Transformative Learning in Level I Occupational Therapy Mental Health Fieldwork

TRANSFORMATIVE MENTAL HEALTH FIELDWORK1

Allison Sullivan

Temple University

Abstract

The development of nuanced clinical reasoning skills, paired with self-awareness and meaningful reflective practice are widely recognized in allied health literature as essential if students are to be effective practitioners. Consequently, for more than four decades, academics in these professions and other fields of adult learning have investigated the best instructional practices to develop and instill these skills in students and in turn have them embrace them as their own (Mesirow, 2000, Schell and Schell, 2008, Scheinholz, 2010). The purpose of this paper is to contribute to the body of evidence regarding best practices in psychosocial occupational therapy education and practice, and promote understanding of how transformative learning practices in Level I fieldwork can strengthen student learning and enhance their understanding of the core values of the profession.

Key words: emerging practice, mental health fieldwork, transformative learning theory

Transformative Learning in Level I Occupational Therapy Mental Health Fieldwork

Introduction

“With the need to produce the highest quality graduates possible to work in complex and rapidly changing workplaces, and the need to respond to issues and challenges in fieldwork education…university programs must be innovative in how they design, deliver, and evaluate fieldwork education” (McAllister, Patterson, HiggsBithell, 2010). This is particularly true with regard to mental health occupational therapy fieldwork education in America, given the fact that according to the 2010 AOTA Compensation and Workforce Survey, only 3% of occupational therapists and 2.4% of all occupational therapy assistants reported their primary work setting to be in a mental health setting (AOTA, 2010).Despite this fact, however, the Occupational Therapy Practice Framework: Domain and Process, 2nd Edition (AOTA, 2008), the Accreditation Council for Occupational Therapy Education (ACOTE) Standards of 2011 (ACOTE, ), and key official documents from AOTA, such as the Specialized Skills and Knowledge in Mental Health Promotion, Prevention, and Intervention in Occupational Therapy(AOTA, 2010) and Occupational Therapy Services in the Promotion of Psychological and Social Aspects of Mental Health (AOTA, 2010) continue to highlight the crucial importance of the role that psychosocial factors play in influencing engagement in occupation. Thus, one challenge facing academic programs is how to develop entry-level competence in mental health skills and knowledge in their students, given that it is highly unlikely that many of them will have Level II fieldwork opportunities in traditional mental health care settings.

Another issue facing educators in confronting this challenge is the fact that current fieldwork placements, even when available, often do not provide opportunities for students to learn and reflect on model practices. As McAllister, Tower, And Walker note, citing Ironside (2004), “…in the time-constrained, complex, specialized field of clinical practice…there may be a tendency to emphasize the technical skills and overlook the humanities and ethic of care. Technical skill acquisition serves the interests of health service efficiency and management, but it may not always serve the interests of a caring community” (2007).

Level I fieldwork provides an ideal opportunity for educators to createmeaningful learning experiences that help students to develop competencies in mental health skills and knowledge while addressing the curriculum in such a way as to promote and model best practice and deep clinical reflection due to the fact that it is intended to, “include experiences designed to enrich didactic course work through directed observation and participation in selected aspects of the occupational therapy process,”(AOTA, 2010)

One instructional methodology that holds great promise for accomplishing the dual objectives of building students’ mental health knowledge and skills while developing their capacity for critical self-reflection is that of transformative learning. Transformative learning theory, as described by Patricia Cranton is, “a comprehensive and complex description of how learners construe, validate, and reformulate the meaning of their experience” (1994). Given that academic instructors can serve as Level I fieldwork educators, using transformative learning practicesand creatingfieldwork activities for vulnerable populations within a given school’s communityallows educators to have greater control in designing specific lessons to address curricular needs with regard to psychosocial content. These planned experiences can create ideal conditions for transformative learning processes about the value of this content and assist in the development of deeply reflective practitioners who will carry the profession into the next century.There is evidenceacross domains of allied health practice literature indicating that students who experience transformative learning may be more likely to adopt caring practices that would promote the treatment planning processes that include consideration of psychosocial factors affecting engagement in occupation regardless of treatment setting (Gelman, 2012; Mallory, 2003; McAllister, Tower, and Walker, 2007; and Rush, 2008). By building students’ knowledge and understanding of psychosocial occupational therapy and structuring Level I fieldwork to enhance its value to future practitioners using transformative learning practices, innovative fieldwork of this nature is relevant to the future of Occupational Therapy and important for educators to understand and value as well.

A literature review was conducted to explore the question, “What are the effective instructional practices for promoting transformative learning during fieldwork opportunities in students enrolled in allied health education programs?” Relevant peer-reviewed articles were identified via computer-assisted search of electronic databases. These databases included Academic Search Premier, Ageline, CINAHL with Full Text, Cochrane Library,Ebsco, Education Index Retrospective, Education Source, ERIC, Humanities and Social Sciences Index, Medline (Pubmed), OT Search, PsycARTICLES, Psychology and Behavioral Sciences Collection, and PsycINFO. This search was limited to articles written in English between the years of 1975 to September 2013. The following search terms and key words were utilized in various combinations: “fieldwork”, “field study”, “fieldstudy”, “fieldwork education”, “fieldwork students” “transformative learning”, “transformational learning”; “transformative learning theory”, “mental health”, and “mental health education”. Search terms that were combined to yield significant results included: “transformative learning and fieldwork”, and “transformative learning and mental health”. The online search yielded 14 studies, nine of which were included for review. Articles were chosen for review based on their relevance to the selected topic.A citation review was conducted by hand after the articles from the database search were obtained, and relevant historical studies were located via this hand search. Additional relevant literature, including official documents of the American Occupational Therapy Association and key chapters from relevant scholarly texts were reviewed by the author as source material as a result of continuing professional development and evidenced based practice, as well as study and discussion done in completion of course requirements for a course in clinical education and fieldwork supervision in the partial fulfillment of the doctoral degree program in occupational therapy at Temple University.

Review of the Literature

The theory of transformative learning originally described by Mezirow (1978) has been developed and extended by Mezirow himself (1991, 2000) as well as other investigators of learning theory (Brookfield, 1991; Cranton, 1994).In occupational therapy literature, Schell and Schell(2008) identified Mezirow’s process of transformation as being fundamental to the students’ development of nuanced clinical and professional reasoning skills. AOTA’s Fieldwork Educator Certification Program (Johnson and Stutz-Tannenbaum, 2009) utilizes a transformative process as its conceptual model, “to support professional development, facilitating parallel role shifts & transitions of the student to OT practitioners, and the OT practitioner to Fieldwork Educator”. In the popular press, Santalucia and Johnson, in their 2010 continuing education article for OT Practice magazinepromote the value of using transformative learning techniques during fieldwork to strengthen student self-evaluation and critical reflection skills.

In allied health literature, Mallory (2008) demonstrated that nursing students who received an educational approach during an innovative fieldwork practicum grounded in transformative learning techniques demonstrated a positive increase in their attitude toward the treatment population. Results from descriptive studiesof practice models and methods for promoting transformative learning in studentssupport the theoretical construct of transformative learning experiences and describe positive effects on students’ attitudes and values regarding skills related to psychosocial practice, including critical reflection, meaning-making, client-centeredness, decreased stereotyping, and increased cultural sensitivity (Gelman, 2012; McAllister, Tower, and Walker, 2007; and Rush, 2008). By reviewing these studies, it becomes apparent that these transformative developments occurred during reflective opportunities instructors designed to elicit this understanding in their students. Mezirowacknowledged the need for intentional practice to promote this change, by distinguishing between truly transformative learning (what he called “transformation of meaning perspective”) and a more general transformation of the individual as a result of development and experience (1991). He describes the components of transformative learning as follows:

A disorienting dilemma occurs
Self-examination with feelings of fear, anger, guilt, and shame follows
A critical assessment of assumptions takes place
Recognition that these feelings and processes are occurring and are shared with others
Exploration of options for new roles, relationships, and actions occurs
A new course of action is planned
The individual acquires knowledge and skills for implementing the plan of action
New roles are explored and tested
Competence and self-confidence in new roles and relationships grows
The transformative experience is integrated into the individual’s life on the basis of conditions dictated by the new perspective (2000, p22).

The literature for this review describesspecific skills and knowledge students demonstrate that are indicative of individuals who had experienced a transformative learning process (Gelman, 2012; Rush, 2008; Mallory, 2003).These skills include: increased critical self-reflection, in which the student is able to identify and express feelings associated with their behavior past and present; an ability to describe new understanding with regard to self, service users, and the value of the service being provided; increased interpersonal communication abilities and professional behaviors with staff, family members, and consumers; changes in assumptions about members of the population receiving services and their family members; and increased professional activity in response to specific interactions with service users (Edmonds-Cady and Sosulski, 2012; Gelman, 2012; Rush, 2008; Mallory, 2003). Thus, in a very specific fashion this skill growth directly addresses ACOTE Accreditation Standard B.2.9: The student will be able to express support for the quality of life, well-being, and occupation of the individual, group, or population to promote physical and mental health and prevention of injury and disease considering context (e.g. cultural, personal, temporal, virtual) and environment [at all educational levels] (AOTA, 2007), as well as 2.6: Analyze the effects of heritable diseases, genetic conditions, disability, trauma, and injury to the physical and mental health and occupational performance of the individual [all levels] (AOTA, 2007).

The literature also describes specific teaching strategies to promote this transformative process, including: planned classroom and fieldwork opportunities for group and individual reflection and discussion with the fieldwork educator/supervisor and the classroom educator;patient and gentle probing of student’s understanding, assumptions, and reasoning; on-site assessment of student skills by the academic instructor during fieldwork; focus on lived experience, opportunities for role reversal, shared responsibility of the learning process by both the student and the instructor; and careful preparation of the student for the fieldwork experience prior to its initiation (Boitel, et al, 2009; Edmonds-Cady and Sosulski, 2012; Gelman, 2012; McAllister, Tower, and Walker, 2007; Mallory, 2003;Rush, 2008). Understanding the best instructional methodologies for promoting transformative learning is significant, as Getty and Geraci note, due to the fact that “Curriculum design is critical in establishing the educational foundation that can link evidence and practice in mental health and facilitate AOTA’s (Centennial) vision” (2013).

. Aside from advancing student skills and knowledge, evidence exists that fieldwork of this nature has positive effects for consumers of these services, the organizations that provide these services, and the community at large (Edmonds-Cady and Sosulski, 2012; Gelman, 2012; andRush, 2008). Rush (2008) specifically identifiedconsumers’ increased sense of one’s “equal status basis”as a benefit to service users who participate in fieldwork experiences designed using these principles. Edmonds-Cady and Sosulski (2012) note that community organizations that take part in assessing the fieldwork design and outcomes of the programs in which its consumers participate have stronger ties to the school with which the program is affiliated than to those for which these relationships do not exist.

Limitations to utilizing transformative teaching practices described in these studies include time constraints related to course duration, given that the rate of student learning is individual; fieldwork that takes place outside of the school setting may reduce student valuation of either the didactic classroom component or the field component, based on students’ assumptions about the relative value of these activities relative to course grading or “real life” application; and by focusing on fieldwork with one client population to allow for the development of transformative understanding necessarily means less time is spent studying the needs of other service user populations that have different characteristics and risk factors (Boitel, et al, 2009; Edmonds-Cady and Sosulski, 2012; Gelman, 2012; Mallory, 2003;Rush, 2008).

Discussion/Recommendations:

Despite the benefits to utilizing instructional practices to promote transformative learning in students during fieldwork opportunities described in these papers, the relative absence of empirical research on this topic is a significant oversight, given the number of arenas in which Mesirow’s theory is promoted as a valuable approach to strengthening adult learning, including education, nursing, social work, and occupational therapy. Mallory’s 2008 study of positive attitude change in nursing students who were exposed to an instructional approach designed to elicit transformative learning on an innovative fieldwork practicum stands out as the only experimental study to date measuring the benefits of this form of instructional practice in recent literature. Given the fact that transformative learning theory is the conceptual basis for AOTA’s own Fieldwork Educator Certification Program (Johnson and Stutz-Tannenbaum, 2009), it follows that there would be a benefit to occupational therapy education specifically and allied health education in general in conducting further research to determine the efficacy of instructional practices designed to promote transformative learning.The purpose of the current undertaking is to contribute to the body of evidence regarding best practices in psychosocial occupational therapy education and practice, and promote understanding of how transformative learning practices in Level I fieldwork can strengthen student learning and enhance their understanding of the core values of the profession

One example of a Level I mental health fieldwork experience that lends itself to transformative learning occurs viathe occupation-based activity program that takes place at American International College in Springfield, MA during a summer session course in applied theory midway through the students’ Masters of Science in Occupational Therapy degree program. The occupation-based activity program is an intervention designed by the author, who teaches the psychosocial curriculum for the program and has a part-time clinical position as an occupational therapist for a day program that provides services for adults with significant developmental disabilities. The day program has four locations which serve 350 consumers in Western Massachusetts.

This activity program runs year-round. It is offered twice a week for up to two hours each session. Over 100 consumers from the day program attend at least one of the two weekly sessions that the program is offered, accompanied by staff from the day program. Although the program takes place at the gymnasium and utilizes the athletic fields, track, and tennis courts of the school as well, it is not a prescriptive exercise intervention. It is designed to address risk factors related to sedentary lifestyle and occupational deprivation via expandedchoice-making opportunities enabled by the environment. Program participants can use their time at the gym actively, and are encouraged to walk laps to music or practice shooting basketballs and kicking soccer balls with one another and staff while on site. Participants choose what they want to do, who they want to do it with and how long they want to engage in the activities being offered; there are no standards set. Social interactions and human rights respecting individual choice-making is honored, with consumers having the opportunity to take breaks from activity and observe or chat with others, and use the water fountain at the gymnasium and the restrooms on request.

Students from the applied theory course attend the program twice weekly as one group. The instructor prepares the students for fieldwork by reviewing the goals of Healthy People 2020 and working with students to identify common issues that both students and adults with developmental disabilities face as a result of adopting sedentary lifestyles. Students do not have an assignment when the fieldwork begins, other than to introduce themselves to program participants and staff, and try to find ways to take part in the activities that are already occurring at the program. Because the consumers possess role competence in this program due to their year-round participation, the initial interactions allow for interesting role reversals regarding students’ common assumptions regarding competence and disability. Due to the fact that the program takes place on campus, the dichotomy that can occur when students take place in fieldwork that is outside of the school is mitigated to a degree. Given that the instructor is the clinician for the program attendees, it is easy for her to model professional skills and caring attitudes on-site that speak to her experience and knowledge of the program participants’ unique needs.