Australian Occupational Therapy Journal (2014) 61, 20–27
doi: 10.1111/1440-1630.12037
Research Article
Working with populations from a refugee background: An opportunity to enhance the occupational therapy educational experience Yda J. Smith, Erika Cornella and Nyles Williams Division of Occupational Therapy, University of Utah, Salt Lake City, UT, USA
Background/aim: The purpose of this study was to determine the educational value of an occupational therapy fieldwork placement where students work with people from a refugee background. Research was designed to contribute to the limited evidence regarding the benefits and challenges of traditional vs. non-traditional fieldwork settings and to explore the application of occupational therapy related to working with refugee populations. Method: Fourteen participants were interviewed using semi-structured, open-ended questions to explore perspectives on how their experience influenced their education and professional development. Face-to-face interviews were audio-recorded and transcribed verbatim. Transcriptions and hard-copy data were analysed to identify emergent themes and subthemes. Triangulation and member-checking increased trustworthiness. Results: Three major themes emerged in this study: Operational therapy at its Core; Cultural Awareness and Competence; and Basic Skills for Any Setting. Subthemes emerged but for the purposes of this article only the major themes are discussed. Conclusion: A fieldwork experience working with people of a refugee background can facilitate the development of cultural awareness and competence, as well as foundational professional skills. In this setting, the importance of occupation-based, client-centred practice can be fully realised. Results indicate that this fieldwork setting is a suitable environment for experiencing occupational therapy principles and that labelling fieldwork experiences working with
Yda J. Smith PhD, OTR/L; Assistant Professor. Erika Cornella MOT, OTR/L; Occupational Therapist. Nyles Williams MOT. Correspondence: Yda J. Smith, Division of Occupational Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108, USA. Email: [email protected] Accepted for publication 8 February 2013. © 2013 The Authors Australian Occupational Therapy Journal © 2013 Occupational Therapy Australia
people from a refugee background as ‘non-traditional’ may be inappropriate. Learning experiences reported by students also reveal the benefits of working independently at times without direct supervision of an occupational therapist. KEY WORDS community, cultural competency, fieldwork, professional education, qualitative research.
Introduction Fieldwork education is a large part of the occupational therapy curriculum. It is the foundation on which students build their education and careers; it enables students to become competent therapists in various areas of practice and facilitates the development of effective practice habits (Bonello, 2001; Crowe & Mackenzie, 2001; Forwell, Whiteford & Dyck, 2001; Pope-Davis, Prieto, Whitaker & Pope-Davis, 1993). This study was designed to determine how fieldwork placements through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program impact the education of occupational therapists. The researchers propose that this fieldwork experience greatly influences one’s educational experience and that it promotes the development of self-confidence and skills necessary to be a culturally aware and competent practitioner in a diverse practice world.
Fieldwork education Fieldwork education refers to observations made and work done in a setting outside the classroom (Everson, 2009). Fieldwork placements provide students with hands-on opportunities to learn how to become empathetic and effective occupational therapists through the application of their ‘theoretical and scientific’ (Accreditation Council for Occupational Therapy Education [ACOTE], 2009; p. 821) knowledge and the implementation of interventions to address the occupational needs of clients throughout the lifespan. Through fieldwork education and experiences, students learn and integrate a multitude of necessary skills, which enable them as future thera-
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pists to better understand clients’ contextual factors and performance skills, as well as strengths and barriers that may impact successful occupational engagement (Kirke, Layton & Sim, 2007; McAllister, Whiteford, Hill, Thomas & Fitzgerald, 2006). Fieldwork education allows students to learn how to competently apply the occupational therapy process in a variety of settings to multiple populations and promotes the development of individual professional identities and behaviours (Kirke et al., 2007). In the United States, students are required to complete two 12 week, full-time fieldwork experiences that provide in-depth opportunities to build autonomy, increase responsibility and apply their academic knowledge of occupational therapy through the delivery of services to clients (ACOTE, 2009; Everson, 2009). Fieldwork education is designed to promote clinical reasoning, instil values and beliefs that ensure ethical and professional practice, and provide students with opportunities to implement a variety of occupational therapy assessments and interventions related to human occupation, performance and participation (ACOTE, 2009).
Non-traditional placement settings Fieldwork education takes place in both traditional and non-traditional settings. Traditional settings include medical facilities, such as acute, inpatient and outpatient care units. Non-traditional fieldwork environments are generally considered to consist of emerging practice contexts, such as welfare-to-work programmes, low vision clinics and ergonomic consulting and typically do not provide one-to-one occupational therapist supervision (Overton, Clark & Thomas, 2009). Specialty areas, including hand therapy or lymphedema clinics, may also be considered non-traditional settings. In addition, non-traditional contexts have included community settings, such as group homes for individuals with mentalhealth issues and refugee-resettlement agencies. Non-traditional settings are greatly expanding in today’s occupational therapy world, and these settings provide specific opportunities and challenges that affect and influence the development of competent occupational therapists (Cooper & Raine, 2009). Strengths of non-traditional fieldwork education placements include opportunities for understanding how foundational tenets of the profession and occupational science can be applied to practice (Gregory, Quelch & Watanabe, 2011). In addition, non-traditional settings promote, ‘development of a strong professional identity; development of independent thinking, planning and problemsolving skills; and greater scope for creativity in client program planning’ (Wood, 2005, p. 377). Although evidence exists that is supportive of fieldwork placements in non-traditional settings, there are those who believe traditional settings provide students with more relevant and appropriate educational experiences (Cooper & Raine, 2009). Challenges of non-traditional fieldwork placements include being forced to work outside one’s
comfort zone in an unfamiliar setting which can be overwhelming and isolating. In addition, some students perceive a lack of educational relevance to future employment opportunities (Overton et al., 2009; Wood, 2005). The following article provides a description of research completed by examining student experiences participating in an emerging practice setting that adds further evidence for discussion of this topic.
University of Utah Refugee Resettlement Community Fieldwork Program The University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program was developed in 2004 to address the occupational needs of people of immigrant or refugee backgrounds. It facilitates collaboration between students, University of Utah faculty, culturally diverse populations living in the local community and community organisations, including University Neighbourhood Partners-Hartland Partnership, the International Rescue Committee, the Hser Ner Moo Center and Utah Health and Human Rights Project. As of the summer of 2011, fifteen occupational therapy students from universities across the nation had participated in the fieldwork programme. Through this placement students provide life skills training to people of refugee backgrounds to increase occupational participation and independence, which includes public transportation training, driver’s education, home safety and maintenance, community and health-care access, computer training, money management, pre-employment skills and college preparation (McAllister, Penn, Smith, Van Dort & Wilson, 2010). Interventions are provided one-on-one, to families and in groups. Preservation of culture and participation in meaningful occupations are also addressed through gardening groups, weaving groups for Karen women from Burma, and a PAR FORE programme, which is a gang prevention mentor programme for at-risk youth (PAR FORE, 2011).
Fieldwork with refugee populations This fieldwork setting includes opportunities to collaborate with refugee resettlement agencies, which are in place to protect and support people who seek a safe refuge. A refugee is defined as a person who ‘owing to a wellfounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his or her nationality’ and who is unable to, or unwilling to, return to the country of origin (United Nations High Commissioner for Refugees [UNHCR], 2011). The population of displaced persons, including internally displaced, as well as people forced outside of their country of origin, has dramatically risen in the last 20 years with the current world estimate of refugees at 43 million (UNHCR, 2011). With the ever-growing increase in immigrants, displaced persons and resettled refugees, occupational
© 2013 The Authors Australian Occupational Therapy Journal © 2013 Occupational Therapy Australia
22 therapy students and practitioners are required to provide services in diverse environments to multicultural populations (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; McAllister et al., 2006; Whiteford & Wilcock, 2000; Wilson, 2008). Refugee populations face many barriers when they are forced to leave their homes, relocate and adapt to an environment and culture that is different from their own. A majority of refugees suffer from occupational deprivation, which refers to diminished participation in meaningful occupations (Whiteford, 2000); they are unable to participate in occupations that are valuable and purposeful due to language barriers, technology barriers, social isolation and mental-health issues (McAllister et al., 2010). Resettled refugees often find themselves ‘isolated and occupationally restricted’ (Whiteford, 2000, p. 202) in a new world that is not their home. There are consequences with detrimental, long-lasting effects to the occupational deprivation and imbalance that many refugees endure: routines are disrupted leading to inefficient time use; refugees develop maladaptive responses to many of the stressors associated with their new lives; diminished participation in meaningful occupations makes it difficult for refugees to engage in community activities; occupational deprivation leads to decreased occupational performance capacity and fulfilment of fewer occupational roles, which leads to further occupational deprivation (Whiteford, 2000, 2005). Men, women and children with a refugee background have specific occupational needs that must be met to ensure quality of life, some of which include learning a new language, new ways of social interaction, new occupations and new routines, as well as fulfilling new social and occupational roles (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; Whiteford, 2004, 2005; Whiteford & Wilcock, 2000; Wilson, 2008; Yau, 1997).
Impact of fieldwork education Fieldwork education with diverse populations allows students to recognise and explore diverse cultural beliefs, values and lifestyles and better enables them as practitioners to address the occupational needs of people of multicultural backgrounds (Murden et al., 2008). Working with diverse populations during fieldwork education also allows occupational therapy students to examine and expand upon their own cultural beliefs; exposure to cultural issues influences and increases one’s intercultural understanding, knowledge, awareness and competence (Chiang & Carlson, 2003; Forwell et al., 2001; Martins & Reid, 2007; McAllister et al., 2006; Pope-Davis et al., 1993; Rasmussen, Lloyd & Wielandt, 2005; Whiteford, 2005; Whiteford & Wilcock, 2000; Yau, 1997). Competent and effective occupational therapists must have experience with, and be educated about, a variety of cultures other than their own to prepare and deliver effective and successful therapy to a wide array of people from multicultural backgrounds.
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It is evident that fieldwork education has a major impact on the overall learning and preparation of the occupational therapy student, and this experience plays a deciding role in the career choices made by occupational therapy graduates (Crowe & Mackenzie, 2001; Forwell et al., 2001; Kirke et al., 2007; Pope-Davis et al., 1993). However, this evidence is largely based on traditional, mainstream fieldwork placements. With the increase of multicultural populations, the expansion of non-traditional practice areas, and because intercultural fieldwork placements promote culturally aware and competent future occupational therapy practitioners, research is greatly needed to examine how fieldwork education and experience in emerging practice settings influences the education of occupational therapy students. The purpose of this study was to investigate firsthand perspectives of occupational therapy students who have had a 12 week, full-time fieldwork experience through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program. The primary aims were to: ● Determine the educational benefits of this fieldwork placement as perceived by student participants ● Explore how fieldwork placements working with people of multicultural backgrounds can facilitate the development of cultural awareness and competence ● Explore the impact of this experience on the development of competent and effective occupational therapy practitioners
Methods The study was qualitative in nature using a grounded theory approach to create and connect thematic categories from participant data (Strauss & Corbin, 1998). The interviews were conducted using a semi-structured format with open-ended questions to allow the participants to freely generate responses. Interview questions (see Appendix) were designed to elicit in-depth responses from participants regarding their experiences working with people with a refugee background in this setting and how this experience impacted their education and professional development.
Selection of participants After Institutional Review Board approval, participants were recruited using a criterion-based strategy. The researchers sought participants who were current students or alumni of a Masters of Occupational Therapy Program with a 12-week full-time fieldwork experience through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program. Fifteen participants were identified as eligible. Participants included
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students from the University of Utah, Colorado State University and Ithaca College in New York.
Data collection Email addresses were provided to the researchers by their faculty advisor, and potential participants were contacted by email regarding the study. Of the 15 eligible participants, 14 responded and agreed to participate in the study. Six participants engaged in face-to-face interviews with the researchers, one participated in a face-to-face interview via the internet due to the participant’s location in a different state. Seven chose to respond to the interview questions in hard copy, due to time constraints and location issues.
Data analysis The face-to-face interviews were audio-recorded and transcribed verbatim. Transcriptions and questions answered in hard copy were analysed by the researches using grounded theory methods of open, axial and selective coding to identify emergent themes and subthemes that were consistent across interviews (Portney & Watkins, 2009; Strauss & Corbin, 1998). Themes that emerged were analysed to identify dominant themes that appeared with great frequency and were then sorted into related groups which led to the identification of three major themes with related subthemes. Researchers completed the first stages of the analysis procedure independently and then compared findings and worked together to increase trustworthiness in the interpretation of data.
Strategies to establish trustworthiness Triangulation occurred between researchers to promote trustworthiness. Peer review was conducted between the researchers, faculty advisers and student colleagues. The researchers conducted member-checking by emailing coded themes to participants and inviting feedback to enhance accuracy of data interpretation.
Results Analysis of qualitative data resulted in the emergence of three major themes: Operational therapy at its Core, Cultural Awareness and Competence and Basic Skills for Any Setting. Several subthemes emerged as well but for the purposes of this article only the major themes will be discussed.
One participant stated, ‘It’s about peoples’ lives and helping them live life to its fullest’. Clients’ increased participation and independence in daily and meaningful occupations was achieved through work within the clients’ homes and in their communities. These environments facilitated the implementation of client-centred and occupation-based services, which is at the core of occupational therapy practice. According to American Occupational Therapy Association [AOTA] (2008), the purpose of occupational therapy is to facilitate increased participation and improved performance in daily and meaningful occupations through client-centred and occupation-based interventions. Client-centred practice entails establishing goals that are valuable to each individual client. Client-centred practice is especially important when working with refugee populations and other minority groups as it reflects the practitioner’s dedication to equality and empowers clients who have suffered from occupational deprivation (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; Whiteford, 2004, 2005; Wilson, 2008). Occupation-based therapy enables clients to achieve optimal outcomes through participation in the desired activities or tasks. An emphasis on the fundamentals of occupational therapy during this fieldwork experience was illustrated by several participant comments including the following: This is OT at its core…achieving whatever the client wants to achieve through occupation. I felt like with this fieldwork experience I was able to really hit the core of occupational therapy. That is, helping people do the occupations they want or need to do. It was some of the most occupationbased, client-centred OT that I have seen yet. Everything we do here is occupation-based, like, in your face occupation-based, like, there’s no other way to put it, I mean, we’re teaching them how to get jobs, I shouldn’t say teaching, empowering them, you know, to navigate the system, get into college, access health care, drive, access transportation, and then all the way to weaving, maintaining culture, preserving culture. It’s such a unique experience, you know, it’s definitely occupational therapy outside the box… in the truest form. That’s what it’s all about.
One participant, who was employed as an occupational therapist at the time of the interview, commented on how this fieldwork experience influenced her current practice:
Discussion of results Operational therapy at its core The placement through the Immigration and Refugee Resettlement Community Fieldwork Program provided students with in-depth opportunities to apply what has been learned in school to real-life situations. Students realised that occupational therapy can address much more than physical deficits and mental-health issues.
The way I approach intervention is now much more occupation-based than before. Before this placement, I had a tendency to talk about things with clients too much. This is not an option in this placement. Everything is about doing and finding solutions in the moment.
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Participants were able to fully understand the importance of being client-centred and occupation-based in practice and were able to develop and implement interventions that enabled each client to successfully participate in meaningful and purposeful occupations.
Cultural awareness and competence Students were provided with in-depth opportunities to interact with people of various cultural backgrounds. They were encouraged to recognise and respect diverse cultural beliefs, values and lifestyles. Competence in providing culturally responsive care was developed as participants identified their own cultural perspectives. Cognizance of their own cultural beliefs and values led to awareness of personal assumptions and biases and the potential impact these factors could have on the cultivation of a positive therapeutic relationship and overall therapy process, as illustrated by the following participant comment, ‘I think when you’re not exposed to these other groups you have some type of preconceived notion of who they are or who they’re not, and this can impact how you interact with that person’. Through this fieldwork placement students realised that what is considered ‘normal’ in one culture may be out of the norm in another. Lessons learned are reflected in the following comments: I developed a cultural sensitivity that could not have been learned anywhere else… I am [now] able to put aside my own agenda or American perspective to really understand the occupational profile of an individual, which so often is incredibly influenced by culture, and use that information to develop meaningful treatment. I am not afraid to work with someone who doesn’t speak English, and that’s a huge confidence booster for me…It also helped me be more bold in incorporating their culture into the therapy. [I] still feel like I have a long way to go in cultural competency. I think I see now that it’s a process, not really, like an end goal. I consider cultural awareness and competency to be one of the greatest benefits of participating in this FW setting. I now take a slightly different approach with patients from different cultural backgrounds or who speak a language other than English than I may have done before I was involved in this fieldwork. I remember that my fieldwork clients liked it when I was interested in learning about their culture/language, and it is often the same with patients I have now. I still try to keep in mind that people from other cultures may have different views of health and healing in general. [T]his fieldwork really helped to put these factors in the front of my mind, so that I am always careful
that what I say and do matches the values of the people I am working with. It made it easier for me to practice OT according to each client’s values rather than according to my own. [W]hat I learned…is how they work with one another and how they work in their own environments. Their expectations, rules… You would not get that anywhere else… I learned when you sit on a chair, when you don’t sit on a chair, when you shake hands, when you don’t shake hands, when you look somebody in the eyes or don’t, refuse food, so on and so forth. And you never get that anywhere else. You might get it here and there in another setting with a random person from another country coming in with their family, but you wouldn’t get this in-depth exposure because you’re in the home, you’re in their work sites…places like that working with them and you’re the one that’s out of place when you’re there, so you don’t get that experience anywhere else.
Participants realised that culture is not just ethnicity or nationality. Culture is a part of each person as an occupational being; culture shapes what you do, how you do it and why you do it. Opportunities were provided through this fieldwork experience that enabled students to develop cultural awareness and competence, promoting an increased ability to assess and address the cultural needs of every individual.
Basic skills for any setting Opportunities were provided to develop and implement a variety of skills that are required of occupational therapists, including clinical reasoning, documentation skills, rapport building and treatment planning. Participant comments that illustrate this theme include, ‘Those skills of getting to know somebody and their priorities and their needs and their skill levels, their abilities, barriers; it’s all transferable’. Opportunities were available through this fieldwork experience to apply theoretical backgrounds to practice. Every participant mentioned ways in which they implemented the Person-Environment-Occupation (PEO) model (Baum & Christiansen, 2005) to find the best fit for their clients. Students applied observation skills and activity analysis to every task to grade activities up or down according to the client’s ability and to provide the ‘just right challenge’ for every individual. Students learned how to independently develop treatment plans to address the needs and desires of each client. Students also learned that treatment sessions did not always go as planned and that it was mandatory to have a back-up plan for the back-up plan. As mentioned, language was a major barrier in this setting, and students learned how to implement multiple means of communication. Participants also commented on their increased ability to produce timely and concise documentation and to advocate for their clients. One alumni summed it up by saying:
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I was surprised at how much the skills I developed during this FW transferred over to traditional practice areas… There were different barriers, different goals, and different types of treatments, but all the elements of therapy and clinical reasoning are still there… this FW provided me opportunities to develop the basic skills that any therapist needs in any setting: clinical reasoning, being occupation-based, being client-centered, documentation writing, rapport building, treatment planning, designing and leading groups, and we even helped write a grant during FW. These are all skills that I use at my current place of employment.
Learning through doing Through the independence experienced at this fieldwork placement, students developed a sense of autonomy. Participants acquired increased confidence in their abilities as practitioners, which led to an increased sense of professional identity. Clients were not medically compromised which created an opportunity for students to work on their own, safely experimenting with therapeutic approaches and learning through trial and error. Direct supervision by an occupational therapist was provided at times and otherwise the supervisor was available by phone or email. Without constant, direct supervision, students were encouraged to collaborate and support each other by validating and critically appraising each other’s treatment plan ideas. Indirect supervision freed participants from concern about what they should be doing in the eyes of a clinical supervisor, which allowed them to focus on the needs of their clients. At a weekly meeting of all of the students with the supervisor, cases were reviewed and students had the opportunity to ask questions and receive advice. The following comments illustrate how much students valued working independently and how much they gained from this type of supervisory structure: [Y]ou went in as a student and had to act like the professional and really trust yourself to be that professional. And I absolutely loved being able to go through my own trial and error, check in with somebody and know that I was providing appropriate therapy. And you’re a student, but in this setting, I didn’t feel like I had so many risks, which opened the world wide up…the most amazing thing, too, is you actually had the opportunity to collaborate [you’re your client] whereas other places have, you know, like, everything’s rote: you need to meet these goals by this time and insurance will only pay for so much. Whereas this place, the world was your oyster, literally, it was awesome! And because of that, you were independent, nobody was watching over you, you had to make the best judgment that you could and help the person.
[Y]ou’re not dealing with somebody who is medically fragile and if you mess up, you know… you learn and you move on and it’s a safe place to do it. I think it’s good. It definitely forces you to just jump right in and just, you know, do it.
Challenges Participants were faced with many challenges, the greatest of which the language barrier. Translators were occasionally available, but students mainly relied on multiple means of communication to interact with refugees who did not speak English, including non-verbal communication, gestures and even pictures. One participant commented, ‘Language was the hardest, I used every form of communication you could imagine’. Time management was another challenge for most of the participants. The students had the flexibility to create their own schedules, which was a benefit. However, this challenged students to prioritise time to see clients and to document, while also making time to coordinate schedules between agencies, clients, translators and other professionals. Although the information provided by participating students was overwhelmingly favourable with regard to their opinions on the value of this fieldwork experience, there were a few frustrations mentioned. The issue mentioned most often was frequent missed appointments due to misunderstandings caused by communication barriers and different cultural attitudes towards keeping appointments. Even after a positive experience with the programme, one student had regrets stating, ‘I wish I had had a [full-time fieldwork] in a rehab setting, since that is where most of the jobs are…I wish I had more experience in this area’. This student perception of missed opportunities for development of clinical skills has also been expressed by students in prior studies (Overton et al., 2009). It would be helpful to interview these same students after they have been employed for some time, to determine if this perception persists.
Implications Effective educational experiences have clearly been facilitated through this fieldwork placement. Results from this study demonstrate that fieldwork experiences such as the one described in this article can provide educational lessons and opportunities much like those available in traditional medically based settings. Students can discover the value of meaningful occupations, and can gain experience with rapport building, clinical reasoning skills and documentation while, at the same time, newly arrived refugees are able to receive life skills training they otherwise might not be able to access. Fieldwork placements working specifically with refugee populations have the potential to provide powerful student experiences that are not readily available in
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26 most fieldwork environments. Working with non-English speakers from a variety of cultures creates substantive opportunities for personal growth in observation and communication skills along with cultural awareness. Students have opportunities to recognise and address occupational deprivation and imbalance caused by the refugee and migration experience. Due to the refugees’ desire to learn specific life skills and the location of student work in the community, rather than a clinic, nearly every session with the clients is, by default, occupation-based. A fieldwork setting such as this would likely be labelled as ‘non-traditional’ but with direct exposure to and practise with fundamental aspects of occupational therapy practice, it would be best to consider an experience such as this as ‘traditional’ and as a suitable environment for experiencing the core principles of the occupational therapy profession. Analysis of participant interviews revealed the additional benefits that occurred due to distant supervision and independent work. Providing services in a nonmedical setting created an opportunity for students to apply their own ideas for therapeutic strategies and learn through trial and error. A majority of the students interviewed highly valued this aspect of the experience which may imply that occupational therapy academic curriculums should consider offering more experiences where students are encouraged to work on their own in environments where it is safe to do so. However, it is important to keep in mind that not every student is ready for this level of independence when coming directly from the academic environment.
Strengths and limitations Data collected for this study were retrospective in nature which could be considered a limitation or a strength. As a limitation, the retrospective collection of data carries the potential for participants to either forget or inaccurately recall details of their experience. In contrast, this is also a strength as it allowed participants time to process and reflect on their experiences working with refugee populations. The opportunity to reflect on their fieldwork experiences allowed participants to consider the educational and professional implications of the expertise gained and how these experiences were integrated into their professional identities. Limitations include incomplete member-checking as the researchers did not receive feedback from all of the participants. There is also the potential for subjective bias on the part of the researchers as both have completed a fieldwork placement in this setting.
Conclusion The University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program is an innovative and unique programme that provides occupational therapy students with real-life
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opportunities to work with people with a refugee background, while learning and developing the core skills necessary to become effective and competent occupational therapy practitioners. Cultural awareness and confidence in implementing therapeutic strategies are particular strengths of the programme. Through this experience, occupational therapy students develop the ability to work with diverse and under-served populations, which is a necessity in our growing and changing world. While participating in this programme, students are able to practise and provide client-centred, occupation-based training that promotes client engagement in meaningful occupations while facilitating the ability of people with a refugee background to adapt to life in the United States. The results of this study provide further supportive evidence for placement of occupational therapy students in non-traditional fieldwork settings. Although there are challenges inherent in this type of setting, the numerous benefits clearly outweigh these potential challenges.
Acknowledgements There are no financial grants or funding sources related to this research study. The authors are involved in no potential conflicts of interest relevant to this study.
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Willard & Spackman’s Occupational Therapy, (11th ed.) (pp. 252–261). Baltimore, MD: Lippincott Williams & Wilkins. Forwell, S., Whiteford, G. & Dyck, I. (2001). Cultural competence in New Zealand and Canada: Occupational therapy students’ reflection on class and fieldwork curriculum. Canadian Journal of Occupational Therapy, 68, 90–103. Gregory, P., Quelch, L. & Watanabe, E. (2011). The student experience of a role emerging placement. In: M. Thew, M. Edwards, S. Baptiste & M. Molineux (Eds.), Role Emerging Occupational Therapy (pp. 54–65). West Sussex, UK: Wiley-Blackwell. Kinebanian, A. & Stomph, M. (1992). Cross-cultural occupational therapy: A critical reflection. American Journal of Occupational Therapy, 46, 751–757. Kirke, P., Layton, N. & Sim, J. (2007). Informing fieldwork design: Key elements to quality in fieldwork education for undergraduate occupational therapy students. Australian Occupational Therapy Journal, 54, 13–22. Martins, V. & Reid, D. (2007). New-immigrant women in urban Canada: Insights into occupation and sociocultural content. Occupational Therapy International, 14, 203–220. McAllister, L., Whiteford, G., Hill, B., Thomas, N. & Fitzgerald, M. (2006). Reflection in intercultural learning: Examining the international experience through a critical incident approach. Reflective Practice, 7, 367–381. McAllister, L., Penn, C., Smith, Y., Van Dort, S. & Wilson, L. (2010). Fieldwork education in non-traditional settings or with non-traditional caseloads. In: L. McAllister, M. Paterson, J. Higgs & C. Bithell (Eds.), Innovations in Allied Health Fieldwork Education: A Critical Appraisal (pp. 39– 47). Rotterdam, Netherlands: Sense. Murden, R., Norman, A., Ross, J., Sturdivant, E., Kedia, M. & Shah, S. (2008). Occupational therapy students’ perceptions of their cultural awareness and competency. Occupational Therapy International, 15, 191–203. Overton, A., Clark, M. & Thomas, Y. (2009). A review of non-traditional occupational therapy practice placement education: A focus on role-emerging and project placements. British Journal of Occupational Therapy, 72, 294–301. PAR FORE. (2011). Promoting adult success through healthy occupations. Retrieved October 29, 2011, from http://www.parfore.org. Pope-Davis, D., Prieto, L., Whitaker, C. & Pope-Davis, S. (1993). Exploring multicultural competencies of occupational therapists: Implications for education and training. American Journal of Occupational Therapy, 47, 838–844. Portney, L. & Watkins, M. (2009). Foundations of clinical research: Applications to practice (3rd ed.). Upper Saddle River, NJ: Pearson/Prentice Hall. Rasmussen, T., Lloyd, C. & Wielandt, T. (2005). Cultural awareness among Queensland undergraduate occupational therapy students. Australian Occupational Therapy Journal, 52, 301–310. Strauss, A. L. & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, CA: Sage. United Nations High Commissioner for Refugees. (2011). Statistics and operational data. Retrieved October 27, 2011, from http://www.unhcr.org.
Whiteford, G. (2000). Occupational deprivation: Global challenge in the new millennium. British Journal of Occupational Therapy, 63, 200–205. Whiteford, G. (2004). Occupational issues of refugees. In: M. Molineux (Ed.), Occupation for occupational therapists (pp. 183–199). Malden, MA: Blackwell Publishing. Whiteford, G. (2005). Understanding the occupational deprivation of refugees: A case study from Kosovo. Canadian Journal of Occupational Therapy, 72, 78–88. Whiteford, G. & Wilcock, A. (2000). Cultural relativism: Occupation and independence reconsidered. Canadian Journal of Occupational Therapy, 67, 324–336. Wilson, C. (2008). Illustrating occupational needs of refugees. In: N. Pollard, D. Sakellariou & F. Kronenberg (Eds.), A political practice of occupational therapy (pp. 191– 195). Philadelphia, PA: Churchill Livingstone Elsevier. Wood, A. (2005). Student practice contexts: Changing face, changing place. British Journal of Occupational Therapy, 68, 375–378. Yau, M. K. (1997). The impact of refugee resettlement on Southeast Asian adolescents and young adults: Implications for occupational therapists. Occupational Therapy International, 4, 1–16.
Appendix: Interview Guiding Questions Why did you choose to participate in this FW experience? Describe your overall experience working with people with a refugee background as a Level II fieldwork student. How has working with refugees and/or immigrants affected your educational experience? What did you learn from working with refugees/ immigrants that could not have been obtained through other types of FW? What foundational occupational therapy skills did you learn during this FW and how did it prepare you for later FW placements or for your current place of employment? Describe the aspects of occupational therapy that relate to working with immigrants and/or refugees in a non-traditional fieldwork setting. How has this FW experience impacted the development of your cultural awareness and competence? In what ways has this FW prepared you for occupational therapy practice? What practice habits have you developed due to your fieldwork placement in a non-traditional setting working with refugees? Did this FW experience influence your ability to pass the US certification exam? If yes—expand. Has this FW influenced your choice of practice setting? Where is your current place of employment? Did this FW experience impact your ability to work on a multi-disciplinary team? Describe.
© 2013 The Authors Australian Occupational Therapy Journal © 2013 Occupational Therapy Australia
doi: 10.1111/1440-1630.12037
Research Article
Working with populations from a refugee background: An opportunity to enhance the occupational therapy educational experience Yda J. Smith, Erika Cornella and Nyles Williams Division of Occupational Therapy, University of Utah, Salt Lake City, UT, USA
Background/aim: The purpose of this study was to determine the educational value of an occupational therapy fieldwork placement where students work with people from a refugee background. Research was designed to contribute to the limited evidence regarding the benefits and challenges of traditional vs. non-traditional fieldwork settings and to explore the application of occupational therapy related to working with refugee populations. Method: Fourteen participants were interviewed using semi-structured, open-ended questions to explore perspectives on how their experience influenced their education and professional development. Face-to-face interviews were audio-recorded and transcribed verbatim. Transcriptions and hard-copy data were analysed to identify emergent themes and subthemes. Triangulation and member-checking increased trustworthiness. Results: Three major themes emerged in this study: Operational therapy at its Core; Cultural Awareness and Competence; and Basic Skills for Any Setting. Subthemes emerged but for the purposes of this article only the major themes are discussed. Conclusion: A fieldwork experience working with people of a refugee background can facilitate the development of cultural awareness and competence, as well as foundational professional skills. In this setting, the importance of occupation-based, client-centred practice can be fully realised. Results indicate that this fieldwork setting is a suitable environment for experiencing occupational therapy principles and that labelling fieldwork experiences working with
Yda J. Smith PhD, OTR/L; Assistant Professor. Erika Cornella MOT, OTR/L; Occupational Therapist. Nyles Williams MOT. Correspondence: Yda J. Smith, Division of Occupational Therapy, University of Utah, 520 Wakara Way, Salt Lake City, UT 84108, USA. Email: [email protected] Accepted for publication 8 February 2013. © 2013 The Authors Australian Occupational Therapy Journal © 2013 Occupational Therapy Australia
people from a refugee background as ‘non-traditional’ may be inappropriate. Learning experiences reported by students also reveal the benefits of working independently at times without direct supervision of an occupational therapist. KEY WORDS community, cultural competency, fieldwork, professional education, qualitative research.
Introduction Fieldwork education is a large part of the occupational therapy curriculum. It is the foundation on which students build their education and careers; it enables students to become competent therapists in various areas of practice and facilitates the development of effective practice habits (Bonello, 2001; Crowe & Mackenzie, 2001; Forwell, Whiteford & Dyck, 2001; Pope-Davis, Prieto, Whitaker & Pope-Davis, 1993). This study was designed to determine how fieldwork placements through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program impact the education of occupational therapists. The researchers propose that this fieldwork experience greatly influences one’s educational experience and that it promotes the development of self-confidence and skills necessary to be a culturally aware and competent practitioner in a diverse practice world.
Fieldwork education Fieldwork education refers to observations made and work done in a setting outside the classroom (Everson, 2009). Fieldwork placements provide students with hands-on opportunities to learn how to become empathetic and effective occupational therapists through the application of their ‘theoretical and scientific’ (Accreditation Council for Occupational Therapy Education [ACOTE], 2009; p. 821) knowledge and the implementation of interventions to address the occupational needs of clients throughout the lifespan. Through fieldwork education and experiences, students learn and integrate a multitude of necessary skills, which enable them as future thera-
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pists to better understand clients’ contextual factors and performance skills, as well as strengths and barriers that may impact successful occupational engagement (Kirke, Layton & Sim, 2007; McAllister, Whiteford, Hill, Thomas & Fitzgerald, 2006). Fieldwork education allows students to learn how to competently apply the occupational therapy process in a variety of settings to multiple populations and promotes the development of individual professional identities and behaviours (Kirke et al., 2007). In the United States, students are required to complete two 12 week, full-time fieldwork experiences that provide in-depth opportunities to build autonomy, increase responsibility and apply their academic knowledge of occupational therapy through the delivery of services to clients (ACOTE, 2009; Everson, 2009). Fieldwork education is designed to promote clinical reasoning, instil values and beliefs that ensure ethical and professional practice, and provide students with opportunities to implement a variety of occupational therapy assessments and interventions related to human occupation, performance and participation (ACOTE, 2009).
Non-traditional placement settings Fieldwork education takes place in both traditional and non-traditional settings. Traditional settings include medical facilities, such as acute, inpatient and outpatient care units. Non-traditional fieldwork environments are generally considered to consist of emerging practice contexts, such as welfare-to-work programmes, low vision clinics and ergonomic consulting and typically do not provide one-to-one occupational therapist supervision (Overton, Clark & Thomas, 2009). Specialty areas, including hand therapy or lymphedema clinics, may also be considered non-traditional settings. In addition, non-traditional contexts have included community settings, such as group homes for individuals with mentalhealth issues and refugee-resettlement agencies. Non-traditional settings are greatly expanding in today’s occupational therapy world, and these settings provide specific opportunities and challenges that affect and influence the development of competent occupational therapists (Cooper & Raine, 2009). Strengths of non-traditional fieldwork education placements include opportunities for understanding how foundational tenets of the profession and occupational science can be applied to practice (Gregory, Quelch & Watanabe, 2011). In addition, non-traditional settings promote, ‘development of a strong professional identity; development of independent thinking, planning and problemsolving skills; and greater scope for creativity in client program planning’ (Wood, 2005, p. 377). Although evidence exists that is supportive of fieldwork placements in non-traditional settings, there are those who believe traditional settings provide students with more relevant and appropriate educational experiences (Cooper & Raine, 2009). Challenges of non-traditional fieldwork placements include being forced to work outside one’s
comfort zone in an unfamiliar setting which can be overwhelming and isolating. In addition, some students perceive a lack of educational relevance to future employment opportunities (Overton et al., 2009; Wood, 2005). The following article provides a description of research completed by examining student experiences participating in an emerging practice setting that adds further evidence for discussion of this topic.
University of Utah Refugee Resettlement Community Fieldwork Program The University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program was developed in 2004 to address the occupational needs of people of immigrant or refugee backgrounds. It facilitates collaboration between students, University of Utah faculty, culturally diverse populations living in the local community and community organisations, including University Neighbourhood Partners-Hartland Partnership, the International Rescue Committee, the Hser Ner Moo Center and Utah Health and Human Rights Project. As of the summer of 2011, fifteen occupational therapy students from universities across the nation had participated in the fieldwork programme. Through this placement students provide life skills training to people of refugee backgrounds to increase occupational participation and independence, which includes public transportation training, driver’s education, home safety and maintenance, community and health-care access, computer training, money management, pre-employment skills and college preparation (McAllister, Penn, Smith, Van Dort & Wilson, 2010). Interventions are provided one-on-one, to families and in groups. Preservation of culture and participation in meaningful occupations are also addressed through gardening groups, weaving groups for Karen women from Burma, and a PAR FORE programme, which is a gang prevention mentor programme for at-risk youth (PAR FORE, 2011).
Fieldwork with refugee populations This fieldwork setting includes opportunities to collaborate with refugee resettlement agencies, which are in place to protect and support people who seek a safe refuge. A refugee is defined as a person who ‘owing to a wellfounded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his or her nationality’ and who is unable to, or unwilling to, return to the country of origin (United Nations High Commissioner for Refugees [UNHCR], 2011). The population of displaced persons, including internally displaced, as well as people forced outside of their country of origin, has dramatically risen in the last 20 years with the current world estimate of refugees at 43 million (UNHCR, 2011). With the ever-growing increase in immigrants, displaced persons and resettled refugees, occupational
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22 therapy students and practitioners are required to provide services in diverse environments to multicultural populations (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; McAllister et al., 2006; Whiteford & Wilcock, 2000; Wilson, 2008). Refugee populations face many barriers when they are forced to leave their homes, relocate and adapt to an environment and culture that is different from their own. A majority of refugees suffer from occupational deprivation, which refers to diminished participation in meaningful occupations (Whiteford, 2000); they are unable to participate in occupations that are valuable and purposeful due to language barriers, technology barriers, social isolation and mental-health issues (McAllister et al., 2010). Resettled refugees often find themselves ‘isolated and occupationally restricted’ (Whiteford, 2000, p. 202) in a new world that is not their home. There are consequences with detrimental, long-lasting effects to the occupational deprivation and imbalance that many refugees endure: routines are disrupted leading to inefficient time use; refugees develop maladaptive responses to many of the stressors associated with their new lives; diminished participation in meaningful occupations makes it difficult for refugees to engage in community activities; occupational deprivation leads to decreased occupational performance capacity and fulfilment of fewer occupational roles, which leads to further occupational deprivation (Whiteford, 2000, 2005). Men, women and children with a refugee background have specific occupational needs that must be met to ensure quality of life, some of which include learning a new language, new ways of social interaction, new occupations and new routines, as well as fulfilling new social and occupational roles (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; Whiteford, 2004, 2005; Whiteford & Wilcock, 2000; Wilson, 2008; Yau, 1997).
Impact of fieldwork education Fieldwork education with diverse populations allows students to recognise and explore diverse cultural beliefs, values and lifestyles and better enables them as practitioners to address the occupational needs of people of multicultural backgrounds (Murden et al., 2008). Working with diverse populations during fieldwork education also allows occupational therapy students to examine and expand upon their own cultural beliefs; exposure to cultural issues influences and increases one’s intercultural understanding, knowledge, awareness and competence (Chiang & Carlson, 2003; Forwell et al., 2001; Martins & Reid, 2007; McAllister et al., 2006; Pope-Davis et al., 1993; Rasmussen, Lloyd & Wielandt, 2005; Whiteford, 2005; Whiteford & Wilcock, 2000; Yau, 1997). Competent and effective occupational therapists must have experience with, and be educated about, a variety of cultures other than their own to prepare and deliver effective and successful therapy to a wide array of people from multicultural backgrounds.
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It is evident that fieldwork education has a major impact on the overall learning and preparation of the occupational therapy student, and this experience plays a deciding role in the career choices made by occupational therapy graduates (Crowe & Mackenzie, 2001; Forwell et al., 2001; Kirke et al., 2007; Pope-Davis et al., 1993). However, this evidence is largely based on traditional, mainstream fieldwork placements. With the increase of multicultural populations, the expansion of non-traditional practice areas, and because intercultural fieldwork placements promote culturally aware and competent future occupational therapy practitioners, research is greatly needed to examine how fieldwork education and experience in emerging practice settings influences the education of occupational therapy students. The purpose of this study was to investigate firsthand perspectives of occupational therapy students who have had a 12 week, full-time fieldwork experience through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program. The primary aims were to: ● Determine the educational benefits of this fieldwork placement as perceived by student participants ● Explore how fieldwork placements working with people of multicultural backgrounds can facilitate the development of cultural awareness and competence ● Explore the impact of this experience on the development of competent and effective occupational therapy practitioners
Methods The study was qualitative in nature using a grounded theory approach to create and connect thematic categories from participant data (Strauss & Corbin, 1998). The interviews were conducted using a semi-structured format with open-ended questions to allow the participants to freely generate responses. Interview questions (see Appendix) were designed to elicit in-depth responses from participants regarding their experiences working with people with a refugee background in this setting and how this experience impacted their education and professional development.
Selection of participants After Institutional Review Board approval, participants were recruited using a criterion-based strategy. The researchers sought participants who were current students or alumni of a Masters of Occupational Therapy Program with a 12-week full-time fieldwork experience through the University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program. Fifteen participants were identified as eligible. Participants included
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students from the University of Utah, Colorado State University and Ithaca College in New York.
Data collection Email addresses were provided to the researchers by their faculty advisor, and potential participants were contacted by email regarding the study. Of the 15 eligible participants, 14 responded and agreed to participate in the study. Six participants engaged in face-to-face interviews with the researchers, one participated in a face-to-face interview via the internet due to the participant’s location in a different state. Seven chose to respond to the interview questions in hard copy, due to time constraints and location issues.
Data analysis The face-to-face interviews were audio-recorded and transcribed verbatim. Transcriptions and questions answered in hard copy were analysed by the researches using grounded theory methods of open, axial and selective coding to identify emergent themes and subthemes that were consistent across interviews (Portney & Watkins, 2009; Strauss & Corbin, 1998). Themes that emerged were analysed to identify dominant themes that appeared with great frequency and were then sorted into related groups which led to the identification of three major themes with related subthemes. Researchers completed the first stages of the analysis procedure independently and then compared findings and worked together to increase trustworthiness in the interpretation of data.
Strategies to establish trustworthiness Triangulation occurred between researchers to promote trustworthiness. Peer review was conducted between the researchers, faculty advisers and student colleagues. The researchers conducted member-checking by emailing coded themes to participants and inviting feedback to enhance accuracy of data interpretation.
Results Analysis of qualitative data resulted in the emergence of three major themes: Operational therapy at its Core, Cultural Awareness and Competence and Basic Skills for Any Setting. Several subthemes emerged as well but for the purposes of this article only the major themes will be discussed.
One participant stated, ‘It’s about peoples’ lives and helping them live life to its fullest’. Clients’ increased participation and independence in daily and meaningful occupations was achieved through work within the clients’ homes and in their communities. These environments facilitated the implementation of client-centred and occupation-based services, which is at the core of occupational therapy practice. According to American Occupational Therapy Association [AOTA] (2008), the purpose of occupational therapy is to facilitate increased participation and improved performance in daily and meaningful occupations through client-centred and occupation-based interventions. Client-centred practice entails establishing goals that are valuable to each individual client. Client-centred practice is especially important when working with refugee populations and other minority groups as it reflects the practitioner’s dedication to equality and empowers clients who have suffered from occupational deprivation (Chiang & Carlson, 2003; Kinebanian & Stomph, 1992; Martins & Reid, 2007; Whiteford, 2004, 2005; Wilson, 2008). Occupation-based therapy enables clients to achieve optimal outcomes through participation in the desired activities or tasks. An emphasis on the fundamentals of occupational therapy during this fieldwork experience was illustrated by several participant comments including the following: This is OT at its core…achieving whatever the client wants to achieve through occupation. I felt like with this fieldwork experience I was able to really hit the core of occupational therapy. That is, helping people do the occupations they want or need to do. It was some of the most occupationbased, client-centred OT that I have seen yet. Everything we do here is occupation-based, like, in your face occupation-based, like, there’s no other way to put it, I mean, we’re teaching them how to get jobs, I shouldn’t say teaching, empowering them, you know, to navigate the system, get into college, access health care, drive, access transportation, and then all the way to weaving, maintaining culture, preserving culture. It’s such a unique experience, you know, it’s definitely occupational therapy outside the box… in the truest form. That’s what it’s all about.
One participant, who was employed as an occupational therapist at the time of the interview, commented on how this fieldwork experience influenced her current practice:
Discussion of results Operational therapy at its core The placement through the Immigration and Refugee Resettlement Community Fieldwork Program provided students with in-depth opportunities to apply what has been learned in school to real-life situations. Students realised that occupational therapy can address much more than physical deficits and mental-health issues.
The way I approach intervention is now much more occupation-based than before. Before this placement, I had a tendency to talk about things with clients too much. This is not an option in this placement. Everything is about doing and finding solutions in the moment.
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Participants were able to fully understand the importance of being client-centred and occupation-based in practice and were able to develop and implement interventions that enabled each client to successfully participate in meaningful and purposeful occupations.
Cultural awareness and competence Students were provided with in-depth opportunities to interact with people of various cultural backgrounds. They were encouraged to recognise and respect diverse cultural beliefs, values and lifestyles. Competence in providing culturally responsive care was developed as participants identified their own cultural perspectives. Cognizance of their own cultural beliefs and values led to awareness of personal assumptions and biases and the potential impact these factors could have on the cultivation of a positive therapeutic relationship and overall therapy process, as illustrated by the following participant comment, ‘I think when you’re not exposed to these other groups you have some type of preconceived notion of who they are or who they’re not, and this can impact how you interact with that person’. Through this fieldwork placement students realised that what is considered ‘normal’ in one culture may be out of the norm in another. Lessons learned are reflected in the following comments: I developed a cultural sensitivity that could not have been learned anywhere else… I am [now] able to put aside my own agenda or American perspective to really understand the occupational profile of an individual, which so often is incredibly influenced by culture, and use that information to develop meaningful treatment. I am not afraid to work with someone who doesn’t speak English, and that’s a huge confidence booster for me…It also helped me be more bold in incorporating their culture into the therapy. [I] still feel like I have a long way to go in cultural competency. I think I see now that it’s a process, not really, like an end goal. I consider cultural awareness and competency to be one of the greatest benefits of participating in this FW setting. I now take a slightly different approach with patients from different cultural backgrounds or who speak a language other than English than I may have done before I was involved in this fieldwork. I remember that my fieldwork clients liked it when I was interested in learning about their culture/language, and it is often the same with patients I have now. I still try to keep in mind that people from other cultures may have different views of health and healing in general. [T]his fieldwork really helped to put these factors in the front of my mind, so that I am always careful
that what I say and do matches the values of the people I am working with. It made it easier for me to practice OT according to each client’s values rather than according to my own. [W]hat I learned…is how they work with one another and how they work in their own environments. Their expectations, rules… You would not get that anywhere else… I learned when you sit on a chair, when you don’t sit on a chair, when you shake hands, when you don’t shake hands, when you look somebody in the eyes or don’t, refuse food, so on and so forth. And you never get that anywhere else. You might get it here and there in another setting with a random person from another country coming in with their family, but you wouldn’t get this in-depth exposure because you’re in the home, you’re in their work sites…places like that working with them and you’re the one that’s out of place when you’re there, so you don’t get that experience anywhere else.
Participants realised that culture is not just ethnicity or nationality. Culture is a part of each person as an occupational being; culture shapes what you do, how you do it and why you do it. Opportunities were provided through this fieldwork experience that enabled students to develop cultural awareness and competence, promoting an increased ability to assess and address the cultural needs of every individual.
Basic skills for any setting Opportunities were provided to develop and implement a variety of skills that are required of occupational therapists, including clinical reasoning, documentation skills, rapport building and treatment planning. Participant comments that illustrate this theme include, ‘Those skills of getting to know somebody and their priorities and their needs and their skill levels, their abilities, barriers; it’s all transferable’. Opportunities were available through this fieldwork experience to apply theoretical backgrounds to practice. Every participant mentioned ways in which they implemented the Person-Environment-Occupation (PEO) model (Baum & Christiansen, 2005) to find the best fit for their clients. Students applied observation skills and activity analysis to every task to grade activities up or down according to the client’s ability and to provide the ‘just right challenge’ for every individual. Students learned how to independently develop treatment plans to address the needs and desires of each client. Students also learned that treatment sessions did not always go as planned and that it was mandatory to have a back-up plan for the back-up plan. As mentioned, language was a major barrier in this setting, and students learned how to implement multiple means of communication. Participants also commented on their increased ability to produce timely and concise documentation and to advocate for their clients. One alumni summed it up by saying:
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I was surprised at how much the skills I developed during this FW transferred over to traditional practice areas… There were different barriers, different goals, and different types of treatments, but all the elements of therapy and clinical reasoning are still there… this FW provided me opportunities to develop the basic skills that any therapist needs in any setting: clinical reasoning, being occupation-based, being client-centered, documentation writing, rapport building, treatment planning, designing and leading groups, and we even helped write a grant during FW. These are all skills that I use at my current place of employment.
Learning through doing Through the independence experienced at this fieldwork placement, students developed a sense of autonomy. Participants acquired increased confidence in their abilities as practitioners, which led to an increased sense of professional identity. Clients were not medically compromised which created an opportunity for students to work on their own, safely experimenting with therapeutic approaches and learning through trial and error. Direct supervision by an occupational therapist was provided at times and otherwise the supervisor was available by phone or email. Without constant, direct supervision, students were encouraged to collaborate and support each other by validating and critically appraising each other’s treatment plan ideas. Indirect supervision freed participants from concern about what they should be doing in the eyes of a clinical supervisor, which allowed them to focus on the needs of their clients. At a weekly meeting of all of the students with the supervisor, cases were reviewed and students had the opportunity to ask questions and receive advice. The following comments illustrate how much students valued working independently and how much they gained from this type of supervisory structure: [Y]ou went in as a student and had to act like the professional and really trust yourself to be that professional. And I absolutely loved being able to go through my own trial and error, check in with somebody and know that I was providing appropriate therapy. And you’re a student, but in this setting, I didn’t feel like I had so many risks, which opened the world wide up…the most amazing thing, too, is you actually had the opportunity to collaborate [you’re your client] whereas other places have, you know, like, everything’s rote: you need to meet these goals by this time and insurance will only pay for so much. Whereas this place, the world was your oyster, literally, it was awesome! And because of that, you were independent, nobody was watching over you, you had to make the best judgment that you could and help the person.
[Y]ou’re not dealing with somebody who is medically fragile and if you mess up, you know… you learn and you move on and it’s a safe place to do it. I think it’s good. It definitely forces you to just jump right in and just, you know, do it.
Challenges Participants were faced with many challenges, the greatest of which the language barrier. Translators were occasionally available, but students mainly relied on multiple means of communication to interact with refugees who did not speak English, including non-verbal communication, gestures and even pictures. One participant commented, ‘Language was the hardest, I used every form of communication you could imagine’. Time management was another challenge for most of the participants. The students had the flexibility to create their own schedules, which was a benefit. However, this challenged students to prioritise time to see clients and to document, while also making time to coordinate schedules between agencies, clients, translators and other professionals. Although the information provided by participating students was overwhelmingly favourable with regard to their opinions on the value of this fieldwork experience, there were a few frustrations mentioned. The issue mentioned most often was frequent missed appointments due to misunderstandings caused by communication barriers and different cultural attitudes towards keeping appointments. Even after a positive experience with the programme, one student had regrets stating, ‘I wish I had had a [full-time fieldwork] in a rehab setting, since that is where most of the jobs are…I wish I had more experience in this area’. This student perception of missed opportunities for development of clinical skills has also been expressed by students in prior studies (Overton et al., 2009). It would be helpful to interview these same students after they have been employed for some time, to determine if this perception persists.
Implications Effective educational experiences have clearly been facilitated through this fieldwork placement. Results from this study demonstrate that fieldwork experiences such as the one described in this article can provide educational lessons and opportunities much like those available in traditional medically based settings. Students can discover the value of meaningful occupations, and can gain experience with rapport building, clinical reasoning skills and documentation while, at the same time, newly arrived refugees are able to receive life skills training they otherwise might not be able to access. Fieldwork placements working specifically with refugee populations have the potential to provide powerful student experiences that are not readily available in
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26 most fieldwork environments. Working with non-English speakers from a variety of cultures creates substantive opportunities for personal growth in observation and communication skills along with cultural awareness. Students have opportunities to recognise and address occupational deprivation and imbalance caused by the refugee and migration experience. Due to the refugees’ desire to learn specific life skills and the location of student work in the community, rather than a clinic, nearly every session with the clients is, by default, occupation-based. A fieldwork setting such as this would likely be labelled as ‘non-traditional’ but with direct exposure to and practise with fundamental aspects of occupational therapy practice, it would be best to consider an experience such as this as ‘traditional’ and as a suitable environment for experiencing the core principles of the occupational therapy profession. Analysis of participant interviews revealed the additional benefits that occurred due to distant supervision and independent work. Providing services in a nonmedical setting created an opportunity for students to apply their own ideas for therapeutic strategies and learn through trial and error. A majority of the students interviewed highly valued this aspect of the experience which may imply that occupational therapy academic curriculums should consider offering more experiences where students are encouraged to work on their own in environments where it is safe to do so. However, it is important to keep in mind that not every student is ready for this level of independence when coming directly from the academic environment.
Strengths and limitations Data collected for this study were retrospective in nature which could be considered a limitation or a strength. As a limitation, the retrospective collection of data carries the potential for participants to either forget or inaccurately recall details of their experience. In contrast, this is also a strength as it allowed participants time to process and reflect on their experiences working with refugee populations. The opportunity to reflect on their fieldwork experiences allowed participants to consider the educational and professional implications of the expertise gained and how these experiences were integrated into their professional identities. Limitations include incomplete member-checking as the researchers did not receive feedback from all of the participants. There is also the potential for subjective bias on the part of the researchers as both have completed a fieldwork placement in this setting.
Conclusion The University of Utah Division of Occupational Therapy Immigration and Refugee Resettlement Community Fieldwork Program is an innovative and unique programme that provides occupational therapy students with real-life
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opportunities to work with people with a refugee background, while learning and developing the core skills necessary to become effective and competent occupational therapy practitioners. Cultural awareness and confidence in implementing therapeutic strategies are particular strengths of the programme. Through this experience, occupational therapy students develop the ability to work with diverse and under-served populations, which is a necessity in our growing and changing world. While participating in this programme, students are able to practise and provide client-centred, occupation-based training that promotes client engagement in meaningful occupations while facilitating the ability of people with a refugee background to adapt to life in the United States. The results of this study provide further supportive evidence for placement of occupational therapy students in non-traditional fieldwork settings. Although there are challenges inherent in this type of setting, the numerous benefits clearly outweigh these potential challenges.
Acknowledgements There are no financial grants or funding sources related to this research study. The authors are involved in no potential conflicts of interest relevant to this study.
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Appendix: Interview Guiding Questions Why did you choose to participate in this FW experience? Describe your overall experience working with people with a refugee background as a Level II fieldwork student. How has working with refugees and/or immigrants affected your educational experience? What did you learn from working with refugees/ immigrants that could not have been obtained through other types of FW? What foundational occupational therapy skills did you learn during this FW and how did it prepare you for later FW placements or for your current place of employment? Describe the aspects of occupational therapy that relate to working with immigrants and/or refugees in a non-traditional fieldwork setting. How has this FW experience impacted the development of your cultural awareness and competence? In what ways has this FW prepared you for occupational therapy practice? What practice habits have you developed due to your fieldwork placement in a non-traditional setting working with refugees? Did this FW experience influence your ability to pass the US certification exam? If yes—expand. Has this FW influenced your choice of practice setting? Where is your current place of employment? Did this FW experience impact your ability to work on a multi-disciplinary team? Describe.
© 2013 The Authors Australian Occupational Therapy Journal © 2013 Occupational Therapy Australia
