximal outcomes: understanding occupational therapy; understanding clients; finding out about myself and developing skills. The extent to which the valued outcomes were attained was determined by eight critical experiences: observing an occupational therapist in action; seeing real clients with real issues; seeing positive impact; seeing the bigger picture; accessing the occupational therapist’s reasoning; hands-on doing; getting feedback on skills and thinking analytically/reflectively.

Conclusion

In designing first-year placements, practice educators and academics need to ensure that students are provided with experiences that incorporate reality, participation and making connections to a bigger picture of occupational therapy service provision.

Keywords

Clinical education students health occupations occupational therapy qualitative studies practice education curriculum

Introduction and literature review

Quality practice education placements (also referred to as fieldwork) are an essential component of any occupational therapy pre-registration degree. Placements are where “students get to do in context” (Haynes, 2011: 258), learning to think and act like the allied health professionals they aspire to be. Placements provide opportunities for students to observe how theory is implemented in practice, to participate in occupation-centred practice and to practice specific occupational therapy skills (Johnson et al., 2006; Lalor et al., 2019). They support the development of professional identity and generic work readiness skills (Gibson et al., 2019; Haynes, 2011; Mulholland and Hall, 2013).

The timing and duration of placements across occupational therapy degrees varies according to each country’s interpretation of the international World Federation of Occupational Therapists (2016) minimum educational standards, their own member association standards and/or university requirements. For example, the Royal College of Occupational Therapists (2019) standards require a “logical progression and structure to practice-based learning” (39), with sufficient hours to ensure integration of theory into practice. Similarly, the Occupational Therapy Council of Australia (2018) stipulates that the duration and quantity of practice education experiences are sufficient to ensure competent graduates. With this degree of international and national flexibility, it is not uncommon to find short-duration placements of between one and four weeks scheduled in the first or second year of undergraduate (UG) or first year of graduate entry master (GEM) programmes (Gustafsson et al., 2017; Mulholland and Derdall, 2007). In Australia, for example, in 2017, 19 of the 21 programmes scheduled placements in the first year of the GEM and first 2 years of the UG programme, with about 50% of these categorised as using an observational placement model (Gustafsson et al., 2017).

Generally, the first placement is rated positively by students and practice educators alike (Brown et al., 2011; Hall et al., 2012). These placements are thought to be important in assisting students to ground their academic learning in the ‘real-world’ context, enabling transfer of understanding of the context back to the classroom and improving motivation to learn (Haynes, 2011; Mulholland and Derdall, 2007). Students have gained a deeper understanding of the diversity and complexity of the occupational therapist’s role, what it means to be a health professional and the importance of teamwork (Mulholland and Hall, 2013), or experienced significant personal growth through the challenging of preconceptions in an inpatient mental health setting (Beltran et al., 2007). Unsurprisingly, this first placement may also lead to affirmation of occupational therapy as the right career choice (Boehm et al., 2017).

Despite the potential value of early placements, their sustainability is currently being called into question. Health service budget cuts, staffing shortages (Roberts et al., 2015) and service delivery changes threaten the number of placements that can be offered, at a time when numbers of programmes and student cohort sizes are increasing (Gustafsson et al., 2017). The resources needed to source, prepare and support students and educators in short placements are akin to that of the longer placements, yet placement providers often do not see early-year students as adding value to services and the effort required to support their learning may be considered burdensome (Ingwersen et al., 2017).

These findings are important to consider in the context of any major curriculum review. While the issue of sustainability needs to be addressed, research to inform any decisions is somewhat fragmented. Few studies focus specifically on first-year placements and those that do often investigate specific questions such as students comparing their ‘actual’ with their preferred practice education environment (Brown et al., 2011) or whether including a structured tutorial component in a first-year mental health placement positively influenced students’ attitudes (Beltran et al., 2007). Studies looking at students’ experiences of placement tend to use quantitative analysis of written questionnaires (for example, Brown et al., 2011; Mulholland and Hall, 2013) rather than qualitative methods designed to elicit in-depth and contextualised experiences. Most report GEM students’ experiences (for example, Bagatell et al., 2013; Haynes, 2011), which may well differ from those of UGs, who have less work and life experience from which to draw. The student perspective is an important aspect of determining the value and critical features of practice placement (Brown et al., 2011). Yet only one study within the last 20 years (Mulholland and Derdall, 2007) was located that focused on understanding student experiences of the strengths and challenges of first-year placements. This was a primarily quantitative analysis of written survey data from GEM students. Missing from the literature is an in-depth understanding of UG students’ perspectives on the potential benefits of first-year placements and how these benefits can be achieved.

The aim of this study was to address this gap by examining undergraduate occupational therapy students’ perspectives of what they gained from their first-year placements and which aspects of these placements were important to them. Unlike other studies, retrospective accounts were collected to enable students to view their first-year experience and its impacts with the hindsight provided by later study and placements.

Method

We conducted a qualitative thematic analysis of focus group data, using analysis techniques drawn from grounded theory (Glaser, 1978). A qualitative approach was required to enable an in-depth understanding of students’ experiences of first-year placement (Glaser and Strauss, 1969). While this exploratory study did not set out to develop a full theory, some of the techniques of grounded theory – constant comparative analysis and concurrent data collection and analysis – were used to ensure a rigorous analysis and to develop a conceptual framework to explain students’ experiences of their first-year placements. Ethical approval was obtained from the Human Research Ethics Committee at the University of Sydney, Australia (Reference no: 2015/825).

Context

This study was conducted within the undergraduate programme of an Australian university. The programme includes a one-week placement in the second semester of the student’s first year. The placement is embedded in a one-semester unit of study that teaches professional practice skills and builds on first semester units that introduce occupational therapy theory and models, occupational analysis and interviewing skills.

Sampling and recruitment

The practice education administrator sent an email invitation to all undergraduate occupational therapy students who had completed a first-year practice education placement. This totalled approximately 300 students. By including all year groups, we hoped to draw participants with a wide variety of experiences, from those whose first-year placement experiences were recent to those who were able to look back on their first placement from the perspective of having completed subsequent study and placements. Students were invited to provide contact details if they were interested in participating as well as brief information about themselves and their first-year placement (year cohort; overall rating of first-year placement (excellent, good, okay, not good/bad); placement site). All students who volunteered in the initial round of recruitment were included in the study. Written informed consent was gained from all participants. After the last focus group from this round had been analysed it was clear that no new codes were emerging, and existing codes were well filled out, indicating that the sample size was sufficient. Therefore, while further recruitment strategies were available, it was determined that no further recruitment was required.

Data collection

Focus groups were identified as the data collection method of choice. These are appropriate for gaining insight into shared issues and experiences where the relevant variables are unclear (Barbour, 2007). The opportunity for interactions between group members has benefits such as: generating new insights and jogging participants’ memories by sharing and comparing experiences; encouraging the use of participants’ own language and concepts; facilitating meaning-making through common experiences and optimising participants’ comfort and willingness to share (Barbour, 2007). While focus groups often contain 6–10 members, fewer are required when participants are invested in a topic and are likely to have a lot to say (Barbour, 2007; Morgan and Scannell, 1998), as was the case in this research. We therefore aimed for focus groups of 3–4 students to ensure that each student had sufficient time and opportunity to contribute their own perspectives (Kitzinger, 1995; Krueger, 2000). Participants were split by year cohort to ensure that group members had had similar experiences with academic preparation and placement systems. In addition, being familiar with each other was considered to be of benefit for participant comfort (Barbour, 2007). In reality, fitting focus groups in with students’ academic and personal commitments and preferences resulted in two interviews being conducted with only two participants and one student being interviewed alone at her request. While group, pair and individual formats may result in different data being collected, this is not problematic within a grounded theory framework where identification of a wide variety of concepts is desired and gaining the same data from each participant is not necessary (Glaser and Strauss, 1969).

Data collection was conducted on campus by the first author, an experienced qualitative researcher known to students through teaching, but with no involvement in placement education, which is run by a separate unit at the faculty. Participant comfort was paramount and both the existing rapport between the interviewer and potential participants and their shared contextual knowledge were considered to outweigh theoretical concerns about power inequality between staff and students. Students understood that the focus of the study was on placement suitability, not student performance, and were assured that their choice to participate could have no impact on their future opportunities within the university. A total of seven focus groups/ interviews were conducted with 18 students in December 2015 and March 2016.

Students were asked a series of questions designed to generate discussion. These were organised around anticipating (for example, what were you hoping to get from your first-year placement?), experiencing (for example, what did you find most valuable about your first-year placement?) and reflecting (for example, what are the critical things that students most need from their first-year placement?). The facilitator allowed participants to discuss what was important to them, and asked additional questions to clarify, probe for further detail and ensure each participant was included in the discussion. Each focus group or interview lasted for around 1 hour. They were audio-recorded with participants’ permission and transcribed verbatim (with identifying details removed) for detailed analysis.

Data analysis

Data were analysed using constant comparative analysis, a systematic approach to inductive coding commonly associated with the grounded theory method (Glaser, 1978). Each incident or chunk of data (such as a phrase or sentence) was examined and allocated one or more codes. These codes were inductively derived to identify the underlying concepts within the data. For example, the statement ‘in my [evaluation], my supervisor really gave me what I should work on for my next placement’ was coded as ‘learning what I need to improve’. Each additional incident was compared to existing data and codes to identify conceptual similarities and differences, allowing for codes to be refined. Comparing codes to each other allowed them to be grouped into higher-level categories, and the relationships between them to be explored (Glaser and Strauss, 1969). For example, the code ‘learning what I need to improve’ was grouped with other codes such as ‘finding out what work I enjoy’ into the higher-level code ‘finding out about myself’. Coding was carried out by the first author using NVivo 11 software (QSR International, 2018) and discussed throughout the process with both the second author, an academic with responsibility for clinical placements, and other academic staff. A summary of findings was sent to participants and feedback was welcomed. Two participants responded, both indicating agreement with the findings, which one described as ‘very insightful’.

Participants

Eighteen students took part in this study. Their characteristics, and those of their first-year placements, are summarised in Table 1.

Table 1.

Participants.

Focus group/interview	1	2	3	4	5	6	7	Total
Number of participants	3	3	4	2	3	2	1	18
Cohort year	4	3	2	2	1	1	1
Total participants in each cohort	3	3	6		6			18
Gender
Female	3	1	4	2	3	2	1	16
Male	0	2	0	0	0	0	0	2
Enrolment
Domestic	3	3	4	2	2	2	0	16
International	0	0	0	0	1	0	1	2
Overall rating of first-year placement
Excellent			2	1	1	1		5
Good	1	2	2	1	1	1	1	9
OK	1	1						2
Not good/bad								0
No response	1				1			2
Placement type
Hospital – acute	2	2	1		1			6
Hospital – rehabilitation	1	1	1	1	1	1		6
Community			1	1	1			3
Combination			1			1	1	3
Placement location
Sydney	3	2	1	2	2	1	1	12
Central Coast			2			1		3
Rural NSW		1	1		1			3

In the following section, students are identified by pseudonym and year cohort.

Findings

Analysis of the data revealed two types of outcomes valued by students. The broad, overarching outcomes – confirmation of occupational therapy as a career choice, and experience to draw on for future learning and practice – were achievable through realising a combination of the proximal, more specific outcomes of: understanding occupational therapy; understanding clients; finding out about myself; and developing skills. Interestingly, senior students talked about not appreciating some of these outcomes until they were further along in their degree, as Phoebe (year 3) explained:

It keeps changing you. It doesn’t change you at the time, because you’re too busy, caught up in meeting the requirements of it, but like, it still is changing me … I still think back and reflect on that [first-year placement], being like, ‘oh if I was a supervisor’, or ‘when I am out practising…’

The extent to which students attained the valued outcomes was determined by their access to eight critical experiences on their placements: observing an occupational therapist in action; seeing real clients with real issues; seeing positive impact; seeing the bigger picture; accessing the occupational therapist’s reasoning; hands-on doing; getting feedback on skills and thinking analytically/reflectively. Figure 1 depicts the relationships between categories.

Figure 1.

Valued outcomes and critical experiences framework.

Overarching valued outcomes

Participants reported two broad outcomes that were ultimately the core of what they wanted and valued from their first-year clinical placement.

First, for many students the most essential outcome was confirmation that they did actually want to be occupational therapists and were therefore on the right course. This validation was seen as important in their first year to enable early exit if it were not the case, and to motivate students for their study. India (year 2), for example, explained that after the placement ‘I can actually see myself in this profession, whereas before I couldn’t’, while Fiona (year 2) said in another focus group that ‘it kind of solidified for me that that’s what I want to do’.

Second, all students valued having experiences of occupational therapy that they could now reflect on to help them in their learning and practice. This was seen as shaping their engagement with their academic work and future placements. Alycia (year 4), for example, said that, when discussing a situation in class, remembering placement ‘gave you something to draw from’. Conversely, Grace (year 2) thought that not getting enough occupational therapy experience in her placement ‘did affect me just during the course work and stuff because I just had no idea’.

Proximal valued outcomes

The two overarching valued outcomes were achievable through realising four more specific proximal outcomes. These are described below and exemplified in Table 2. All students talked about the importance, through first-year placement, of developing their understanding of occupational therapy. This encompassed a range of aspects, the salience of which depended on students’ existing knowledge. These included understanding: what an occupational therapist does; the role of the occupational therapist in the specific setting; the breadth of occupational therapy; the differentiation of occupational therapy from other disciplines; how occupational therapists work with other disciplines; the logistics of working as an occupational therapist; and how academic learning and theory is used in practice.

Table 2.

Example quotes for proximal valued outcomes.

Proximal valued outcome	Example quotes
Understanding occupational therapy	I'd never seen an OT [occupational therapist] do anything. So I still was figuring out what they did … when I got to placement, I was like, okay this is what an occupational therapist does. (Chloe, year 4) I wanted to understand more clearly what the role of OT was in a mental health setting. (Nikki, year 1) It gave me an understanding of how a hospital ran. (Brianne, year 4) I wasn't expecting how much we interacted with the other disciplines. (Elaine, year 2) Just how they manage their time, as well. (Kara, year 1) At the end of the placement I did realise how important the theory is. (Lucinda, year 1) I think taking what you've learnt in those first couple of subjects and really showing you how that gets applied into practice [is important]… whereas I didn't get to see that as much in mine. (Alycia, year 4)
Understanding clients	With strokes, there's so many different ways you can be affected and I had no idea about anything of that, really. (Kara, year 1) You’re dealing with people from all walks of life. (Di, year 2) It's so much more than just like their condition … they each had a different reason or a different factor that would influence them (Nikki, year 1)
Finding out about myself	[I found out that] I can actually do this and I am okay at it – like obviously not amazing but it's doable. (Hannah, year 2) My supervisor really gave me what I should work on for my next placement, what I should think about, what skills I'm good at, which was really encouraging as well, what I need to work on. (Rory, year 3) I didn't think that I'd be able to relate to [elderly clients] or that it was something that I would be interested in … I surprised myself . (India, year 2)
Developing skills	[The most valuable thing I took from placement was] communication, I would say, with real clients, yeah. Being able to show empathy when it's required. (Olivia, year 1) It was not something that I had foreseen that I would have wanted to get out of placement … But then that was something I was really glad to get out of it, like the practice to document. (Martina, year 1) It's something that comes with just experience and when you actually see it, you become better at clinical reasoning over time. (Alycia, year 4) Being able to do interviews and assessments. I think I came away from it feeling pretty confident in my ability to do that. (Grace, year 2)

Students also gained an understanding of clients. This included not only gaining knowledge about conditions, symptoms and their functional implications, but about the uniqueness and complexity of the clients with whom they were working.

Students not only learned about occupational therapy and clients, they also learned about themselves. They discovered their capabilities and found out what they were more and less good at. Placement also often helped students to start to figure out in which areas of occupational therapy they would and would not enjoy working and, through modelling from their practice educator, start to learn what kinds of occupational therapists they wanted to be.

More than just understanding and knowledge, however, most students developed important occupational therapy skills through their first placements. Diverse skills were reported, such as doing initial assessments, observing environments, working under time constraints, communicating with clients and professionals, documentation and clinical reasoning.

Critical experiences

The following eight critical experiences together determined the extent to which students achieved the proximal outcomes and, therefore, the overarching outcomes that they wanted. Most critical experiences contributed to multiple outcomes, as depicted by the arrows in Figure 1. The line below critical experiences in Figure 1 indicates that the critical experiences are not independent, but interdependent. For example, observing an occupational therapist in action and seeing real clients with real issues is often necessary (though not sufficient) for students to see the positive impact of occupational therapy. Table 3 exemplifies each critical experience.

Table 3.

Example quotes for critical experiences.

Critical experience	Example quote
Observing an occupational therapist in action	My one thing is actually seeing OT [occupational therapy] in practice. I enjoyed the doing, but I would put the watching others before the doing. (Chloe, year 4) A role model was really key to understanding what an [occupational therapist] does and what’s really expected. (Hannah, year 2) Taking what you've learnt in those first couple of subjects and really showing you how that gets applied into practice. (Alycia, year 4)
Seeing real clients with real issues	I think [the most valuable thing was] hearing from the patients directly. Real patients, real stories, real experiences. (Brianne, year 4) You can always read the research saying that they are having cognitive problems … But the thing is you can barely imagine how its look like in the patients… I was like ‘oh, so this is what you mean by they're having cognitive problems’. (Jocelyn, year 1) When you're doing a case study in class it's like, Michael has had a stroke and he has left hemiplegia. He's going to have reduced ability to do ADL [activities of daily living] … but then when you actually meet Michael, it's just like, it's a real person. He's really affected by this. (Martina, year 1)
Seeing positive impact	That's the sort of stuff that I think is really important on first year [placement], that goes, ‘yeah OT is making a difference’… I walked out and I was like, ‘[occupational therapists] have a really important job because they have to problem solve around how [getting a client home] can occur’. (Brianne, year 4) It was almost like invalidating. It was like, it doesn't seem like this role is really well regarded. Like, why bother having [an occupational therapist] at all at that hospital? (Quentin, year 3)
Seeing the bigger picture	I think I just needed some sort of structure to fit in. Because I only got a brief snapshot and there was no structure to help me fit that in to what an [occupational therapist] did. (Grace, year 2) I think that left a big impression on me because it made me see the whole story of this one patient … I think it just resonated with me because it just made me realise there's so much outside OT that influences what we do as well. (Chloe, year 4) I was only seeing such a like, like, small piece of the puzzle … I was like – Ok but like, I don't know, I was in the sense of like ‘I'm seeing what you're doing, so what else is there?’ (Di, year 2)
Accessing the occupational therapist’s reasoning	One of the greatest things was to be able to ask all those questions that I asked in my first year … Why did you do this? What was that about? Yeah, so just seeing their justification behind why they did things. (Chloe, year 4) They would just tell me what they were doing. It's like ‘well why are we doing the initial?’ – ‘Because we need to get to know them’. It's like ‘why do we need to get to know them?’ (Grace, year 2)
Hands-on doing	I know for someone like me, who is very practical, let me give it a go, I want to try. Opportunities is probably the [most important feature of the placement]. (Fiona, year 2) When I actually had to do [an interview], I would fumble and make mistakes and realise that, ‘oh, I actually need to do more practice’… that was a really good learning experience. (Kara, year 1) I didn't get to do anything except take down a few notes, but I guess I felt really involved in the process because I was still doing something. I wasn't just observing, and she was talking to me, it was kind of like a collaboration I guess. (Rory, year 3) Just for me as a first-year, I heard about all these people who were like, ‘yeah I did an initial today’. I was like, ‘what? I haven't done anything’. (Alycia, year 4) I feel like I need to have opportunities to then like, apply it … I was with someone that, you know, wouldn't let me dabble in that experiential learning. (Di, year 2)
Getting feedback on skills	If you're only observing, then what feedback can they give you? (Kara, year 1) We don’t know what we’re doing, so any form of ‘that was good’, ‘that was bad’, we’ll leap a mile for that. (Elaine, year 2)
Thinking analytically and reflectively	After each instance that I would do something, she'd say, ‘did you notice something?’ … She would never ask me directly. She would probe to see if I noticed it … Then she would always make me write down notes at the end of every day. What was good and what was bad? (Elaine, year 2) After each session [my supervisor] would [say] I'd like you to write down a few things which you thought you did badly,… some things that you thought you did well, and she was really helpful. (Hannah, year 2) I felt kind of like a puppy following my trainer around … I didn't feel prompted to really question things, or to ask why, or why this, and could we have done that? (Quentin, year 3)

Observing an occupational therapist in action

Almost all students described the crucial importance of seeing a real occupational therapist doing real occupational therapy within a real health care situation. This was seen as the most basic requirement for a valuable first-year placement, upon which many of their other critical experiences hinged. Several students also discussed wanting to see how occupational therapists applied the theory and skills they had learned in their classes in a real-world setting.

Seeing real clients with real issues

It was important for students to have the opportunity to see and interact with real clients. This helped them to understand symptoms and issues that they had learned about in class, but also to understand clients as real, unique and complex individuals.

Seeing positive impact

In order to fully understand occupational therapy, students needed to not only see what occupational therapists did, but the impact and value of that doing for clients and within the organisation. When students could not see this, they questioned their choice of profession.

Seeing the bigger picture

In a one-week placement, most students got to see a relatively small sample of what their supervisor did. It was important, however, for them to understand how what they saw and did fitted into a wider context. This context included the different stages of care; for example, what interventions a patient had received before the placement, what would happen to them after the student left and how what the student saw and did fitted into that trajectory. It also included the broader worlds of occupational therapy (such as how the supervisor’s role is unique or typical compared to other occupational therapy roles) and client care (such as how the occupational therapist’s role fits with other health professions). Students reported feeling disoriented when they could not see how what they saw and did on placement fit within these bigger pictures.

Accessing the occupational therapist’s reasoning

It was important for students not just to see what an occupational therapist did, but to understand their clinical reasoning. This was typically achieved through the occupational therapist explaining their rationale and reasoning processes to the student after an interaction and providing the space for students to ask questions. Students who did not have these opportunities struggled to make the links needed to understand occupational therapy and develop skills.

Hands-on doing

All students felt that having the opportunity to do things themselves, including interacting with clients, was critical for their skill development, confidence and understanding of their own capacities. Students understood that opportunities to do things like initial interviews and specific assessments differed across settings, yet hands-on doing was a broad concept that encapsulated real-world tasks that could be done in most settings, such as: having informal conversations with clients; writing file notes; drafting reports; providing observations and opinions; explaining roles, assessments and interventions to clients and other health professionals; fetching equipment; assisting with transfers; taking measurements and contributing to group sessions. These tasks not only facilitated skill development, but made students feel involved and valued rather than being ‘the shadow in the room with a student badge’ (Phoebe, year 3). Even where hands-on doing was initially scary, no students regretted having these opportunities, and those whose placements were purely observational tended to feel disadvantaged and concerned about being under-skilled.

Getting feedback on skills

One of the learning benefits of hands-on doing was that it enabled the practice educator to provide clear feedback on the student’s performance. This was seen as crucial for learning, skill development, and understanding one’s own strengths and areas for improvement.

Thinking analytically and reflectively

Some students felt that their first placements had enabled them to really begin to think analytically about clients, problems and situations. This was promoted when professional practice educators encouraged them to ask questions, asked them what they thought, and required them to analyse both the client’s performance and their own.

Discussion and implications

The aim of this study was to gain an in-depth understanding of undergraduate occupational therapy students’ experiences of their first-year placements in terms of what they gained and what was important to them. It is the first study in occupational therapy to inductively derive a framework to explain students’ overall experiences with first-year placement, bringing together many issues discussed in diverse quantitative and qualitative studies on related topics. For example, previous studies have described experiences that align with confirmation of occupational therapy as a career choice, gaining experience to draw on for future learning and practice, understanding occupational therapy, developing skills (Boehm et al., 2017; Haynes, 2011; Johnson et al., 2006; Mulholland and Derdall, 2007), understanding clients (Beltran et al., 2007; Mulholland and Derdall, 2007) and finding out about myself (Beltran et al., 2007; Dyck and Forwell, 1997). Similarly, previous studies have mentioned one or more of the eight critical experiences presented in this paper (for example, Beltran et al., 2007; Gibson et al., 2019; Mulholland and Derdall, 2007; Nielsen et al., 2017; Patton et al., 2018). However, the unique contribution of this study is in the development of a conceptual framework that brings these outcomes and experiences together, identifies their relationships and both summarises and encapsulates students’ experiences.

The findings have implications for both practice educators and universities. These relate to facilitating three critical aspect of student experiences: reality, participation and making connections.

Reality

Similar to findings in medicine (Dornan et al., 2007) and physiotherapy (Patton et al., 2018), students in this study valued being embedded in the reality of practice. Seeing real occupational therapists doing real interventions with real clients and achieving real outcomes was deemed critical by the students to achieving valued proximal outcomes, especially understanding the role of occupational therapy and understanding clients. This is perhaps more critical in occupational therapy than in other disciplines such as medicine and physiotherapy, where students are more likely to have been patients or clients of these professionals.

Another important aspect for the students in this study was seeing how the client and/or broader team and organisation valued the contribution of occupational therapy. This is a theme recently identified in a systematic review of allied health practice educators’ skills and qualities and their effect on student learning and patient care (Gibson et al., 2019), yet not represented in the medical (Dornan et al., 2007) or physiotherapy (Patton et al., 2018) models. This difference may relate to the relative profile of the profession and the related challenge that early-year students often have in articulating the role of occupational therapy and establishing their professional identity (Gibson et al., 2019).

Participation

As Brown et al. (2011) found in their large-scale survey, students highly value being included as part of the team, with students feeling less nervous when they are engaged in activities alongside their supervisor. Students in this study also emphasised the benefits of not just watching but being involved and doing things alongside their educators. The tasks they described reflect the level of knowledge and skill of the students, for example engaging in informal conversation with a client, fetching equipment, providing education on how to complete a task, or contributing to a group session. Lave and Wenger (2002: 113) describe this process as ‘legitimate peripheral participation’ whereby a newcomer (or student) enters the periphery of the professional community. At the periphery the new member is ‘observing and performing basic tasks’ (Mann, 2011: 64) and, as with the students in this study, aiming to become a fully participating member in the community’s sociocultural practices (Gibson et al., 2019). Molesworth (2017) describes peripherality as an empowering position for student learning, enabling the student to move along the continuum from non-participation to active participation. However, practice educators who perceive first-year placements to be only observational tend to limit the student’s role to observer. Thus, the student remains marginalised on the edge of the community (Molesworth, 2017) and, for the students in this study, feeling disadvantaged, under-skilled and thus less prepared for subsequent placements.

Being held in the observational role can also hamper the student’s ability to accurately self-appraise their emerging competence as there are limited opportunities for the feedback conversations known to be essential for learning (Ramani et al., 2019). In first-year placements students are learning what they need to do to meet the required standards and developing the skill of evaluative judgement. Molloy and Boud (2013) assert that these capacities are important in health professionals committed to lifelong learning. The educator’s role in this is paramount, both in enabling the doing, articulating the standard and facilitating the feedback conversations that contribute to the students’ perception of their emerging competence (Gibson et al., 2019), as well as assisting students to determine and manage the risks to themselves and the service user.

Making connections

Making connections between learning opportunities in placement and the theory studied is seen as one of the benefits of an early placement (Haynes, 2011). Students in this study saw it as critical to reflect on their experiences, making connections between what they were seeing and doing, and (a) the broader context of occupational therapy and client care; (b) the aims and goals of treatment, via clinical reasoning; (c) their existing knowledge and (d) their past and future selves. The practice educators’s role in facilitating this level of critical thinking through scaffolding the learning experiences is central (Gibson et al., 2019; Patton et al., 2018). Practices identified as necessary for making these connections are provision of timely feedback, consistency of expectations, and open and honest relationships where opportunities to make and learn from mistakes are supported (Gibson et al., 2019). Perhaps most important, as identified in Gibson et al.’s (2019) review, was the educator assisting allied health students to develop a sense of professional identity. This finding was seen as unique to allied health and is supportive of the first overarching valued outcome of this study: confirmation of occupational therapy as a career choice.

Implications for practice and research

Although this study was explorative with a small sample size, there are a number of implications for the profession. Using the framework from this study may assist placement educators to reframe their understanding of what first-year placements can offer and therefore what learning experiences to create for students. The framework encourages educators to move away from predominantly observational placements, to creating opportunities for students to experience reality, participation and connections, all of which appear to be critical for students’ ongoing learning throughout the degree.

For academics, the conceptual framework can contribute to deliberations about first-year placements and their potential alternatives. Acknowledging that, in the current climate, early placements are not always feasible to create, the framework provides insight into the types of learning experiences that will need to be incorporated into the early years of the curriculum if first-year placements are not available. Role-emerging placements provide opportunities for students to develop therapeutic skills and, depending on their design, to work with clients to determine occupational issues and ways of addressing these. However, these placement types do not always provide students with what they appear to seek in first-year placements: a strong understanding of what occupational therapy is, and their progress towards becoming an occupational therapist. How these learning needs can be met effectively is a complex question, yet to be determined. Further research is needed to determine to what extent the valued outcomes can be met through other experiential activities such as combinations of: observing and/or interviewing a number of occupational therapists working with clients combined with reflexive activities in class; simulated clinical placements; and virtual learning environments. Such research would help establish which learning is best achieved in the real environment and which might be achieved through alternatives such as those posed here.

As with all qualitative research, the findings need to be interpreted with due regard to the sample. Students in this study had completed their first-year placement in traditional settings. Their beliefs about the importance of aspects associated with these placements are therefore not based on experience of an alternative model. Recruitment was voluntary, so while the experiences they discussed fit along a spectrum from disappointing, through neutral to ‘brilliant’, the sample may not be reflective of all students, especially those for whom their first-year placement experience was not memorable or influential in their lives. The strengths of the study included its qualitative design, flexible data gathering and systematic analytic methods enabling development of a conceptual framework. The retrospective design allowed students to reflect on the impact of their placements in terms of their subsequent learning and experiences, providing a more nuanced view than may otherwise have been possible.

Conclusion

First-year placements were highly valued by occupational therapy students in this study and have the potential to provide a range of important benefits. Yet not all students achieve these benefits and first-year placements are becoming increasingly difficult to sustain. The findings from this study provide a framework for academics and practice educators to consider, both when designing first-year placements, and when considering or proposing alternatives to existing placement structures.

Key findings

Quality first-year placements support student-valued outcomes and facilitate professional socialisation and future learning.

Learning is enabled when students experience and participate in the real-world of occupational therapy practice.

What the study has added

This study has provided a framework for designing learning experiences that support the development of the student’s sense of self as an emerging occupational therapist.

Footnotes

Acknowledgements

The authors would like to acknowledge the contributions of the students who provided their insights for this paper.

Research ethics

Ethical approval was obtained from the Human Research Ethics Committee at the University of Sydney. Reference no: 2015/825. Year of approval: 2015.

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, authorship, and/or publication of this article: Funding for transcribing was provided by Work Integrated Learning, School of Health Sciences, The University of Sydney. Written informed consent was obtained from all participants.

Contributorship

Anne Honey and Merrolee Penman designed the study. Anne Honey completed interviews and data analysis. Merrolee Penman primarily reviewed the literature. Both authors contributed to findings, interpretation and writing, and approved the submitted version.

ORCID iDs

Anne Honey

Merrolee Penman

References

Bagatell

Lawrence

Schwartz

, et al. (2013) Occupational therapy student experiences and transformations during fieldwork in mental health settings. Occupational Therapy in Mental Health 29(2): 181–196.

Barbour

(2007) Doing Focus Groups. Los Angeles: SAGE.

Beltran

Scanlan

Hancock

, et al. (2007) The effect of first year mental health fieldwork on attitudes of occupational therapy students towards people with mental illness. Australian Occupational Therapy Journal 54(1): 42–48.

Boehm

Cordier

Thomas

, et al. (2017) The first year experience of occupational therapy students at an Australian regional university: Promoting student retention and developing a regional and remote workforce. Australian Journal of Rural Health 25(1): 22–27.

Brown

Williams

McKenna

, et al. (2011) Practice education learning environments: The mismatch between perceived and preferred expectations of undergraduate health science students. Nurse Education Today 31(8): e22–e28.

Dornan

Boshuizen

King

, et al. (2007) Experience-based learning: A model linking the processes and outcomes of medical students’ workplace learning. Medical Education 41(1): 84–91.

Dyck

Forwell

(1997) Occupational therapy students’ first year fieldwork experiences: Discovering the complexity of culture. Canadian Journal of Occupational Therapy 64(3): 185–196.

Gibson

Porter

Anderson

, et al. (2019) Clinical educators’ skills and qualities in allied health: A systematic review. Medical Education 53(5): 432–442.

Glaser

(1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley: The Sociology Press.

10.

Glaser

Strauss

(1969) The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine Publishing Company.

11.

Gustafsson

Brown

McKinstry

, et al. (2017) Practice education: A snapshot from Australian university programmes. Australian Occupational Therapy Journal 64(2): 159–169.

12.

Hall

McFarlane

Mulholland

(2012) Positive clinical placements: Perspectives of students and clinical educators in rehabilitation medicine. International Journal of Therapy and Rehabilitation 19(10): 549–556.

13.

Haynes

(2011) Active participation in Fieldwork Level I: Fieldwork educator and student perceptions. Occupational Therapy in Health Care 25(4): 257–269.

14.

Ingwersen

Lyons

Hitch

(2017) Perceptions of fieldwork in occupational therapy. The Clinical Teacher 14(1): 55–59.

15.

Johnson

Koenig

Piersol

, et al. (2006) Level I fieldwork today: A study of contexts and perceptions. American Journal of Occupational Therapy 60(3): 275–287.

16.

Kitzinger

(1995) Qualitative research: Introducing focus groups. British Medical Journal 311(7000): 299–302.

17.

Krueger

(2000) Focus Groups: A Practical Guide for Applied Research. Thousand Oaks: SAGE.

18.

Lalor

Brown

, et al. (2019) Occupational therapy international undergraduate students’ perspectives on the purpose of practice education and what contributes to successful practice learning experiences. British Journal of Occupational Therapy 82(6): 367–375.

19.

Lave

Wenger

(2002) Legitimate peripheral participation in communities of practice. In: Clarke

Hanson

Harrison

, et al. (eds) Supporting Lifelong Learning. London: Routledge, 111–126.

20.

Mann

(2011) Theoretical perspectives in medical education: Past experience and future possibilities. Medical Education 45(1): 60–68.

21.

Molesworth

(2017) Nursing students’ first placement: Peripherality and marginality within the community of practice. Journal of Nursing Education 56(1): 31–38.

22.

Molloy

Boud

(2013) Seeking a different angle on feedback in clinical education: The learner as seeker, judge and user of performance information. Medical Education 47(3): 227–229.

23.

Morgan

Scannell

(1998) Planning Focus Groups. London: SAGE.

24.

Mulholland

Derdall

(2007) An early fieldwork experience: Student and preceptor perspectives. Canadian Journal of Occupational Therapy 74(3): 161–171.

25.

Mulholland

Hall

(2013) The influence of environment on the fieldwork experience: Exploring interprofessional student perspectives. Work 44(3): 345–354.

26.

Nielsen

Jedlicka

Hanson

, et al. (2017) Student perceptions of non-traditional Level I fieldwork. Journal of Occupational Therapy Education 1(2): 1–23.

27.

Occupational Therapy Council of Australia (2018) Accreditation Standards for Australian Entry-Level Occupational Therapy Education Programs. Perth: Occupational Therapy Council of Australia.

28.

Patton

Higgs

Smith

(2018) Clinical learning spaces: Crucibles for practice development in physiotherapy clinical education. Physiotherapy Theory and Practice 34(8): 589–599.

29.

QSR International (2018) About NVivo. Available at: www.qsrinternational.com/nvivo/home. (accessed 5 February 2018).

30.

Ramani

Könings

Ginsburg

, et al. (2019) Twelve tips to promote a feedback culture with a growth mind-set: Swinging the feedback pendulum from recipes to relationships. Medical Teacher 41(6): 625–631.

31.

Roberts

Hooper

Wood

, et al. (2015) An international systematic mapping review of fieldwork education in occupational therapy. Canadian Journal of Occupational Therapy 82(2): 106–118.

32.

Royal College of Occupational Therapists (2019) Learning and Development Standards for Pre-Registration Education, Revised Edition 2019. London: Royal College of Occupational Therapists.

33.

World Federation of Occupational Therapists (2016) Minimum Standards for the Education of Occupational Therapists Revised 2016. Fitzroy: World Federation of Occupational Therapists.