Collaborative Fieldwork Supervision Model in Occupational Therapy

Introduction

The collaborative fieldwork supervision model was introduced to occupational therapy 18 years ago as an innovative approach to prepare students for the 21st-century health care arena (Cohn et al., 2001). Cohn described the model as a process-oriented approach to prepare future practitioners to be life-long learners engaged in cooperative problem solving. The collaborative fieldwork supervision model is complementary to peer-assisted learning. Peer-assisted learning is the acquisition of knowledge and skills through a process where students of similar level work together collaboratively. Fieldwork presents an ideal opportunity whereby students are able to learn cooperatively to share the learning experience, resulting in both students benefiting from differing perspectives and problem solving (Sevenhuysen et al., 2017). The fieldwork educator role is key in guiding student exploration, questioning, researching, interpreting and integrating the knowledge into practice (Cohn, 2001).

Numerous articles have described the use of the collaborative fieldwork supervision model in a variety of practice contexts over the past decade (Bartholomai & Fitzgerald, 2007; Blakely, Rigg, Joynson & Oldfield, 2009; Flood, Haslam & Hocking, 2010; Lekkas et al., 2007; Martin et al., 2004, Rindflesch et al., 2009). Several studies support the value of the collaborative fieldwork supervision model to facilitate student learning as compared to other supervision approaches (Alpine, Caldas, & Barrett, 2018; Lekkas, 2007; Martin, et al., 2004; Sevenhuysen, 2014). In addition, Briffa and Porter (2013) conducted a systematic review of collaborative clinical education and described an overall positive perception by clinical educators. Yet, a recent national survey of 817 fieldwork educators in the United States revealed that only 15% of occupational therapists (OTs) and 2% of occupational therapy assistants (OTAs) used the model (Evenson et al., 2015). This survey explored preferred models of supervision, benefits and challenges of being a fieldwork educator. Fieldwork educators identified challenges to supervising students as workload, physical space, concerns with student capabilities, cost of staff time, and potential difficulties with clients. The authors found the most valued supports provided by academic programs were student readiness for practice, availability of the academic fieldwork coordinator (AFWC), free continuing education on fieldwork related topics, and face to face meetings with fieldwork educator and student. These varied reports illustrate the need to identify and measure the factors affecting use of the collaborative fieldwork supervision model.

Background of the Problem

Fieldwork educator preparation and support may play a key role in model use. Briffa and Porter (2013) suggested that fieldwork educators’ ability to provide appropriate supervisory support and teaching approaches influence student perceptions about the quality of their learning experiences. For example, the ability of the fieldwork educator to ask complex questions, and to skillfully direct peer interactions in a manner that leads to increased confidence enhances student autonomy, a key feature of the collaborative fieldwork supervision model. Alpine, Caldas, and Barrett (2018) found fieldwork educators asked for additional training to support student professional relationships and to give effective peer feedback and that when this was realized, fieldwork educators experienced decreased student demands for teaching and supervisory time. Successful strategies included being prepared to support a peer-learning environment through shared activities and clinical tasks. They reported that students’ knowledge of each other’s learning styles at the onset resulted in stronger support for each other’s learning. Price and Whiteside (2016) also note the value of creating an environment with professional colleague support for the peer-assisted model, including the availability of important resources and coverage during staff annual leave. Hanson and Deluliis (2015) suggest that universities hold a level of responsibility to prepare students for participation in the collaborative fieldwork supervision model through selection of appropriate students, education on collaborative learning principles and reflection on model applications to learning goals prior to placement. 

Concerns include having adequate time for supervision, managing student interpersonal conflicts, and difficulty making projects meaningful (Sevenhuysen et al, 2014). Reported benefits of the collaborative fieldwork supervision model include greater supervisor satisfaction with balanced workload, improved peer learning, and shared problem solving (Price & Whiteside, 2016). Those who attempt to use the collaborative fieldwork supervision model with an apprenticeship approach rather than adopting true collaborative learning strategies expressed more concerns about the quality of the students’ learning experience (Dawes & Lambert, 2010; Sevenhuysen et al., 2014).

Thomas et al (2007) described the student activities supporting the OT process, as well as special projects to educate clients and in-services for staff. Thomas identified the benefits and challenges for supervising students, ranging from recruitment, developing staff clinical reasoning skills, and staff organization and time management skills. The challenges identified were limited physical space, workload pressures, potential difficulties with clients, and concern for student capability. The barriers included staff turnover, limited resources, workload pressures, and settings deemed inappropriate for student placements.

Krupnick et al (2002) describes three components of a successful fieldwork experience: the fieldwork educator, student, and fieldwork environment. He found a sensitive balance inherent in the three components which dynamically shift to influence the quality of the learning experience for the student and supervisory process for the fieldwork educator. For example, the fieldwork environment considers the client conditions, therapy approaches and setting characteristics as key factors in student learning. The fieldwork educator’s attitude, teaching strategies, and professional attributes interact with the student attitude, learning behaviors, and the learning environment to influence the quality of the fieldwork learning process.

Sevenhuysen’s (2017) systematic review of peer-assisted learning noted that most articles failed to describe peer-assisted learning or evaluate whether collaboration actually occurred or had been facilitated between students. There were no objective measures to determine the occurrence of peer-assisted learning, and the majority of the studies analyzed were qualitative, lacking information about outcomes, including fieldwork educator workload, student performance, and productivity. Authors concluded there were no formal training supports to guide fieldwork educators in fully utilizing this learning approach. 

Development of a measurement tool will help the fieldwork education community, specifically the academic fieldwork coordinator, to identify factors that impede model use and highlight model benefits. Systematic collection of data will enable development of resources to address model obstacles or make refinements to the learning model as needed to facilitate use. The purpose of this study is to develop a tool to identify and measure key factors essential to use of the collaborative fieldwork supervision model .

METHODS

Survey Creation 

Approval was received from all participating university’s institutional review board offices to conduct this research study. The development of the survey is informed by both the lived-experiences of the authors who have all been academic fieldwork coordinators and a review of the literature. The authors have developed collaborative fieldwork supervision sites, including educating and mentoring fieldwork educators as they navigated the unique aspects of supervision. The survey item development began with knowledge inherent with these experiences, which augmented the review of collaborative fieldwork supervision literature.

Item selection grew from relevant topics in the literature to inform the item development and organization for the collaborative fieldwork supervision survey, capturing the range of benefits, challenges, and supports influencing the model. The survey was designed using Qualtrics online survey software and was intended for Level II fieldwork educators to complete. Level II fieldwork requires a total of 24 weeks of full time clinical experience where the student needs to demonstrate entry-level skills in a minimum of two settings and a maximum of four settings. The original survey was composed of 38 questions and required approximately 15 minutes to complete. The following four categories were used to structure the survey questions: demographics, beliefs about the benefits and limitations of the collaborative fieldwork supervision model, ease of use of the collaborative fieldwork supervision model strategies, and collaborative fieldwork supervision model supports. 

Pilot Survey 

A pilot survey was disseminated to fieldwork educators who were familiar with the collaborative fieldwork supervision model. Seven occupational therapists completed the survey and responded with feedback about the survey. The respondents’ experience ranged from 4-20 years supervising occupational therapist and occupational therapy students within the last five years. Five of the pilot participants had provided collaborative fieldwork supervision. Based on feedback the survey was modified to reflect recommendations, specifically to separate items for participants who had used the collaborative fieldwork supervision model from those who did not, in order to streamline items for each group. The survey was separated into smaller sections with fewer items to answer in each section to make it less overwhelming and easier to recall the stimulus question.

Survey Sample

The final survey collected data only from fieldwork educators who supervised a Level II fieldwork student within the last five years and used skip logic to ask questions appropriate to the respondents experience with collaborative supervision. The same four categories utilized in the pilot survey were kept for structuring the 35 questions on the final survey. A mixed style of questions and answers was used on the survey, such as Likert scale, open-ended questions, and multiple choice. Respondent fieldwork educators who had never used the collaborative fieldwork supervision model received 25 questions, and respondent fieldwork educators who had used the collaborative fieldwork supervision model received 30 questions. In April of 2018, an email was sent to the American Occupational Therapy Association Academic Fieldwork Coordinator Listserv. At that time there were 22 doctorate programs, 166 Masters programs with 10 additional sites, and 218 Associate programs with 2 additional sites totaling 418 accredited occupational therapy and occupational therapy assistant program sites. The listserv consists of the academic fieldwork coordinators from those sites. The email requested that the academic fieldwork coordinators distribute the provided survey link to their fieldwork educators who supervise Level II fieldwork students. The survey was open for four months from April 2018 to August 2018.

DATA ANALYSIS

Principal component factor analysis with varimax rotation was done on the 23 Likert scale questions using 382 respondents. Eigenvalues were used to determine the number of factors in a model. Two models with eigenvalues near 1.0 or higher were considered. Questions with factor loadings greater than 0.4 or less than -0.4 were retained for defining a factor. Measures based on the factors were created using the average of the respondents’ scores (1 to 5) for each set of questions. Questions with negative factor loadings were reverse coded in the measure calculations. The measures were described using their mean, standard deviation, and the correlations of the questions within each measure. Cronbach’s alpha was used to test the reliability of each measure.

RESULTS

Of the 391 respondents, 382 rated the 23 statements regarding collaboration. 181 (47%) were from the Census region Midwest, 89 (23%) were from the Northeast, 78 (20%) were from the West, and 33 (9%) were from the South. Nearly all (95%) were OTR and 248 (65%) had a post-bachelors degree. Most (90%) were employed full time, where the average years of experience was 15.7 (S.D. 10.7, range “just starting” to 45 years), and the average years of experience with fieldwork were 11.6 (S.D. 9.7, range “just starting” to 39 years). About two thirds supervised one or fewer students per year, 21% about 2 per year, and only 12% more than two students per year. Three in ten respondents have used a collaborative fieldwork supervision model; 17% felt slightly familiar with it, 19% somewhat familiar, 15% moderately familiar, and 13% extremely familiar with collaborative fieldwork.

There were 23 statements used in a principal component factor analysis with varimax rotation. The first six Eigenvalues were 6.05, 2.57, 1.27, 1.08, 0.99, and 0.94. The three-factor model (Eigenvalue of 1.27) was determined not to provide sufficient distinction between measures. The six-factor model (Eigenvalue of 0.94) produced three factors consisting of only two statements and did not define measures fully as much as necessary. The analysis of the tool led to two models, one with four-factors and one with five-factors. Each model comprised different considerations that were categorized into four areas, except for one additional area in the five-factor model. The four and five-factor model categories are: Perceived Value of the Collaborative Fieldwork Supervision Model Use, Pragmatic Considerations for Collaborative Fieldwork Supervision Model Use, Fieldwork Educator Considerations for Collaborative Fieldwork Supervision Model Use, Site Considerations for Collaborative Fieldwork Supervision Model Use, and the addition of the Client Consideration when using the Collaborative Fieldwork Supervision Model created the five-factor model.

The statements grouped into the four and five-factor models are presented in Table 1. The first factor was labeled “Perceived Value of the Collaborative Fieldwork Supervision Model Use” and consisted of eight to ten statements regarding the benefits of model use. For both the four and five-factor models there were eight statements that loaded highly (over .500). These were positive statements regarding efficient orientation, student group projects, learning, and case management, teaching/learning opportunities, recruitment, less pressure, and more time (16_1, 16_3, 16_4, 17_4, 18_3, 18_4, 19_2, and 20_2). The four-factor model added two statements regarding multiple students and competence (17_2 and 19_1); these had negative loadings indicating a need for reverse coding. Both statements loaded positively on later factors.

The second factor (Table 1) was labeled “Pragmatic Considerations for Collaborative Fieldwork Supervision Model Use” and consisted of five negatively worded core statements regarding site demands, time preparation and commitments, AFWC support, and student advance preparation (17_1, 18_1, 18_2, 20_3, and 20_4). These were seen as potential difficulties of procedural actions when using the collaborative fieldwork supervision model. The four-factor model also had two statements regarding interpersonal conflicts and AFWC resources (19_3 and 20_5). These statements were more indirect in suggesting the fieldwork educator will need to work harder implementing the collaborative fieldwork supervision model. They were not loaded into any factor of the five-factor model.

The third factor (Table 1) was labeled “Fieldwork Educator Considerations for Collaborative Fieldwork Supervision Model Use”. This consisted of four negatively worded statements for both factor models regarding time for projects, individual time for each student, determining entry-level competence, and number of fieldwork placement demands (18_4, 19_1, 19_4, and 20_1). All were related to potential difficulties of fieldwork educators when using the collaborative fieldwork supervision model.

The fourth and fifth factors (Table 1) were based on concerns with the site and the client. In the four-factor model, these concepts were one factor, but in the five-factor model, the concepts regarding clients were separated out. The fourth factor labeled “Site Considerations for Collaborative Fieldwork Supervision Model Use” consisted of two negatively worded core statements, (16_2 and 17_1), regarding workspace and site demands. The four-factor model added two statements (17_2 and 17_3) regarding demands on clients and the need for sufficient clients. In the five-factor model, “Site Considerations for Collaborative Fieldwork Supervision Model Use” did not include the two statements on clients but added a statement on time commitments (18_2). The fifth factor was labeled “Client Considerations when Using the Collaborative Fieldwork Supervision Model”. For the five-factor model, the fifth factor consisted of four negatively worded statements, two about clients (17_2 and 17_3) as well as the addition of two statements regarding competence and student-client contact (19_1 and 19_2).

After the  statements were grouped into four to five factors measures were created by taking the average score of a respondent for all the statements within a factor. The statements were not weighted; each statement was worth a score of one to five based on the respondent’s answer. Three statements (17_2, 19_1, and 19_2) had negative loadings and needed reverse coding before they were averaged into the measure. Six statements (17_1, 17_2, 18_2, 18_4, 19_1 and 19_2) had high loadings on multiple factors and were used in the calculations of multiple measures. Two statements (19_3 and 20_5) were only used in the four-factor solution and were not part of the five-factor solution.

The measures based on average scores are described in Table 2. There was a little variation in the average scores (2.93 to 3.76) and their standard deviations (0.56 to 0.75). The correlations between the individual statements within each measure were significant (p<.01) for all but two sets of statements (individual correlations not shown). The absolute value of the correlations ranged from .020 to .752. Cronbach’s Alpha was calculated for each measure. The first two measures, “Perceived Value of the Collaborative Fieldwork Supervision Model Use” and “Pragmatic Considerations for Collaborative Fieldwork Supervision Model Use” had values greater than .7, as well as the fifth measure “Client Considerations for Collaborative Fieldwork Supervision Model Use”. “Fieldwork Educator Considerations for Collaborative Fieldwork Supervision Model Use” had an Alpha of only .400, and the Alpha for both versions of “Site Considerations for Collaborative Fieldwork Supervision Model Use” was also lower (.640 and .665).

Discussion 

The data provided an objective measure of factors impacting collaborative fieldwork supervision model use. The developed survey identified key factors to begin data collection on the feasibility of collaborative fieldwork supervisory and peer-assisted learning approaches with broad-reaching implications for clinical learning in allied-health education. Each created measure consistently showed a precise and reliable strength with little within measure variability and high item correlations. This led to building a theoretical foundation for the development of The Collaborative Fieldwork Supervision Process Model (Figure #1). The Collaborative Fieldwork Supervision Process Model organizes the factors when considering the use of the collaborative fieldwork supervision model. Based on the findings, the researchers developed an initial version of the Collaborative Fieldwork Supervision Tool to measure the concepts identified in The Collaborative Fieldwork Supervision Process Model.

Looking at each factor more closely, the Perceived Valuedescribes how the value of the collaborative fieldwork supervision approach is viewed by the fieldwork educator. The 10 items on the four-factor solution represent both positive and negative perceptions, in line with the literature review findings. The items represented in this factor demonstrated consistency in strength (Cronbach’s alpha > =0.8) suggesting that the values measured in this factor are inclusive of likely factors to be considered in measuring fieldwork educator perceptions.

The range of items considered in the Perceived Value illustrates how multiple aspects influence the fieldwork educator’s perception of the effectiveness of collaborative fieldwork supervision model and the need to address these perceptions when preparing fieldwork educators for collaborative fieldwork supervision model use. Often the AFWC prepares the site with consideration to detailed steps for orientation, student learning activities and student to client interventions. Calling attention to this factor will enable upfront discussion of both positive and negative perceptions of model use, enabling exploration of the validity of the perceptions and informed decision-making about model use.

Identification of practical considerations for collaborative fieldwork supervision model use, represented in the Pragmatic Considerations factor (Cronbach’s alpha > =.8), will assist fieldwork educators to realistically identify unique preparation and resource needs in advance of student placement. Mixed findings about practical considerations may lead to insufficient preparation. Attention to Pragmatic Considerations in advance of student placement has the potential for increasing student ownership for their learning, and thus increasing student perceptions of the quality of their learning. When Pragmatic Considerations are addressed, the fieldwork educator will likely experience fewer student demands for supervisory and teaching time. 

The Fieldwork Educator Considerations factors (Cronbach’s alpha = .4) capture fieldwork educator perceptions of the potential ambivalence for weighing the positives (time for backlogged projects) with the negatives (determining entry-level competence).  In addition, there are underlying pressures between academic programs and fieldwork educators to recruit adequate numbers of sites and supervisors needed for student placements. Due to this pressure, fieldwork educators may feel compelled to participate in collaborative fieldwork supervision without adequate background understanding of the model. Therefore, they may not realize the need or know how to alter their teaching approach for the collaborative fieldwork supervision model. To be successful in utilizing the collaborative fieldwork supervision model, fieldwork educators must shift their perceptions about their role from that of a teaching expert to a facilitator supporting collaborative student learning (Hanson & Deluliis, 2015). Failure to grasp the change of supervisory role is more likely to result in sway toward a negative view of the collaborative student learning experience (Sevenhuysen, 2014). Advanced training and support likely play a key role in how fieldwork educators perceive the educational benefits and drawbacks of the model (Alpine et. al, 2018; Sevenhuysen, 2014; Price & Whiteside, 2016).

In reality, fieldwork education supervision is a highly skilled technical field analogous to specialization in practice (e.g., hand therapy, neonatal intensive care unit, burn rehab), but there is limited acknowledgment of the skills required for clinical teaching (Recker-Hughes et.al, 2014). Although there are a variety of clinical instructor training programs (e.g., American Occupational Therapy Association Fieldwork Educator Certificate Program, American Physical Therapy Association Clinical Instructor Certificate, and Center Coordinator of Clinical Education), the focus is on foundational supervisory skills rather than the advanced skills needed to facilitate the collaborative fieldwork supervision model (Recker-Hughes et.al., 2014). Measurement of fieldwork educator considerations in this area can be used to support the development of advanced training options.

Site and Client Considerationsbring attention to the various demands placed upon the fieldwork site when hosting multiple students. The Site Considerations factor (Cronbach’s alpha = .6) identifies the increased time commitment, demands on physical space and expendables (e.g., materials, equipment). Hanson and Deluliis (2015) suggest that consideration of the culture of the organization and support from administration is critical to the implementation of a collaborative learning approach. The inclusion of site and client considerations in an assessment tool will help the fieldwork educator to anticipate the demands and work with the administration to plan for the impact in order to increase efficiency. For example, students may be able to share workspace and a computer. Jointly, fieldwork educators and students can create a peer-supported learning environment and use peer-feedback and evaluations prior to the fieldwork educator’s review to use time efficiently by working smarter. Client caseload is discussed in the literature from the perspective of student learning but does not include explicitly asking clients for their lived experience when the model is used (Sevenhuysen et. al. 2014; Price & Whiteside, 2016). 

It is not surprising that adequacy of client contact and measure of entry-level competence are factored together under Client Considerations (Cronbach’s alpha = .7), as this is a long-standing variable of concern when addressing student competency. Fieldwork educators describe an interplay between the level of depth students gain learning new skills with fewer clients, resulting in less stress in fieldwork educators, clients, and students (Alpine et.al. 2018). There has often been a focus on student performance with the number of clients on a caseload, maybe due to the productivity-based business model of health care (e.g., Medicare, insurance). The occupational therapy profession has not yet identified what is an appropriate caseload for students, how many clients are warranted to determine competency, or whether a “full” caseload is really required. Questions to consider include: Is the ability for the student to demonstrate effectiveness while managing a full caseload of prime importance in determining entry-level competency? What role does the quality of student services play in determining student readiness? What are the “essential” competencies students must display to be ready for practice? Is it important that entry-level competence is established by students carrying similar caseloads as their supervisors? How does the in-depth quality of service provision with smaller caseloads impact clients and student learning?

The results support the use of either the four-factor or the five-factor survey solutions, with Site and Client Considerations combined in the four-factor model but separated in the five-factor model. The model includes all of the 23 items but does not individually focus on Client Considerations. The five-factor model recognizes all factors, and one-factor Site Considerations has only three items, suggesting that this factor can be strengthened by adding more questions to identify additional site considerations when using the collaborative fieldwork supervision model. 

Study Limitations

This survey reached a large geographic area of the United States and a wide range of experience and education levels, making a strong sample. The familiarity of the model was high, but the results may have been biased by respondents who had no use or familiarity of the collaboration model (though including them likely captured pre-conceived ideas).

The sample size was adequate to produce consistent, strong measures. The reliability analysis, however, indicated that certain factors, such as Fieldwork Educator Considerations (Cronbach’s alpha = .400) and Site Considerations (both Cronbach’s alphas < .700), would benefit from more items measuring these concepts. Future research using new samples could also incorporate a confirmatory factor analysis to measure not only the strength of this model but any covariance between the measures.

Implications, Applications, and Recommendations

This study brings forward a clearer understanding of the complexity of variables to be considered with the use of a collaborative fieldwork supervision model. When done well, students and fieldwork educators appreciate the value of cooperative learning and the freeing-up of precious supervisory time for other projects. When there is inadequate planning, client resistance, insufficient physical resources, and student conflict, the outcomes are disappointing. This study gives a new understanding to why the collaborative fieldwork supervision model is not used as commonly as academic fieldwork coordinators would like, to address the global challenge for recruiting fieldwork placements.

Having a visual process model is useful for analyzing and evaluating how to approach implementation. The survey tool and graphic model could be used in multiple ways to support fieldwork education teams to provide more effective collaborative fieldwork supervision programs. When used as a preparatory tool to assess the preparation of the site, the students, the fieldwork educators, and the health care team, in addition to perceptions surrounding model use, it can be used as a checklist for fieldwork educators to self-assess steps that need to be taken in anticipation of using the collaborative fieldwork supervision model. When used during the implementation of the collaborative fieldwork supervision model, it could be used to troubleshoot problems and identify gaps in the program. It could also be used to debrief following the placement so that fieldwork educators, students and team members at each local site might process what happened and how the learning process might be improved during future student placements.

The authors recommend future research to identify additional relevant items for Site and Client Considerations, to strengthen and clarify additional site and client considerations for use of the collaborative fieldwork supervision model. Qualitative research might be conducted to validate the concepts of the Fieldwork Supervision Process Model from the perspective of the lived experience of fieldwork educators using the collaborative fieldwork supervision model. Comparison studies might be conducted to verify the impact of the Collaborative Fieldwork Supervision Process model on student and fieldwork educator satisfaction with the educational process and comparison of students who complete a traditional fieldwork rotation versus a peer-assisted learning rotation.

Summary

A measurement tool was developed to identify factors impacting collaborative fieldwork supervision model use, building a theoretical foundation for the development of The Collaborative Fieldwork Process Model. Applications to research inquiry and support for fieldwork educator and student training are explored.

Figure 1. Four measurements of the collaborative fieldwork supervision model.

Table 1. Rotated factor loadings for four and five-factor models of 23 collaboration questions.

Table 2. Description of measures created by factor analysis.

Rating of 26 items by 382 people was used in the factor analysis.

Cronbach’s Alpha standardized for the number of items is shown.

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