Intraprofessional Fieldwork Education: Occupational Therapy And Occupational Therapist Assistant Students

Intraprofessional fieldwork education: Occupational therapy and occupational therapist assistant students learning together doi: 10.2182/cjot.06.05. This paper was published in the CJOT Early Electronic Edition, Spring 2006.

Bonny Jung

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Penny Salvatori

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Adele Martin

Key words n

Intraprofessional relationships

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Collaboration

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Occupational therapy education

Mots clés n

Relations intraprofessionnelles

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Collaboration

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Formation en ergothérapie

Abstract Background. In the past 10 years, the use of support personnel in Canada has generated significant interest from occupational therapists, professional associations, regulatory bodies, employers, educational institutions, and government agencies. Purpose. The purpose of this study was to explore the impact of a combined collaborative fieldwork placement and weekly tutorial as a teaching strategy for intraprofessional education. Methods. Seven pairs of student occupational therapists and occupational therapist assistants were assigned to fieldwork placements. Tutorials were scheduled during the placements to discuss intraprofessional issues and provision of occupational therapy services in the clinical setting. Journaling and focus groups were used to collect data from students, tutors, and preceptors. Findings. Three key themes emerged from the data: (1) developing the relationship, (2) understanding roles, and (3) recognizing environmental influences on learning. Implications. Intraprofessional learning experiences prior to graduation can help prepare occupational therapy and occupational therapist assistant students for future collaborative practice.

Résumé Description. Dans les 10 dernières années, l’utilisation du personnel auxiliaire au Canada a suscité un intérêt chez les ergothérapeutes, les associations professionnelles, les organismes de réglementation, les employeurs, les établissements d’enseignement et les organismes gouvernementaux. But. Le but de cette étude était d’examiner les effets d’une stratégie d’enseignement dans le domaine de la formation intraprofessionnelle basée sur un stage fondé sur la collaboration et un cours hebdomadaire. Méthodologie. Sept paires formées d’étudiants en ergothérapie et d’aide-ergothérapeutes ont suivi des stages cliniques. Des cours étaient prévus pendant les stages pour discuter de questions intraprofessionnelles et de la prestation de services d’ergothérapie dans ce milieu clinique. La rédaction d’un journal et des groupes de discussion ont permis de recueillir des données sur les étudiants, les superviseurs de stages et les tuteurs. Résultats. Les données ont permis de mettre trois thèmes en évidence : (1) développer la relation, (2) comprendre les rôles, et (3) reconnaître les influences de l’environnement sur l’apprentissage. Conséquences. Les expériences d’apprentissage intraprofessionnel avant l’obtention du diplôme peuvent préparer les étudiants en ergothérapie et les étudiants aide-ergothérapeutes à collaborer dans l’exercice futur de leur profession. n the past 10 years, the use of occupational therapy support personnel in Canada has generated significant interest from occupational therapists, professional associations, regulatory bodies, employers, educational institutions, and government agencies. Although role delineation, supervision, membership in professional associations, and accreditation of educational programs remain issues that require further clarification and resolution, the use of support personnel is gaining national support as a viable and credible means of providing occupational therapy services (Canadian Association of Occupational Therapists [CAOT], 2003; Ferron, 2000). On behalf of the American Occupational Therapy Association, Yarett Slater and

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Willmarth (2005) reported that occupational therapists (OT) and occupational therapist assistants (OTA) often struggle to understand their roles and describe their own scope of practice to colleagues and the general public. Salvatori (2001) has suggested that “shared learning experiences for both professional entry-level and assistant level students would facilitate collaborative relationships prior to entering practice” (p. 226). Clearly there is a need not only to define roles and responsibilities of those involved in providing occupational therapy services but also to educate students at the professional and assistant level for future collaborative practice. This paper reports the findings of a qualitative study involving pairs of student OTs and student OTAs who particVOLUME

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JUNG ET AL. ipated in a unique intraprofessional learning experience that combined a shared fieldwork placement with a small group weekly tutorial. A review of the literature, methodology, findings, discussion, and implications for the future are presented.

real world clinical practice by pairing student OTs and student OTAs to provide client care, and (c) expanding opportunities for collaboration and teamwork (DeClute & Ladyshewsky, 1993; Higgins, 1998; Jung, Sainsbury, Grum, Wilkins, & Tryssenaar, 2002). Mostrom, Ribesky, and Klukos (1999) paired student physical therapists and student physical therapist assistants in clinical education placements and identified similar benefits, such as peer support, enhanced adaptation to the clinic, and increased knowledge of roles and responsibilities. In spite of the benefits of such placements, it has often been difficult to provide these collaborative learning experiences. Some of the challenges associated with collaborative learning include compromising individual learning needs because of a group supervision model and difficulties associated with poorly defined roles in some settings (Jung et al., 2002). Problem-based learning (PBL) approaches that combine small-group tutorials with case-based learning in the education of health professionals are now used worldwide (Salvatori, 2000). Studies show that these approaches facilitate the development of lifelong learners and are enjoyable for both students and faculty (Maxwell & Wilkerson, 1990; Norman & Schmidt, 1992; Solomon, 1994; Steinert, 2004). Visschers-Pleijers et al. (2006) have suggested that PBL approaches are consistent with the theory and research on collaborative learning. Salvatori (1999) concluded that “learning in a student-centred, problem-based curriculum constitutes ‘meaningful occupation’ for occupational therapy students” (p. 207). The role of the PBL tutor or facilitator is primarily to ask questions, promote problem solving and critical thinking, facilitate discussion among group members, and manage interpersonal or conflict issues rather than lecturing, disseminating information, and answering “content-related” questions as in the traditional role of teacher (Baptiste, 2003; Barrows & Tamblyn, 1980). Tremblay, Tryssenaar, and Jung (2001) have suggested that the role of the tutor is to act as a guide and an advocate, “challenging students to explore depths and set standards of achievement” (p. 565).

Literature review There is a paucity of literature on intraprofessional collaborative practice and intraprofessional collaborative learning in the health professions, particularly in the field of occupational therapy. However, there is some emerging evidence that collaborative practice makes a difference in patient/ client outcomes and that collaborative learning is useful to prepare therapists and assistant personnel for practice. Valuable insights can also be gained from the burgeoning literature on interprofessional collaborative practice and interprofessional education that presents similar arguments.

Collaborative practice According to Mickan and Rodger (2005), “the use of health care teams to achieve quality and efficient patient care has become widespread” (p. 358). Hayden-Sloane (2005) has identified the OTA as an important member of a collaborative health team. Similarly, Blechert, Christiansen, and Kari (1993) have discussed the importance of teamwork and team building for the effective delivery of occupational therapy services. Roberts (2000) defines collaboration as the ability “to work together, act jointly and cooperate” (p. 4). Key characteristics of collaborative practice are similar to those of effective teamwork and include a common purpose, professional competence, interpersonal skills, trust and respect, effective communication, shared decision making, and a shared value of interdependence (Hayden-Sloane, Mickan & Rodger; Rainville, Blechert, Christiansen, & Kari, 2005). In a qualitative study of 22 pairs of OT and OTA teams, Dillon (2001) concluded that “effective intraprofessional relationships enhance the quality of occupational therapy services provided” (p. 1).

Collaborative learning Support from the interprofessional literature

Fieldwork experiences have long been used and highly valued to bridge the gap between classroom preparation and entry to practice for both professional-level and assistant-level students in occupational therapy. Blechert and Christiansen (1993) have discussed the importance of fieldwork in the socialization process for occupational therapy support personnel because it not only gives student OTAs opportunities to apply new knowledge and skills but also “to learn supervisory relationships” (p. 289). Pairing OT and OTA students in collaborative fieldwork placements to explore these relationships has not been common practice. Nevertheless, there is increasing evidence that such collaborative learning experiences can generate positive learning outcomes that include (a) learning about the roles of OTs and OTAs,(b) emulating © CAOT PUBLICATIONS ACE

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The rationale for more interprofessional education in the preparation of health care providers can also be used to support the need for more intraprofessional education. For example, Freeth and Reeves (2004) attest to the value of collaborative learning as a core aspect of professional practice. In a survey of occupational therapy and physiotherapy programs across Canada, Tryssenaar, Perkins, and Brett (1996) reported a trend to maintain or increase levels of interdisciplinary educational activities at Canadian occupational therapy and physiotherapy programs and undergraduate levels. They add that educators need to make explicit in current educational practice what is anticipated for future clinical 1

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JUNG ET AL. practice. Similarly, Gilbert et al. (2000) have argued that “increasing emphasis on the delivery of integrated, interdisciplinary, client-centred health care services in Canada demands that health care professionals have a sound knowledge of the services provided by their colleagues as well as the knowledge and skills to work effectively with them as a team” (p. 223). The interprofessional education literature also supports the use of interactive problem-based learning approaches to enhance future collaboration in practice (D’Eon, 2004; Solomon, Salvatori, & Guenter, 2003; McNairn, Stone, Sims, & Curtis, 2005) In summary, there is some evidence in the literature that collaborative fieldwork educational experiences and smallgroup, problem-based tutorials can enhance learning for student OTs and OTAs. However, no occupational therapy program to date has used a combination of these two educational strategies to foster intraprofessional education.

educational strategies to facilitate effective team building within the fieldwork setting while attempting to address some of the student concerns identified in the former study by Jung et al. (2002). Ethics approval was obtained through the McMaster University Occupational Therapy Program Education Committee and the Mohawk College Rehabilitation Science Advisory Committee. At the time of the study, Mohawk College offered a 42-week certificate program for a combined Occupational Therapist Assistants and Physiotherapist Assistants (OTA and PTA) role, which included 18 weeks of fieldwork placement. McMaster University offered a 24-month master’s-level entry program in occupational therapy, which included 28 weeks of fieldwork placement. This study was conducted in March and April in two consecutive years because it was the only time when students from both programs were doing a full-time fieldwork placement at the same time.

Purpose and objectives of the project

Participants

The purpose of this study was to explore the impact of a collaborative fieldwork placement combined with weekly small group tutorials on intraprofessional learning for OT and OTA students. It builds on the previous work of Jung et al. (2002) that paired student OTs and student OTAs in fieldwork placements. Although Jung et al. reported positive outcomes in terms of intraprofessional learning and collaboration, they also identified several challenges that the students faced, including limited understanding of assignment, delegation, and supervision issues; lack of awareness of current national guidelines re OT and OTA roles; minimal awareness of education programs and skills training for OTs and OTAs; and limited student commitment to equal learning partnerships. The combined fieldwork–tutorial experience in this study was designed to provide more opportunities for students to discuss these problematic issues in a tutorial setting while learning to work together during a fieldwork placement to provide occupational therapy services to clients. There were two learning objectives in this program: (1) to learn about the roles and responsibilities of OTs and OTAs including supervisory relationships, and (2) to share knowledge and work collaboratively in pairs to deliver occupational therapy services to individual clients. Essentially, the small group tutorials were designed to enhance fieldwork learning and thus strengthen the process of students’ acquiring knowledge, developing skills, and building relationships in the placement setting.

Methods Context Two educational institutions, McMaster University MSc (OT) Program and the Mohawk College occupational therapist assistant/physiotherapist assistant certificate program, continued their collaboration in this study to further explore 44

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Seven pairs of student OTs and OTAs participated in this study. The usual procedures for fieldwork placement selection and assignment were followed, that is, these placements were listed along with other placement options for student review. The students had opportunities to express their interest, and the fieldwork course coordinators used this information to assign the students to the placements. The fieldwork course coordinator then asked the students if they wanted to participate in the study, and all but one pair agreed. Students were given the option to withdraw from the study at any time with no consequences to their learning experience or evaluation. The student pairs were assigned to six in-patient hospital fieldwork settings in the southern Ontario region where OT and OTA roles had been established. One site offered the placements during both years. The client populations served through these placements were adults and older adults, and the practice areas were in mental health and physical health. The tutors and student preceptors (often referred to as fieldwork supervisors or clinical educators) served as secondary sources of information in this study. As Berg (2004) and Steinert (2004) have suggested, a comparison of student and teacher perceptions adds an important research perspective and serves to create a more comprehensive picture of the student experience. The preceptors were experienced fieldwork educators and they agreed to participate in the study because of their interest in this unique educational model. In each clinical setting, one OT preceptor ultimately was responsible for and supervised both the student OT and student OTA. The OTA contributed to this learning model by supervising the student OTA and actively facilitating the learning of both students. Two educators with tutoring experience, one OT affiliated with McMaster University and one OTA affiliated with Mohawk College, were recruited as co-tutors for the two-year VOLUME

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JUNG ET AL. project. The researchers thought that this co-tutoring approach would serve as a model of collaborative practice for the students. See Table 1 for information on study participants and learning experiences.

the previous week. Each pair of students was also responsible for preparing one case scenario from their clinical setting for group discussion each week. Group discussions often focused on issues concerning role overlap, role conflict, assignment of tasks, supervision, accountability, report writing, and collaborative planning.

Learning experiences During their placements, the OT and OTA students were expected to meet the fieldwork objectives prescribed by their education programs. In addition, the OT and OTA student pairs were expected to meet the specific intraprofessional learning objectives outlined for this study. During the five weeks when placements overlapped, the students spent some time working alone and some time working together in the clinical setting under the supervision of their preceptors. In addition, student OT/OTA pairs from all fieldwork sites would meet together for a small group tutorial. Tutorials were scheduled once per week for two-and-a-half hours and took place at the Institute for Applied Health Sciences, the academic setting which housed both the OT and OTA/PTA programs. Each student received a resource binder with journal articles and documents published by professional associations and the provincial regulatory body that addressed current issues facing support personnel within the profession in Canada. During the tutorials, students had the opportunity to discuss and debate these readings and to share any critical incidents or key learning experiences that had occurred in

Data collection A qualitative design was used to explore how this educational model contributed to the students’ learning experiences. Student journals were the primary data collection tool. Journaling is an effective tool that encourages self-reflection, critical thinking, and professional growth (Perkins, 1996: Solomon et al., 2003). The students submitted reflective journals at least twice a week throughout the placement period and were asked to provide comments on any thoughts, feelings, concerns, or issues arising from the placement and tutorial experiences. The students were encouraged to address some guiding questions: What do you hope to gain from this experience? Do you anticipate any difficulties? What did you learn about yourself, the client, OT/OTA team, or the role of the health care team this week? What critical events had an impact on you and why? How could you apply what you have learned to another population/situation in the future? The students also participated in a post-placement, focus group discussion. Those students who could not attend received a questionnaire with the same questions used for the focus group discussion: What were the strengths and weaknesses of this placement experience? Did you benefit from the tutorial experience in terms of your clinical performance and increased knowledge? Did you feel adequately prepared for this supervision model? Were the binder resource material and pre-placement orientation session helpful? What are your recommendations for future placements? Would you recommend this type of learning opportunity for your classmates/students in the future? The tutors submitted reflective journals throughout the placement and had weekly debriefing meetings with one of the study investigators. The preceptors participated in a postplacement focus group to share their perspectives on the student placement experience. The preceptors were not asked to journal because of the extensive time commitment involved in this process, and it was felt that the focus group discussions would yield sufficient data to inform the study.

TABLE 1 Study participants and learning experiences Participants and Learning Experiences

2003

2004

Students

• 4 OTA/PTA Year 1 Certificate Students • 4 MSc OT students • ( 2 Year 1 & 2 Year 2)

• 3 OTA/PTA Year 1 Certificate Students • 3 MSc OT students • ( 1 Year 1 & 2 Year 2)

Preceptors

• 1 OT and 1 OTA for each pair of OT/ OTA students

• 1 OT and 1 OTA for each pair of OT/OTA students

Tutors

• 2 (1 OT & 1 OTA)

• 2 (1 OT & 1 OTA)

Fieldwork Sites

• Adult physical • Adult physical health health (n=3) (n=2) • Adult mental health • Adult mental health (n=1) (n=1)

Placement Duration

• OTA - 7 weeks • OT - 5 weeks

Tutorials

• 1 per week for 3 of 5 • 1 per week for 5 weeks weeks (2 cancelled because of SARS)

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Data analysis The journals and audiotaped focus group discussions were transcribed. The three authors initially read the student journals using a retrospective content analysis. Major topics were clustered into codes and categories were developed. The tutor and preceptor data were then reviewed to further refine the categories that were developed from the student data. To strengthen the trustworthiness of the data, the students

• OTA – 7 weeks • OT - 5 weeks

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JUNG ET AL. received the categories for review. They were asked to comment on the information relative to their experiences and subsequent changes were made. This member checking ensures that the information has been translated as accurately as possible and decreases the chances of misinterpretation (Creswell, 2003; Krefting, 1990). Overarching themes were then developed from the identified categories.

We have been getting quite a lot accomplished due to our great working relationship and respect for each other. I hope that everything continues this great until the end of the placement (student OT). I enjoy being around the OT student. This allows me to see how she works. We were told that she would be assigning me tasks by week 4 and at first I was a bit taken aback but realize that is her job and my job is to go through those tasks (student OTA). I don’t know if it’s [only] my third day, but I don’t really feel like I take orders from her. In fact, it doesn’t seem to be that way with the OTs and the OTA either (student OTA).

Findings Data gathered from students, tutors, and preceptors supported the benefits of intraprofessional learning for OT and OTA students. Three key themes emerged: (1) developing the relationship, (2) understanding roles, and (3) recognizing environmental influences on learning.

Developing the relationship The students identified the importance of developing their relationship through activities that required shared learning, communicating effectively, and building trust and respect. A number of strategies facilitated the peer/shared learning process. For example, at the beginning of their placements, students developed learning objectives that involved some joint activities. They also worked together on projects and client interventions in the clinical environment. In addition, at their weekly tutorials each student pair presented a case study to illustrate their complementary clinical teamwork. The nature of the student supervision model promoted peer/shared learning within the clinical environment as evidenced by this student’s comment: “I have been able to teach [my student partner] what we have learned in our OTA classes and she taught me what they have learned” (student OTA). The importance of communication in client service delivery between students and practicing clinicians surfaced early in both the clinical and tutorial settings. Students discussed profession-specific literature, consulted with each other about client cases, resolved conflicts about caseloads, and clarified terminology and methods of documentation. Communication is the key among all team members and the OT and OTA need to be on the same page for all clients to be able to chart their progress and report at team meetings (student OT). We actually resolved [the issue of] too many people putting responsibility on the other person. I was getting a lot of directions from two OTAs and the OT preceptor and the OT student. I didn’t know whose work to do first. I actually worked it out by the end of the placement but think that’s something you need to talk about right away from the beginning (student OTA). Building trust and respect were promoted early on starting with the pre-placement orientation session at which students were encouraged to begin to develop relationships with their peers, preceptors, and tutors. This initial step in the process was paramount in enhancing clinical service partnerships. 46

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Understanding roles Defined OT and OTA roles in the clinical setting as well as role modeling by the tutors in the educational setting, affected student collaborative learning. As students learned to work together, they began to understand their own roles better and then to describe their roles in relation to their student partners. At times I feel as though they [OT students] are looked on as being much more intelligent and superior and this sometimes makes me feel not so important; however, over the last week I realized that my job is important and I play a big role in occupational therapy. (student OTA) I think that every OT student should have at least one opportunity to work alongside OTAs [student or graduates] so that they may learn the value of their role. (student OT) I have had the opportunity to work with the OT student on a module for the mentally ill. This I think has been a turning point in our relationship because it gave us the opportunity to actually see what the other was capable of doing. (student OTA) Students were able to articulate the differences and the similarities in their respective roles. Many expressed some surprise at the other’s knowledge and skills. It was interesting to learn that they (OTA students) were familiar with concepts that are widely used in the OT program (like client-centredness) and that they have to know a lot of the same things that we learn about. (student OT) While we worked together with this client throughout the past two weeks, we would have a small discussion after each intervention, and we would discuss the difference in our roles as OT and OTA. It was a very interesting experience, and really clarified our roles to both of us. (student OTA) Finally through understanding each other’s roles and effective communication there emerged a sense of teamwork and genuine interest in collaborating on a very comprehensive client plan that ultimately complemented the delivery of occupational therapy services. This sense of team competence was evident in these student comments. So far within this week, I have been brainstorming with VOLUME

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JUNG ET AL. the student OT and the OT, concerning different clients and possible activities and devices for them. I have found we all tend to be on the same wavelength with our ideas. Except we will all have a different spin on the idea. . . . This is a major example of how each discipline and education level may have different views, levels of knowledge, and reasoning but still can come together as a team respecting these differences and form a very complete and creative plan for a client. (student OTA) It is kind of a relief to know that I may get to work with an OTA after graduation, as I have seen how large a caseload can be in a hospital setting. I think that having the assistance of an OTA would make the workload less overwhelming, especially for new grads! (student OT) In support of the student comments on understanding roles, the occupational therapist tutor stated: “Reading is not enough. The experience of sharing and collaborating [in the clinical and tutorial setting] was the clinching factor to improved relationships and appreciation of each others’ roles.”

For one student, supervision issues became much clearer after reviewing some of the information in the tutorial. The clarification in one of our first tutorials of assigning vs. delegating really helped me when working with the OTA student and realizing the power sharing between us. (student OT) The tutor played an important role in the learning process, as the student OT stated, “The tutors were quite helpful in stimulating the group with discussions and helping us phrase out our thoughts so that they would be meaningful to the groups’ learning.” Another task that the student pairs had was to present client cases for discussion in the tutorial groups. The students benefited from this exercise as evidenced in this comment: Our [tutorial] group worked together to come up with the idea to ask the client what was wrong and then make a list about how the client could solve that problem or make the problem better. Overall, I think that these presentations really do bring out some interesting discussions and very helpful solutions that as OT/OTAs we can definitely apply in the future. (student OTA) This tutor made an interesting observation reporting that the OT and OTA students who were pairs exchanged more information and interacted more closely during these tutorials than with their own respective classmates at school. They appeared very comfortable together like old friends; they laughed, looked at and touched each other frequently. They complimented one another and spoke of their mutual respect. They indicated that they did not have similar working relationships with other staff and students. They were all very positive about their experiences and recommended that this working model be mandatory. (OTA tutor) In addition, the scenarios brought up in the student discussions evoked in this OTA tutor a personal and powerful reaction based on her own past experiences. She reflected on this: “I was reminded of similar situations in my working experience and the depth of stirring by the events. I was also encouraged by their idealism and resolve.” Her confidence in their ability to influence the future was heartening.

Recognizing environmental influences The students identified the impact of the clinical (hospital) and educational (tutorial) environment on their learning process. The clinical environment presented the students with both opportunities and challenges to their learning as individual learners and as learning pairs. Students enjoyed the client interactions, preceptor relationships, and wealth of learning opportunities that their clinical settings offered. They began to have an emerging sense of self in relationship to their learning partners and to their own professions. However the students also were immersed in the health care culture and experienced the real-life work dilemmas that challenged their notions of ideal practice. Increased workload and stress, staff attrition driven by salary scales, reduced client services, team conflict, limited preceptor role appreciation by the institutions were some issues raised. On the topic of workload, one student suggested that efficiency could be improved through better use of the services of an OTA. The assistants do absolutely no charting on clients at this facility. I am really surprised. I don’t see the harm in having assistants do some SOAP notes if the actual therapist did not see their patient that day. I think that would take a load off the therapists from not having to write down their interpretation of the verbal report from the assistant and it would save them some time. (student OTA) One tutor explicitly noted that the clinical environment, despite the available learning opportunities, plays a powerful role in supporting or hindering the building of relationships. It appears that despite the stated goals of [our] research study, the [hospital] organization structure determines the students’ ability to work collaboratively by controlling the frequency, duration. and quality of their interactions. (OTA tutor) © CAOT PUBLICATIONS ACE

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Discussion Our findings in the area of peer learning, communication, and respect have been consistent with the existing literature. Others have discussed the emergence of peer learning as a benefit of a cooperative or group placement (Farrow, Gaiptman, & Rudman, 2000; Jung, Martin, Graden, & Awrey, 1994; Mason, 1998). According to Ladyshewsky (2000), learners use each other as sources for mutual discovery, reciprocal feedback, and exchange of ideas. Communication is critical in the development of a collaborative relationship between the OT and OTA. Dillon (2001) has discussed the importance of communication, 1

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JUNG ET AL. mutual respect, and trust as key characteristics in establishing effective working relationships between OTs and OTAs. He coined the term “intraprofessional unity” to reflect this basic element in the ongoing daily practice of occupational therapy. Mickan and Rodger (2005) and Tjosvold (1997) have all discussed the similar concept of “interdependence.” In a similar vein, Hayden-Sloane (2005) has suggested that “communication is the essential factor in successful partnerships” (p. 30) and Rainville et al. (2005) have stated that effective teamwork and team building are essential processes within the profession of occupational therapy. Student participants all agreed that working together in a clinical setting not only enhanced their understanding of each other’s roles, including similarities and differences, but also fostered the development of competence and confidence in one’s own skills and abilities as well as one’s partner. DeClute and Ladyshewski (1993) reported that the achievement of clinical competence in patient evaluation, program planning, implementation of treatment, communication, and professional behaviours was enhanced through a collaborative clinical education model. Mickan and Rodger (2005) have suggested that “to communicate well and build up a sense of commitment, individuals need a certain level of self-knowledge and confidence in their own professional role and skills” (p. 359). They also purport that good teamwork results in improved coordination of care, efficient utilization of services, increased patient satisfaction, and improved health outcomes. The tutorial, as the unique aspect of the learning experience, appeared to play a key role in facilitating and enhancing learning. Students could debrief and work through their thoughts and emotions and gain new knowledge in a safe environment. They found the intraprofessional case discussions useful because of their practical focus on real clients. As Steinert (2004) recommends, the clinical relevance and integration of scenarios are important characteristics for effective small group functioning. The tutor notes revealed that the students also used the tutorials to discuss personal experiences that were uncomfortable, for example, issues of role overlap and role conflict that they had observed in their fieldwork settings or experienced themselves. One student OTA stated, “No one held anything back. We all said what was on our minds.” Blechert and Christiansen (1993) have suggested that “despite all of the positive aspects and efforts of teaming, it is inevitable that conflict sometimes will arise” (p. 292). However, if managed well, conflict can often be productive and result in people feeling more powerful, efficacious, and interdependent (Tjosvold, 1997). It was clear that students appreciated the opportunity to discuss sensitive issues in a supportive environment, which served to help them bridge the gap between their impressions of ideal practice and the realities of work. Baptiste (2003) states that within the tutorial experience, the principles of partnership, honesty and openness, respect, and 48

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trust are central to the process, and if a learning system is going to maintain integrity, it is critical that the partners respect one another. Once there is respect, trust can begin to grow. It appeared that the tutorial experience in conjunction with the placement provided the opportunity for the OT and OTA students to consolidate and enhance the different parts of their learning. Lessons learned in relation to the following educational and organizational issues may provide food for thought for other OT and OTA educators.

1. Curriculum development With current credentialing shifts taking place, as OT programs make the transition to the master’s degree level and OTA programs to the diploma level, this is an opportune time to work together to develop complementary curricula and enhance collaborative learning experiences for both groups of students. Although it would be ideal to have students enter a collaborative placement with some knowledge of each other’s roles, this may not be feasible given differences in curriculum design and organization. However, it is critical to stress the significance of communication, respect, and trust and the building of relationships in the respective curricula.

2. Site selection and preceptor preparation In planning fieldwork experiences, it is important that selected sites have defined OT and OTA roles in order to create learning environments that illustrate collaborative practice relationships. Education for clinicians about the OT and OTA educational programs and student expectations is necessary to garner their support and develop their confidence to serve as preceptors in such a collaborative fieldwork educational model.

3. Tutorial planning and tutor training The resource binders with current and selected documents and journal articles proved to be a useful resource for students and preceptors. Tutors need to be experienced or at least receive training on how to facilitate small group learning. The role of the tutor is important in facilitating and guiding student learning, promoting collaborative interactions, and resolving conflict when it arises.

Limitations There were several limitations to this study. The most important perhaps is that the students participated in a combined collaborative learning experience (fieldwork placement plus a weekly tutorial) and the results speak to this combined experience. Data were not collected separately on the learning that occurred in the fieldwork placement and in the tutorial. This means that it is not possible to know which component contributed the most learning and in what way. The first set of students (four pairs) was in the middle of VOLUME

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JUNG ET AL. their placements when Severe Acute Respiratory Syndrome (SARS) became a major health care issue in Ontario. The student and preceptor experiences were altered because they had to deal with disruptions in their caseloads, drastically changed roles, and the anxiety of coping with an unknown and lethal syndrome. As a result of SARS, the placements were discontinued because of directives from the Ministry of Health. The last two tutorials were cancelled as well. Although the students’ collaborative learning experiences were more limited than planned, all four student pairs submitted journals for a four-week period and also participated in post-placement focus groups. Interestingly, some of the students identified the desire to continue the tutorials because they saw them as an oasis of stability within a period of confusion in the health care system. In some ways this crisis might have helped the students see how much of a bond they had developed in a short period of time. One OTA student stated, “When we were told that we had to leave our placement because of SARS….we all just kind of looked at each other in a shocked state. We had all become so close working together, depending on each other, and now for a brief time it is over.” In addition, the participants were recruited from only one OT and one OTA/PTA educational program. Therefore, the findings are limited to the experiences of students from these two programs and may not be transferable to other educational programs. Finally, because of the malfunction of the audiotape equipment during one of the preceptor focus group discussions, no transcript was available. To ensure that the written notes taken at the meeting were reflective of the discussion, a summary was sent to the preceptor participants for their comments. Nonetheless, it is possible that some valuable feedback or insights from the preceptors was missed.

standing roles, and recognizing environmental influences in the delivery of health care provide an important message for better preparation of students for the realities of clinical practice. The perceptions that the student OTs and OTAs reported in this study suggest that they gained new knowledge and developed new teamwork skills that have helped prepare them for collaborative practice in the future. Since completion of this study, the intraprofessional fieldwork placements and tutorials have continued. In a recent placement, a student OT provided this optimistic comment. This process definitely helped foster the relationship between OTA and OT for me, and I am now much more comfortable with the idea and position of working with an OTA in the future. I now am aware of what our roles are, how they are different and how they are similar. I can work with an OTA to determine the best use of our abilities.

Acknowledgements We wish to thank the students, tutors, and preceptors for generously sharing their thoughts and time. This study was supported by joint funding from McMaster University, School of Rehabilitation Science, and Mohawk College of Applied Arts and Technology, Health Sciences and Human Services, Occupational Therapist Assistant/Physiotherapist Assistant Program. Parts of this paper were presented at the CAOT Annual Conference in Vancouver, British Columbia, May 2005.

References Baptiste, S. (2003). Problem-based learning: A self-directed journey. Thorofare, NJ: Slack. Barrows, H. S., & Tamblyn, R. (1980). Problem-based learning: An approach to medical education. New York: Springer. Berg, B. (2004). Qualitative research methods for the social sciences (5th ed.). Boston, MA: Pearson Education, Inc. Blechert, T. & Christiansen, M. (1993). Intraprofessional relationships and socialization. In S. E. Ryan (Ed.), Practice issues in occupational therapy. Intraprofessional team building (pp. 287297). Thorofare, NJ: Slack. Blechert, T. Christiansen, M, & Kari, N. (1993).Teamwork and team building. In S. E. Ryan (Ed.), Practice issues in occupational therapy. Intraprofessional team building (pp. 15-21). Thorofare, NJ: Slack. Canadian Association of Occupational Therapists. (2003). Position statement on support personnel in occupational therapy services. Canadian Journal of Occupational Therapy, 65, 111-112. Creswell, J. (2003). Research design: Qualitative, quantitative, and mixed methods approaches (2nd ed.). Thousand Oaks, CA: Sage. DeClute, J., & Ladyshewsky, R. (1993). Enhancing clinical competence using a collaborative clinical education model. Physical Therapy, 73, 683-697. Dillon, T. (2001). Practitioner perspectives: Effective intraprofessional relationships in occupational therapy. Occupational Therapy in Health Care, 14, 1-15. D’Eon, M. (2004). A blueprint for interprofessional learning. Medical Teacher, 26, 604-409. Farrow, S., Gaiptman, B., & Rudman, D. (2000). Exploration of a

Conclusion The combined collaborative placement and tutorial experience generated positive learning outcomes for students. In addition to the day-to-day encounters in the clinical setting, the tutorials allowed the students to continue to develop their relationships, gain new knowledge about their roles in various settings, discuss issues of professional concern, and also explore real-life clinical dilemmas. All students agreed that the small group tutorials added significant learning to their collaborative fieldwork experience. However, further research is needed to determine what impact each component has on student learning. Although hospital sites were used in this study, research is needed to determine if and how community settings could be used for intraprofessional placements. Since this study entailed the use of a combined placement tutorial experience, it would be also valuable to clearly discern the educational impact of the fieldwork experience as distinct from the tutorial experience. The three themes of developing relationships, under© CAOT PUBLICATIONS ACE

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Authors Bonny Jung, MEd, is Assistant Professor, School of Rehabilitation Science, Institute for Applied Health Science, McMaster University, 1400 Main Street West, Room 427, Hamilton, ON, L8S 1C7. Telephone: 905-525-9140, ext. 27807. E-mail: jungb@ mcmaster.ca Penny Salvatori, MHSc is Professor, School of Rehabilitation Science, Institute for Applied Health Science, McMaster University, 1400 Main Street West, Room 420, Hamilton, ON, L8S 1C7. Adele Martin, Dip P & OT is Coordinator and Professor, Occupational Therapist Assistant and Physiotherapist Assistant Diploma Program, Mohawk College, and Professional Associate, Institute for Applied Health Science, McMaster University, 1400 Main Street West, Hamilton, ON, L8S 1C7. Copyright of articles published in the Canadian Journal of Occupational Therapy (CJOT) is held by the Canadian Association of Occupational Therapists.Permission must be obtained in writing from CAOT to photocopy,reprint,reproduce (in print or electronic format) any material published in CJOT.There is a per page,per table or figure charge for commercial use.When referencing this article,please use APA style,citing both the date retrieved from our web site and the URL.For more information,please contact: [email protected]. VOLUME

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