Canadian Journal of Occupational Therapy 2014, Vol. 81(3) 173-182 DOI: 10.1177/0008417414534629

Article

Becoming an occupational therapist: Perceived influence of international fieldwork placements on clinical practice

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Devenir ergothe´rapeute : perceptions face a` l’influence des stages internationaux sur la pratique clinique

Adriana V. Haro, Brittany P. Knight, Debra L. Cameron, Stephanie A. Nixon, Puja A. Ahluwalia, and Emma L. Hicks

Key words: Clinical competence; Education; Low- and middle-income countries; Practicum. Mots cle´s : compe´tences cliniques; formation; pays a` revenus faibles et interme´diaires; stage.

Abstract Background. Many occupational therapy programs have augmented curricula to provide students with opportunities to engage in international fieldwork placements (IFPs). However, limited research exists exploring the perceived influence that IFPs may have on future occupational therapy roles and characteristics. Purpose. The purpose of this study is to explore how Canadian occupational therapists who participated in IFPs as students perceive the influence of their IFP experience on their subsequent practice. Method. Semistructured interviews were conducted with 20 occupational therapists who participated in IFPs as occupational therapy students. The interview guide was developed based on the Profile of Occupational Therapy Practice in Canada and relevant literature. A directed content analysis was used in conjunction with the DEPICT model of data analysis to guide the analysis process and summarize the results. Findings. Participants described how IFPs nurtured the development of six skills, or active ingredients, which supported the development of competence in occupational therapy roles. IFPs were also perceived as providing a competitive edge. Implications. This study suggests that IFPs shape the development of competence in key practice skills and occupational therapy roles. Abre´ge´ Description. De nombreux programmes de formation en ergothe´rapie ont e´largi leurs programmes d’e´tudes afin d’offrir aux e´tudiants des possibilite´s de participer a` des stages internationaux. Toutefois, peu de recherches ont e´te´ mene´es sur les perceptions quant a` l’influence que les stages internationaux peuvent avoir sur les futurs roˆles et caracte´ristiques de l’ergothe´rapie. But. Le but de cette e´tude est d’explorer les perceptions des ergothe´rapeutes canadiens ayant participe´ a` des stages internationaux quant a` l’influence de leur expe´rience de stage sur leur pratique subse´quente. Me´thodologie. Des entrevues semi-structure´es ont e´te´ re´alise´es aupre`s de 20 ergothe´rapeutes ayant participe´ a` des stages internationaux alors qu’ils e´taient e´tudiants. Le guide de l’entrevue a e´te´ e´labore´ en fonction du Profil de la pratique de l’ergothe´rapie au Canada et de la litte´rature pertinente. Une analyse dirige´e du contenu a e´te´ utilise´e de concert avec le mode`le d’analyse de donne´es DEPICT afin d’orienter le processus d’analyse et de faire le sommaire des re´sultats. Re´sultats. Les participants ont indique´ que les stages internationaux leur avaient permis de faire l’acquisition de six compe´tences, ou ingre´dients actifs, qui ont favorise´ l’acquisition de compe´tences associe´es aux roˆles en ergothe´rapie. Les participants ont e´galement eu le sentiment que les stages internationaux leur avaient procure´ un avantage concurrentiel. Conse´quences. Cette e´tude sugge`re que les stages internationaux favorisent l’acquisition de compe´tences cle´s associe´es a` la pratique et aux principaux roˆles en ergothe´rapie.

Funding: No funding was received in support of this work. Corresponding author: Debra Cameron, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto, 160-500 University Ave., Toronto, ON, M5G 1V7, Canada. Telephone: 416-946-8568. E-mail: [email protected]

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ieldwork placements are an integral component of occupational therapy curricula as they enable students to integrate academic knowledge with clinical skills in various practice settings (Bonello, 2001). Fieldwork placements have also been found to play a significant role in preparing students for clinical practice (Aiken, Menaker, & Barsky, 2001; American Occupational Therapy Association, 2009; Bonello, 2001; Tompson & Ryan, 1996) and in shaping their practice preferences (Crowe & Mackenzie, 2002; Hulse, Cash, & Simons, 2000). Researchers have found that international fieldwork placements (IFPs) foster the development of occupational therapy students in various ways, including increased confidence as a professional, enhanced ability to apply theory to practice, and improved clinical skills (Aiken et al., 2001). Universities face the challenge of evaluating and adapting curricula to provide students with fieldwork opportunities that reflect the current trends in health care (Aiken et al., 2001). With the growing internationalization of health care, there are more opportunities for health care professionals, including occupational therapists, to practise in various regions of the world (Barker, Kinsella, & Bossers, 2010). In response, many occupational therapy education programs have augmented curricula to afford occupational therapy students increased opportunities for IFPs to support them to be competent clinicians in this global workforce (Association of Universities and Colleges of Canada, 2007). Mill, Astle, Ogilvie, and Gastaldo (2010) posit that most health care treatments created within high-income countries (HIC) are not sustainable in other parts of the world and caution that models of health care taught in HIC should not be mapped onto low- and middle-income countries (LMIC). As health care systems can reflect a country’s economic and political stability, occupational therapy students engaging in fieldwork placements in HIC, such as Canada, may have a qualitatively different learning experience compared to those engaging in IFPs in LMIC (Popplow, Sward, & Klinger, 2010; World Health Organization [WHO], 2011; Zakus & Bhattacharyya, 2007). The literature exploring IFPs in occupational therapy focuses primarily on the learning process of students in both HIC and LMIC (Barker et al., 2010; McAllister, Whiteford, Hill, Thomas, & Fitzgerald, 2006). McAllister and colleagues (2006) explored the intercultural learning process of Australian occupational therapy students who participated in IFPs in Indonesia and Vietnam, where increased cultural sensitivity was reported as students moved from an ethnocentric view of foreign cultures to a broader cultural competence and understanding of individuals from other cultures. Barker and colleagues (2010) explored the learning process of Canadian occupational therapy students and clinicians who participated in IFPs in HIC and LMIC, where personal and professional development emerged as the core category of learning identified by occupational therapy students following participation in IFPs. In addition, Barker and colleagues found that IFPs in LMIC have the potential to offer occupational therapy students a unique and transformative learning experience. Canadian Journal of Occupational Therapy

The availability of IFPs within occupational therapy curricula is based on the assumption that they provide beneficial outcomes for students, professional practice, and society as a whole (Kinsella, Bossers, & Ferreira, 2008); however, there is limited research supporting this assumption. Although researchers have previously explored the learning process of occupational therapy students and clinicians while on IFPs, the perceived influence of IFPs on the later development of occupational therapists has yet to be studied. Specifically, research has not explored occupational therapists’ perceptions of the influence that completing an IFP has had on them once entering practice. The purpose of this study was to explore if and how occupational therapists who undertook IFPs in LMIC as occupational therapy students perceive that this experience influenced their subsequent development and occupational therapy roles.

Method Research Design This study was guided by a qualitative interpretivist approach, which views the world as constructed, interpreted, and experienced by people through their interactions with each other and wider social systems (Ulin, Robinson, & Tolley, 2005). This approach is guided by the identification and analysis of the subjective meanings that participants attach to objective experiences. We note that each member of the research team had personal experience with IFPs: AVH and BPK were professional master’s students in occupational therapy at the time of this study who had recently completed an IFP; PAA and ELH are practicing clinicians who conducted IFPs during their training; and DLC and SAN are faculty members who facilitate IFPs. This background was viewed as an asset for understanding the context in which the inquiry was situated; however, during analysis, team members attempted to bracket their personal experiences with IFPs and instead rely on the insights shared by participants in arriving at study results. This study was granted ethical approval by the Health Sciences Research Ethics Board, University of Toronto.

Participants and Recruitment Purposeful and snowball sampling methods were employed (Patton, 2002) to recruit 20 participants who met the following inclusion criteria: currently registered as an occupational therapist, practising for at least 1 year at time of recruitment, graduated from a Canadian occupational therapy program, and participated in an IFP as an occupational therapy student in a LMIC as defined by the WHO (2011). To strive for maximum-variation sampling (Patton, 2005), the researchers sought a pool of participants that contained individuals who graduated from at least three different Canadian occupational therapy programs and had engaged in IFPs in LMIC in at least three distinct geographic regions of the world (WHO, 2011).

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Table 1 Participant Characteristics Pseudonym

IFP location

IFP setting

IFP context

Current practice

Interview mode

Beth Cora Dawn Dora Ella Emma Gina Jack Jimy John Judy Kate Laya Leah Lucy Mary Nina Ruby Sara Zara

India India Trinidad India Cameroon India Tanzania India Trinidad India Cameroon Kenya Colombia Tanzania Trinidad Kenya Kenya Tanzania Cameroon Tanzania

Urban/rural Rural Urban Urban/rural Rural Rural Rural Rural Urban Rural Rural Rural Urban Rural Urban Rural Rural Urban Rural Urban

Hospital and community Hospital School Hospital and community Rehabilitation Hospital Hospital Hospital and community School and vocational Hospital and community Rehabilitation Community Private health care centre Hospital and community Community Community Community Hospital Community Hospital

Hospital Private Rehabilitation Hospital Hospital Hospital Community Other: Education Other: Paediatric school Other: Paediatric school Private practice Other: Paediatric children treatment centre Hospital Hospital Hospital Rehabilitation Hospital (paediatrics) Hospital (mental health) Other: Work rehabilitation Hospital

Telephone Telephone Telephone In person Skype In person Telephone Skype Skype Skype Skype Skype Telephone Skype Telephone Telephone Skype Telephone In-person Skype

Note. IFP ¼ international fieldwork placement.

Participants were recruited primarily through a purposive sampling method where recruitment e-mails were sent to individuals who had registered with the international fieldwork database and listserv developed and run by the International Centre for Disability and Rehabilitation (2012), an organization focused on improving the lives of people with disabilities on a global stage through research and education initiatives. Additional participants were recruited through a snowball sampling method where recruitment e-mails were sent to fieldwork coordinators from other universities requesting suggestions for participants, and potential participants already contacted through the purposive method were asked to forward the recruitment e-mail to acquaintances who fit the recruitment criteria. All participants who responded were included in the study until the target of 20 was reached, except for 1 who had not practised for at least 1 year and 1 who did not follow up to schedule an interview. Study participants were 3 males and 17 females who had been practising from 1.5 to 5.5 years at the time of recruitment (see Table 1). The length of IFPs ranged from 5 to 8 weeks, and the IFPs were completed in six different LMIC: Tanzania, Trinidad, India, Cameroon, Kenya, and Colombia. Sixteen participants graduated from the occupational therapy program at the University of Toronto, 2 from the University of British Columbia, 1 from Queens University, and 1 from McGill University.

Data Collection Data were collected in 2012 using semi-structured in-depth interviews that ranged from 45 to 85 min in length. Three interviews were conducted in person at the researcher’s university, and the remainder were conducted by Skype or telephone. The

two student research team members (AVH, BPK) conducted 10 interviews each. Interview training, including instruction and mock interviews, was provided in their master of occupational therapy program and by the senior members of the research team. The interview guide was constructed based on relevant literature outlining the perceived influence of IFPs (Barker et al., 2010; Bonello, 2001; McAllister et al., 2006) and on the Profile of Occupational Therapy Practice in Canada (Canadian Association of Occupational Therapists [CAOT], 2007), a framework developed to guide the evaluation of competent and proficient occupational therapy practice within a Canadian context. Interviews consisted of three sections: (a) perception of the experience of the IFP in general, (b) perception of the relevance of the IFP to the seven occupational therapy roles within the Profile of Occupational Therapy Practice in Canada, and (c) perception of the most important perceived influence of the IFP on clinical practice (see Table 2 for sample interview questions). Participants were provided with a copy of the Profile of Occupational Therapy Practice in Canada (CAOT, 2007) and a handout containing a brief definition of the seven occupational therapy roles described within this document prior to their interview.

Data Analysis A directed content analysis was employed to analyze the data. In this process, ‘‘analysis starts with a theory or relevant research findings as guidance for initial codes’’ (Hsieh & Shannon, 2005, p. 1277). Relevant literature outlining the perceived influence of IFPs (Barker et al., 2010; Bonello, 2001; McAllister et al., 2006) and the Profile of Occupational

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Table 2 Sample Interview Questions Interview section

Sample question

Reflections on IFP experiences in general

‘‘Can you tell me about how you think these experiences may have influenced your occupational therapy career? Can you provide an example from your IFP that illustrates this?’’ ‘‘Being a collaborator is about working within an interprofesssional team and with other people across multiple settings. Do you feel your IFPs influenced your ability to work as a collaborator in your occupational therapy (OT) career today?’’ ‘‘The role of a communicator has to do with your ability to communicate with clients or others in several forms, verbally, in writing, or picking up on the nonverbal cues of clients and being aware of your own. Do you feel your international experience influenced your ability to work as a communicator in your OT career today?’’ ‘‘A practice manager relates to your ability to organize and manage everything from the daily routine such as your caseload and your use of resources to the big picture, such as your accountability to the public. Do you feel your international experience influenced your ability to work as a practice manager in your OT career today?’’ ‘‘The final competency, expert in enabling occupation, draws upon the competencies we just discussed. Do you feel your international experience influenced your ability to work as an expert in enabling occupation in your OT career today?’’ ‘‘Reflecting on all your experiences, what was one or two things that spoke to the overall impact of this placement on your OT career today? It can be something we have already discussed.’’ ‘‘Do you feel that your IFP has offered you anything a placement in Canada could not?’’

Reflection on the relevance of IFPs to occupational therapy roles

Reflection on the most important impacts of IFPs on clinical practice Note. IFP ¼ international fieldwork placement.

Therapy Practice in Canada (CAOT, 2007) determined the initial coding scheme and relationship between codes. The DEPICT model of data analysis was then employed to guide the data analysis and interpretation process, which involved the following six sequential steps: dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analyzing, and translating (Flicker & Nixon, 2014). Employing this model, all team members contributed to the development of descriptive summaries for each code by asking key questions of the data. Based on this coding framework, each transcript was coded independently by two different members of the research team, in distinct pairs. Data that could not be coded into the initial coding scheme were identified and analyzed by all members of the research team to determine if the data represented a new category or a subcategory of an existing code. Initially, 3 categories and 14 subcategories were identified in addition to the initial coding scheme. All six members of the research team collaboratively discussed, compared, and contrasted data within each code, reflective notes, and interview guides, until a final list of 2 categories and 6 subcategories was developed through majority group consensus.

Trustworthiness The two researchers who conducted the interviews (AVH and BPK) were students who were new to qualitative research and who had each participated in an IFP the previous year. To assist these two researchers in managing their assumptions, they each maintained a reflexive journal in an attempt to identify and bracket their own perceptions of the influence of IFPs and also kept a record of salient Canadian Journal of Occupational Therapy

points made by participants during the interviews and challenges encountered. Furthermore, these student researchers engaged in reflective dialogues with the two faculty team members (DLC and SAN) to assist in discerning between perceptions about IFPs based on personal experience in contrast to perspectives in the data. Although it was only the student researchers who conducted the interviews, all team members were involved in coding and analyzing the data and preparing the manuscript. An audit trail of the recruitment, data collection, and data analysis processes was kept throughout the study. The audit trail included a record of research team meetings and consensus obtained by team members with regard to the recruitment and data collection process, development of the coding scheme and categories, and organization of findings and discussion.

Findings Data analysis resulted in the identification of three main categories: active ingredients, occupational therapy roles, and competitive edge. The active ingredients category was inductively derived from the data and refers to the unique set of skills that were perceived by participants to be considerably enhanced during their IFPs. There was a total of six active ingredients: thinking on your feet, confidence, creativity, cultural sensitivity, independence, and problem solving. These ingredients were perceived to contribute directly to development of the seven occupational therapy roles outlined in the Profile of Occupational Therapy Practice in Canada (CAOT, 2007): expert in enabling occupation, collaborator, communicator, change agent, scholarly practitioner, practice manager, and professional. This category of roles was deductively

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Canadian Journal of Occupational Therapy 81(3) derived from the data as specific questions related to each role were included in the interview guide.

Active Ingredients When asked about the perceived influence of IFPs on the seven occupational therapy roles, participants consistently discussed IFPs as instrumental in fostering the development of a range of skills. These skills have been termed active ingredients and have been organized into six subcategories. Thinking on your feet. Most participants described having to adapt to new environments and a different mode of occupational therapy service delivery while on their IFPs. This skill is time sensitive in that participants described a temporal pressure to ‘‘roll with the punches’’ and ‘‘go with the flow’’ to achieve immediate goals with clients. As Ruby illustrated, If you can gain the ability to be flexible . . . and think on your feet and communicate with people within a number of different contexts, that’s going to serve in the long run of being a professional occupational therapist.

Confidence. Participants stated that IFPs took them out of their ‘‘comfort zone’’ and provided them with opportunities to try out new skills and take risks. Participants stated these experiences instilled a sense of confidence in their competence as a professional when confronted with novel and challenging situations and reported a sense of pride in achieving therapeutic goals with clients with minimal assistance. As Kate stated, ‘‘I would say the biggest influence would be in my confidence in my knowledge and skills because where we were, we didn’t have a lot of resources or support.’’ Creativity. Due to limited resources and exposure to unfamiliar clinical populations, participants stated IFPs enhanced their ability to create innovative solutions that were cost-effective, sustainable, culturally appropriate, and realistic. Participants stated IFPs urged them to ‘‘think outside the box’’ and brainstorm alternative solutions that they had not previously learned from fieldwork placements in Canada. As Ruby explained, [The IFP helped me] to be resourceful, put me in a room with enough junk to make something and I’ll probably come up with something pretty good . . . . Those are useful skills to have, to be creative, because there was no other choice.

Cultural sensitivity. Participants stated IFPs enhanced their awareness of cultural influences on health care delivery and the influence of lifestyle and resource disparities on occupational performance. As Sara described, It’s just made me realize the way you’re going to do outreach and collaborate with different groups is going to be different . . . . I think it’s really wonderful and exciting to be thinking about further work with different groups. It just brings a different richness to your work if you’re able to understand all these different perspectives and attitudes.

177 Independence. Many participants described feelings of being ‘‘thrown into the deep end’’ as they worked with clients with minimal supervision while on IFPs. Some participants perceived this as influential in enhancing their level of independence, autonomy, and comfort in taking initiative. For example, Lucy stated, ‘‘I guess the fact that you are an independent occupational therapy student there, working on your own, you have to do things on your own and be independent . . . something I did not get from any other placement.’’ However, some participants also noted the potential risk that this level of supervision may pose to clients. For example, Lucy described the following scenario with a client: He was becoming physically violent toward himself and it was just a really shocking thing for me to see and everyone was just standing there waiting to see what I would do. He [preceptor] was working with someone else, so I just had to step in and go with what I felt was right . . . . It was a little traumatic, but it made me be like, okay I can do this . . . . I made a decision and went with it and everything turned out okay.

Problem solving. Participants stated IFPs illuminated the benefits of utilizing materials and resources within their immediate environments to develop and implement pragmatic intervention plans in a culturally appropriate manner. This active ingredient differs from the others in that it refers to the actual implementation of solutions and is not dependent on time. Gina illustrates the development of this skill: I see that there are so many different alternatives to assistive devices and really thinking about whether providing someone with a device is really the best option for them or whether we can problem solve a different way that might be a better fit for the client.

Occupational Therapy Roles Participants provided numerous examples illustrating a connection between IFPs and the development of the seven occupational therapy roles to varying degrees. Participants most commonly described how IFPs enhanced the roles of expert in enabling occupation, collaborator, communicator, and change agent. IFPs were also viewed as contributing to the roles of scholarly practitioner, practice manager, and professional, but to a lesser extent. Participants perceived that specific features of IFPs in LMIC influenced the development of some occupational therapy roles over others, such as the availability of resources, the health care and cultural context, the supervisory model, and the learning environment. Participants varied in their perceptions of these features as enablers or disenablers for the development of occupational therapy roles. For example, when reflecting on the supervisory model during IFPs, some participants reported their supervisor was too ‘‘laid back’’ and did not provide enough direction, which was perceived by some as a disenabler for the development of the occupational therapy role of practice manager. Conversely, other participants

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perceived this feature as an enabler, in that they perceived this as an opportunity to self-direct their learning and independently manage their caseload. Below are specific ways in which participants perceived their IFPs as developing each of the occupational therapy roles. Expert in enabling occupation. Participants perceived that IFPs taught them to have trust in their competence in performing occupational therapy services. For instance, participants reported that IFPs facilitated the development of practice knowledge and clinical reasoning. Specific features of IFPs, such as limited resources and immersion in an unfamiliar culture, were discussed as important factors enabling participants to focus on clients’ meaningful occupations. Emma illustrates this role by stating, ‘‘I really learned that enabling occupation is not just what we think it’s about; it’s about addressing various aspects of the person, environment, or occupation and really thinking outside the box.’’ Participants also stated IFPs enhanced their ability to develop rapport with clients from diverse cultural backgrounds. For example, Sara shared, I learned that learning about someone else’s culture and having that genuine curiosity and interest goes a long way with building that rapport with any client, so if I’m able to use a phrase they taught me the next time I see them, and that sort of thing, it’s really great for your interaction with them and to develop that trust and rapport.

A few participants did not perceive IFPs as influencing their competence as experts in enabling occupation, such as Cora, who stated, ‘‘I think my ability to be an expert today stems more so from the practice I’ve had in my specific setting in my [current practice] . . . not from the experiences that I had during my IFP.’’ Communicator. Participants perceived that IFPs enabled the development of verbal and nonverbal communication skills. Some participants described responding to a language barrier by simplifying concepts, changing their rate of speech, and modifying their body language when communicating with clients and colleagues. As Leah illustrates, ‘‘Due to the language barrier you had to take into consideration language, gestures, I guess we even used drawings [to communicate] . . . . You really have to go beyond what you are saying to express yourself.’’ However, participants perceived that written communication skills were not as developed as other forms of communication during IFPs. For instance, Emma reported, ‘‘It [written communication] wasn’t really a big focus when I was there for my [international fieldwork] placement, so I can’t really speak to written documentation.’’ Collaborator. IFPs provided participants with opportunities to collaborate with various stakeholders, including parents, members of the health care team, community members, and other professionals, whom they may not have been exposed to within a Canadian context. As a result, participants described Canadian Journal of Occupational Therapy

an increased awareness of and appreciation for the influence of collaboration in improving client outcomes. As John stated, ‘‘For collaboration, my [IFP] gave me a clearer understanding of what the potential is if you collaborate, if you understand the people you are there with, the clients, the professionals, and what their lens is.’’ Change agent. Due to the nature of IFPs in LMIC, which can include a lack of physical and financial resources to support health care delivery, participants reported numerous opportunities to advocate on behalf of clients, assist communities and families to access health care services, and promote the profession of occupational therapy. Kate exemplified this concept when she said, ‘‘The big take-home thing that I got from this experience [an IFP] is that I have the power to make a difference as a person and as a clinician.’’ Scholarly practitioner. When reflecting upon whether her IFP facilitated the development of this occupational therapy role, Beth initially stated, ‘‘I don’t think it affected me as far as evidence-based practice because we definitely weren’t exposed to that while I was there,’’ a perception shared by other participants. Upon further probing, Beth and other respondents reported relying on a variety of resources, including preceptors, team members, clients, books, and prior knowledge, to inform their clinical reasoning and support participants’ work as evidence-based practitioners while on IFPs. In addition, being in a novel and unfamiliar environment was perceived to heighten participants’ awareness of the world around them and improve their ability to reflect on the influence of these experiences both personally and professionally. As Nina illustrates, Coming from another culture forces you to consider reflecting on whether I’m imposing my thoughts on them [clients], or is this really what their concerns for occupation are? So I think you really had to use that reflective piece in [IFPs] especially coming from another culture.

Participants also stated that IFPs motivated them to maintain and build personal skills by participating in international initiatives as volunteers, supervising occupational therapy students, or joining organizations focused on initiatives abroad. Practice manager. Participants perceived features of IFPs, such as the level of supervision, characteristics of the caseload, and level of structure, to be important factors enabling or hindering the influence of IFPs on this occupational therapy role. Nina expressed her perception that her IFP did not facilitate the development of this role in the following quote: ‘‘I didn’t have a large role in determining my caseload or how to manage that, just because it was such an unpredictable thing.’’ In contrast, Lucy reported, ‘‘Yeah, I think that’s a definite competency, it allowed me to be a good self-sufficient practice manager, you’re organizing, you’re managing yourself, you have your own caseload when your supervisor leaves, you’re on your own even when she’s there.’’

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Canadian Journal of Occupational Therapy 81(3) Professional. Participants believed IFPs provided various opportunities for them to manage ethical dilemmas, including providing safe and effective treatments with limited resources, managing requests for financial assistance, following ethical standards and guidelines, maintaining professional boundaries, and ensuring the sustainability of health care services. For instance, Dawn stated, ‘‘[My preceptor] was able to teach me skills on how to mediate that difficult situation and I feel that I’ve been able to apply that to my professional life,’’ in relation to her experience of the disclosure of sexual abuse while on her IFP. On the other hand, some participants perceived there was a lack of ethical standards and codes that limited their ability to develop this occupational therapy role. As Gina stated, It’s hard to say because the standards of [country of IFP] are so different than the standards here, like their consent policies were different. I mean all their policies are different. So I’d say in that sense I can’t really make a connection because I was really working in a basically completely different health care system.

Competitive Edge One finding that is not reflected in either of the major categories of active ingredients or occupational therapy roles was that several participants described how their IFPs equipped them with a competitive edge over other applicants when seeking employment in Canada. As exemplified in Lucy’s response, ‘‘I think back to when I had interviews, the interviewers were impressed by my having an IFP on my resume. I think during interviews I drew upon a lot of experiences in [IFP] for examples to their questions.’’

Discussion The current study reinforces existing literature and further explores the perceived influence of IFPs on personal and professional development. Barker et al. (2010) found that IFPs in HIC and LMIC enhanced the personal and professional development of occupational therapy students and professionals, including thinking outside the box, adaptability/flexibility, cultural sensitivity, mutuality and interpersonal relationships, and gaining confidence. In the current study, when participants reflected on their perceived influence of IFPs in LMIC on clinical practice, six active ingredients were consistently described that mirror the categories of personal and professional development as identified by Barker et al. For instance, the skill of thinking outside the box (Barker et al., 2010) parallels the finding that IFPs facilitate the development of the active ingredient of creativity within the current study. Categories of confidence and cultural sensitivity also emerged as active ingredients within the current study, which are congruent with skills of the same name from Barker et al.’s study. McAllister and colleagues’ (2006) study explored the learning process of

179 rehabilitation therapy students, including occupational therapy students, who engaged in IFPs in LMICs, and participants reported IFPs enhanced their sense of cultural awareness and acceptance, which resonates with the active ingredient of cultural sensitivity in the current study. Participants found it easier to describe the perceived influence of IFPs on the development of the six active ingredients, indicating that these may be foundational skills enabling the development of the seven occupational therapy roles. This finding was reinforced as all active ingredients except confidence can be found as indicators of various occupational therapy roles within the Profile of Occupational Therapy Practice in Canada (CAOT, 2007). For instance, the active ingredient problem solving can be found as an indicator of the role of expert in enabling occupation (CAOT, 2007, p. 8). The active ingredient of confidence was identified by the majority of participants as being enhanced by IFPs, although it is absent from the occupational therapy roles and their indicators that are used to evaluate the competence of Canadian occupational therapists. Current literature posits that confidence is a necessary foundational skill for occupational therapy students to practise in a competent and proficient manner (Clark, 2010; Derdall, Olsen, Janzen, & Warren, 2002; Lysack, Stadnyk, Paterson, McLeod, & Krefting, 1995). Derdall et al. (2002) differentiate between confidence as a belief or feeling about one’s abilities and competence in the objective skills one performs. For occupational therapists to practise competently and meet the needs of clients, it is held that occupational therapists must develop and project confidence (Clark, 2010). As such, the researchers argue that confidence is an essential active ingredient and necessary requisite trait for practising in a competent manner. Additionally, it is an avenue worthy of further exploration due to its potential implications for occupational therapy clinical practice. Holland, Middleton, and Uys (2012) posit that the development of confidence should be considered as essential as professional competence, as confidence is viewed as underlying competence. IFPs in LMIC were also found to provide participants with a competitive edge when seeking employment. Participants perceived that IFPs provided rich experiences from which to draw to highlight their skills and capabilities as an occupational therapist, thus separating them from other employment candidates. The researchers argue that as IFPs equip occupational therapy students with the building blocks for developing the occupational therapy roles (see CAOT, 2007), it may provide them with a competitive edge in the development of their overall clinical competency. Mill et al. (2010) state there is limited research documenting the outcomes of international practicums, and the knowledge gained during these experiences needs to be further evaluated within university curricula. A fundamental mandate of university curricula should be to integrate international experiences to ensure global citizenship; however, specific suggestions have yet to be explored and articulated (Mill et al., 2010).

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The findings of this study do point to the perceived influence of IFPs on both ‘‘active ingredients’’ and occupational therapy roles. However, it must be recognized that IFPs in LMIC are often very complex experiences that may include differing supervision models, role-emerging contexts, and exposure to different cultures and languages. For this reason, it is difficult to separate out the effects of the IFP from these other elements. For example, IFPs often utilize a variety of supervision models (offsite, role-emerging, distance). These alternate models have been shown to encourage active, deep learning and the opportunity to develop skills in problem solving and therapeutic use of activity (Fieldhouse & Fedden, 2009). A role-emerging setting can offer different opportunities to develop confidence in core skills, such as problem solving and the therapeutic use of activity, than traditional settings (Fieldhouse & Fedden, 2009). Although the current study reinforces findings by other researchers on this topic (e.g., Barker et al., 2010; Humbert, Burket, Deveney, & Kennedy, 2011; McAllister et al., 2006; Simonelis, Njelesani, Novak, Kuzma, & Cameron, 2011), this study contributes novel insights as it was the first to explore the perceptions of practicing Canadian occupational therapists about the influence of IFPs on occupational roles and underlying active ingredients. This study also utilized a widely disseminated competency and practice-based document to frame these perceptions.

Limitations The majority of participants completed their occupational therapy program at the same university, which may be a limitation to gaining an in-depth understanding of the perceived influence of IFPs on occupational therapy practice as university curricula offer different placement opportunities. We also note that we did not attend to the cultural histories of the participants, which could have shaped their interpretation of international fieldwork experiences. The interviews also did not specifically ask about the supervisory model experienced by participants, and thus how the supervisor-student relationship may have shaped their experience was not explored. It is possible that the wording of some of the occupational therapy roles is problematic as several participants questioned the language of certain occupational therapy roles as demonstrated by explicit comments critiquing specific definitions and terms found within the Profile of Occupational Therapy Practice in Canada (CAOT, 2007). Participants required additional time to answer certain questions and requested further explanations to support the reflective process. The occupational therapy roles of change agent, expert in enabling occupation, and scholarly practitioner were challenging for participants to comprehend and appeared to hinder participants’ ability to provide rich and relevant examples. For example, some participants did not consider themselves ‘‘experts’’ as clinicians. In addition, participants found it challenging to separate the occupational therapy roles of communicator and collaborator, often providing the same examples for both roles. Canadian Journal of Occupational Therapy

Future Research Future research may consider identifying and differentially evaluating specific features of IFPs in LMIC to gain a deeper understanding of how they facilitate or hinder the development of the active ingredients and occupational therapy roles, for example, exploring a broad range of supervisory models to examine which models of student supervision might best support all stakeholders involved. Further, researchers may seek to compare the perceived influence of fieldwork placements in resource poor settings within Canada to IFPs in LMIC to elucidate the differences and similarities in these fieldwork placements and their perceived influence on the development of the active ingredients and occupational therapy roles described in this study, as well as the perceived influence on subsequent clinical practice. As participants struggled with the wording and definitions of occupational therapy roles, future research may consider using the Essential Competencies of Practice (Association of Canadian Occupational Therapy Regulatory Organizations, 2011) or the Competency Based Fieldwork Evaluation for Occupational Therapists as a basis for an interview guide (Bossers, Miller, Polatajko, & Hartley, 2007) to explore the perceived influence of IFP on clinical practice. Canadian occupational therapists may be more familiar with these documents in comparison to the Profile of Occupational Therapy Practice in Canada (CAOT, 2007), which may facilitate the reflection process. Finally, we note that the current study did not explore the perceived influence of IFP on receiving communities, which is a topic requiring considerable future attention.

Conclusion As occupational therapy is a profession focused on evidencebased practice, it is necessary to ground the perceived influence of IFPs on occupational therapy practice in research. As a result of the growing trend toward the internationalization of health care, an increasing number of occupational therapy students are participating in IFPs, highlighting the importance of continued research on the possible influence of IFPs on their future practice. Findings from this study provide some evidence for the perceived beneficial influence of IFPs as they foster the development of occupational therapy roles and active ingredients, and may provide a competitive edge when seeking employment. These findings can inform occupational therapy placement education curricula, international fieldwork coordinators, students considering IFPs in LMIC, and other stakeholders concerned with graduating competent and proficient occupational therapists in Canada.

Key Messages  Participants perceived that international fieldwork placements support the development of six active ingredients

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(i.e., thinking on your feet, confidence, creativity, cultural sensitivity, independence, and problem solving), which facilitate the development of the seven occupational therapy roles within the Profile of Occupational Therapy Practice in Canada (CAOT, 2007). International fieldwork placements influence clinical practice as they were perceived to foster the development of occupational therapy roles and active ingredients and to provide a competitive edge when seeking employment.

Acknowledgments We wish to acknowledge the contribution of participants and transcribers, and the International Centre for Disability and Rehabilitation (and ICDR-Kenya in particular), for their assistance with recruitment. This research study was undertaken in partial fulfillment of a master’s degree in occupational therapy for the first two authors in the Department of Occupational Science and Occupational Therapy, University of Toronto.

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Author Biographies Adriana V. Haro, MScOT, OT Reg. (Ont.), is Occupational Therapist, Psychogeriatric Resource Consultant, Psychogeriatric Resource Consultation Program of Toronto, North York General Hospital, Seniors’ Health Centre, Toronto, ON, Canada. At the

time of this study, Adriana was a master’s student in the occupational therapy program at the University of Toronto. Brittany P. Knight, MScOT. At the time of this study, Brittany was a master’s student in the occupational therapy program at the University of Toronto. Debra L. Cameron, PhD, OT Reg. (Ont.), is Assistant Professor and International Fieldwork Coordinator, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, and Education Lead, International Centre for Disability and Rehabilitation, University of Toronto, Toronto, ON, Canada. Stephanie A. Nixon, PhD, PT, is Assistant Professor, Department of Physical Therapy, Faculty of Medicine, and Director, International Centre for Disability and Rehabilitation, University of Toronto, Toronto, ON, Canada. Puja A. Ahluwalia, MScPT, PT, MPH, is Physiotherapist, Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada. Emma L. Hicks, MScOT, OT Reg. (Ont.), is Occupational Therapist, Centre for Addiction and Mental Health, Toronto, ON, Canada.

Book Review Palmieri, Mark J. and Powers, Kristen M. (2013). Feeding your child with autism: A family-centred guide to meeting the challenges. Downsview, ON: Monarch Books of Canada. 145 pp. $21.95. ISBN: 978-1-60613-012-4 DOI: 10.1177/0008417414527572

Though not comprehensive enough to be the only book related to this topic in an occupational therapist’s library, Feeding Your Child With Autism is a welcome addition to mine. The authors, Dr. Palmeri, a licensed psychologist and a certified behaviour analyst, and Ms. Powers, an occupational therapist, are codirectors of a feeding clinic in Connecticut. Their book describes the range of eating challenges faced by children living with autism and their families. It is directed primarily at clinicians but is also family friendly, providing specific, concrete suggestions as to how to make the assessment and treatment process family-centred. The authors speak

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of evidence-based practices; however, the behavioural practices appear to be more clearly based upon evidence than some of the sensory and motor practices. The authors provide samples of helpful data collection forms emphasizing the importance of data in the decision-making process—deciding what new foods to present to a child with restricted oral motor skills and food selectivity and how. This book describes well therapy and home session requirements. However, I find that I still refer to my other resources when developing therapy plans. The book is excellent at emphasizing the importance of generalization of skills learned in therapy sessions to other settings. Readers of this book may find the description of the treatment process daunting, yet it has been my experience that such an intensive approach is often required. I recommend this book because it presents many tools and processes that can be used by occupational therapists in both rural and urban settings.

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Sheila Hamilton