This chapter outlines the context in which contemporary practice occurs from political, professional and educational perspectives; exploring the influence that each perspective has on the learning and practice of pre-registration students. The apparent mismatch of expectations between regulatory, academic and practitioner partners will be discussed, indicating the challenges in educating practitioners for the future.

Concepts of competence will be analysed, considering how a student practitioner becomes competent and eligible for registration as an occupational therapist. The role of emerging placements in facilitating student practitioner development will be examined.

The chapter ends by identifying the value of exposing students to the perceived risks of role-emerging placements, along with some strategies for academics, placement educators and students to mitigate risk and support success in role-emerging areas.

WHAT ARE PRE-REGISTRATION STUDENTS PREPARING FOR?

Occupational therapy involves autonomous and evidence-based practice, requiring practitioners to be knowledgeable, skilful and professional. Their expertise is focused on what people need or choose to do to support their health and sense of wellbeing. In addition, practitioners need to be able to think creatively to find and evaluate solutions for health, social and societal issues. Enabling people to achieve health and wellbeing requires consideration of the person’s occupational needs and wishes, in the contexts of their lives. In parallel, occupational therapy is defined by the varied contexts for practice which are influenced by global, national and local social issues, including politics, policies and resources such as finances.

A Changing World

Occupational therapy takes place within unpredictable and evolving circumstances from local to global levels. The contexts are varied and partly determined by the specific circumstances of the country, region or locale in which the therapists are employed. For example, in some places occupational therapists may work in well-established areas such as paediatrics, orthopaedics or return-to-work programmes, where healthcare is funded largely through personal health insurance or the state. Intervention is specifically focused and clear evidence-based outcomes are expected. In parts of Eastern Europe, where occupational therapy is still emerging, occupational therapists might have to demonstrate their value and define their practice in order to develop legitimate opportunities to establish themselves and their services. In other parts of the world, for example in parts of the UK, what seemed established practice is changing, as NHS services are contracted out to other providers within the private and voluntary sectors. Leicester and O’Hara (2009, p. 16) describe this phenomenon as ‘redesigning the plane while we are on it’.

Consequently, while occupational therapists share the same professional philosophy, not all occupational therapists are necessarily focused on doing the same things. To prepare for practice, it is important to develop and maintain awareness of how occupational therapy is shaped by the political, professional and educational contexts. Although mental health problems can create a specific need for occupational therapy, awareness of the contexts for practice can enhance understanding of the reasoning behind the different actions and roles taken by therapists.

The Political Context

Promoting mental health and wellbeing has been recognized as vitally important for the global population (see Ch. 2), challenging the historic tendency to separate and specialize health services for people with mental health problems and learning disabilities. Being aware of mental health issues and being responsive to them is a requirement of every health and social care context. The World Health Organization’s (WHO) Report on Disability (WHO 2010a) estimated that the number of disabled people worldwide was around 15% of the world’s population. This number, including children with disabilities, continues to grow. Population demand for health and social care services is high, with an expectation that services will continue to be provided where they already exist. Technological advances in treatment and drugs are expensive, and difficult moral decisions are being made about who can receive what treatment, which itself leads to inequalities in access to and provision of healthcare. Austerity measures have an additional impact, with people affected not only by poverty from a reduced income, but also poverty of opportunity as a consequence (see Chs 13, 29).

The political vision to address these challenges has been articulated by organizations such as the World Health Organization (WHO). Using political visions to inform preparations for practice is not about ignoring realities, but supporting professional development. For example, the WHO report Primary Health Care: now more than ever (WHO 2008) indicated the need for reliable and responsive healthcare systems which are individualized and participatory, clearly placing the user of services in the centre. There are four main principles which are important for understanding the political context for occupational therapy:

■ Universal coverage, ensuring that preventative health services are available to all and free at the point of access

■ People-centred services, with community-based, accessible healthcare delivery points

■ Public health policies, acknowledging that much of what affects populations lies outside immediate healthcare needs, for example, community opportunities, poverty, housing, employment

■ Leadership, to guide and steer changes towards greater efficiency and effectiveness.

These four principles could suggest the increasing demand for services is a positive indication of a shared and increased awareness of the central importance of health. A subsequent WHO report on Health Systems Financing (WHO 2010b) picked up on the universal coverage principle. The impact of rising population expectations, rising costs, expensive treatments, demographic challenges and the increase in chronic disease was acknowledged. It was also suggested that efficiencies could be made, based on an estimate that health services globally wasted between 20% and 40% of healthcare spending.

To prepare for practice in this political context, education of student practitioners should navigate the tension between the vision of a right to universal healthcare and the reality of resource-limited service provision. It is the context within which occupational therapists work, impacting on current practice and future development, with many legitimate opportunities for occupational therapists to consider. It is also the context that students need to learn about, understand, reflect on and act upon, as it will affect the way in which their professional career may develop.

Thibeault (2006) suggests that academic institutions have a responsibility to ‘be at the forefront of the action…wake up their students and communities …and plan strategies to bring about rapid change’ (p. 161). In developing Thibeault’s point of view, it should be the responsibility of all occupational therapists to ensure that they make themselves aware of the political context, seeking to understand how it impacts on occupational therapy and proactively contributing to professional development.

The Professional Context

Although occupation has been recognized as a determinant of health and wellbeing throughout human history, like many other health disciplines, occupational therapy did not emerge as a profession until the 20th century (see Ch. 1). Since then, the profession has evolved to address changing health and social care demands with therapeutic occupation, working with individuals, their families and carers and increasingly, with communities. As well as agreeing standards of professional behaviour, occupational therapy has developed a shared knowledge base to inform and support practice. These elements of the professional context are a focus of practice placements for students.

Occupational science, with its focus on understanding the nature of occupations and the challenges to participation in occupations, has helped to broaden where the profession sees its potential influence and legitimate involvement (see Ch. 3). This has led to the idea of role-emerging or non-traditional settings for situated learning on placement.

Emerging Roles

There are clear examples of where occupational therapy has extended beyond traditional services in hospitals and clinics (notably Kronenberg et al. 2005; Lorenzo et al. 2006). Reflecting their setting, many of these examples take a broad view on health, not using diagnostic categories to distinguish between people. Instead, needs are defined in terms of occupational injustice and/or social exclusion. Preparing for professional practice in these settings requires a focus on occupational theories, learning and exploring how to interpret and apply relevant ideas in practice in a creative way.

This expansion into non-clinical settings has been helpful in creating opportunities for the profession. However, it challenges practicing occupational therapists to critically reflect on what students and graduates are being prepared for. Within mental health services, the dominant paradigm is concerned with solving health problems through treatment, therapy or other forms of institutional support. The service user is often a passive consumer of services (see Ch. 11). In contrast, the health improvement paradigm aims at prevention, engagement and participation through social inclusion, offering the service user a more active role. The two paradigms are not mutually exclusive, but the current dominant paradigm is being subtly changed as governments recognize that prevention of ill-health may be cheaper than cure (WHO 2010b).

So we have a challenge in educating students: ensuring that they are competent to work within the dominant paradigm, delivering targeted and highly focused services; while also preparing them to work in other settings which may demand a more flexible approach.

The Educational Context

To practice as a professional, it is necessary to have achieved competence in agreed areas. Debate continues about the vision for the profession and the education of students to achieve it. The process of agreeing on the scope and focus of professional practice is ongoing. The movement towards standardized occupational therapy education began in America and developed as the profession grew in response to the needs of First World War casualties (Colman 1992) (see Ch. 1). The movement to regulate and structure education for occupational therapists has been adopted worldwide (Hocking and Ness 2002; TUNING 2009; College of Occupational Therapists, (COT) 2009). Ensuring that standards of education are set and met is important for occupational therapy as a profession. It is also the responsibility of the educational institutions, such as universities, who provide the learning environment. They have to organize the approval of occupational therapy pre-registration education programmes, involving funders, professional bodies, educational representatives and others who are responsible for registering and regulating practitioners.

Consequently, world regulatory bodies, such as the Health and Care Professions Council in the UK, have developed Standards for Education and Training (SETs) (Health Professions Council 2009) that supersede professional body standards. The SETs are used to validate educational curricula for a number of health professional programmes, including occupational therapy. On successful completion of a validated programme, British graduates are considered to have attained the HCPC Standards of Proficiency (SOP), which are really statements of competence, and they are eligible to apply for registration to practice.

The TUNING Process

In Europe, a system to harmonize educational structures and outcomes across Europe known as the TUNING process, was initiated as a result of the Bologna Accord in 1999. Its aim was to create a set of subject-specific and generic statements of competence at undergraduate, post-graduate and doctoral levels, which would result in comparable degrees across European higher-education institutions. One of the intended outcomes of this process is to support academic and student mobility and employment mobility across Europe. The Council of Occupational Therapists in European Countries (COTEC) and the European Network of Occupational Therapy in Higher Education (ENOTHE) worked together to produce the TUNING competences for occupational therapy. Like other agreed standards for occupational therapy education, the TUNING competences are intended to be points of reference to aid curriculum design rather than prescriptive statements. Occupational therapy was among the first subject areas that created the first- and second-level TUNING points of reference; a process that started in 2002, leading to publication in 2009 (TUNING 2009).

In addition to the above, there are also professional requirements for educational programmes, often expressed as standards for education and/or curriculum guidance, such as the World Federation Revised Minimum Standards for Education (Hocking and Ness 2002) or the Curriculum Guidance for Pre-registration Education (COT 2009). These documents express the intended outcomes of educational programmes either as learning outcomes or as a graduate profile – essentially additional statements of competence. It would be unfair to give the impression that there are vast numbers of competences to be achieved as some are reiterated and referenced across documents, although the number of profession-specific competences for TUNING alone is currently around 36.

Meeting Requirements

The growth in the number of regulators may have led some programmes in occupational therapy to become more focused on attainment of the required competences and less focused on the continuous process of ensuring that graduates are motivated to think and reason critically, although university-based programmes will have relevant internal standards to meet. Lederer (2007) considers developed capacity for critical thinking to be an important outcome of education, although his research was limited to students. The quality of professional practice is linked to the capacity for critical thought. The unquestioning use of evidence-based protocols (used in many medical situations such as medication prescription) or other guidelines for practice are not an indicator of competent practice. In contrast, mental health services require the judicious and reasoned use of the available evidence to meet a particular individual’s specific and contextual needs.

Another issue to be considered is that some standards or competency documents were written at a certain point in time and may no longer address current trends. It takes time to review, revise and approve occupational therapy programmes, a process which does not always keep pace with the changing context for practice. This puts increased responsibility on academics and practitioners to ensure that curricula are sufficiently adaptable and proactive so that evolving opportunities for occupational therapists can be taken up. It could be argued that prescriptive competences, such as those produced by some organizations like HCPC and the TUNING process, may preclude the ability of academic institutions to be responsive to contextual changes in the desire to be seen to be addressing the regulatory requirements.

There is an ongoing challenge to ensure that occupational therapy education programmes have sufficient flexibility to educate graduates to be fit for today’s purpose, yet equipped with the ability to think critically to prepare them for tomorrow’s challenges. The increasing interest in Masters’ level pre-registration education, delivered as accelerated programmes, suggests one response.

PREPARATION FOR PRACTICE

General requirements for the length and outline of an occupational therapy programme are detailed in the World Federation Minimum Standards for the Education of Occupational Therapists (Hocking and Ness 2002). Initially, these standards were the result of identifying the key components of existing programmes in the 1950s, to produce guidelines for any country wishing to develop an occupational therapy programme. Regular revision over the last six decades has reflected developments in education, as well as in the practice of occupational therapy in health and social care environments.

The minimum standards have to be achieved by an occupational therapy programme for it to be recognized by the World Federation of Occupational Therapists. The current requirements indicate that a programme should be a minimum of ‘3000 hours, spaced over 90 weeks, and extended over three years’ (p. 16). It acknowledges that some programmes are 4 years long, but there is evidence that accelerated courses exist for holders of a first degree and also work-based learning programmes, where the programmes may be considerably shorter than the 3000 hours; 90 weeks minimum. There is some debate about whether it is more important to achieve the required input of hours or to achieve the required outcomes of education, irrespective of the length of a programme, to become a competent graduate.

In terms of the proportions of a programme that should be dedicated to certain topics, the minimum standards identify that one-sixth of the time should be spent on basic sciences, half of the programme should be allocated to the theory and application of occupational therapy and one-third of the programme to placement learning (which should equate to a minimum of 1000 hours).

All occupational therapy programmes of education have two distinct areas of interest:

■ Developing the professional knowledge, professional skills and critical thinking abilities of students

■ Ensuring that the above is integrated into placement learning to produce a competent practitioner.

How these elements are delivered is the responsibility of the educational programme to decide, however the delivery should be congruent with the specific educational strategy and programme philosophy. Different learning and teaching methods are used globally, between educational institutions and within individual programmes. Tutor-centred approaches include didactic teaching methods, such as lectures. Student-centred approaches include problem- and enquiry-based learning in seminars, which aim to develop research, critical thinking and problem-solving skills. Appreciative enquiry aims to build positively on what has worked well in the past to seek solutions to issues, using learning and creativity (Rubin et al. 2011). Student-centred approaches are perceived to develop deep learning more readily, thereby creating competent, independent and critical learners and practitioners. They also acknowledge that many students come to occupational therapy education with relevant personal and work experiences, which can form the basis for their professional development. These varied approaches to learning reflect different interpretations of what is involved in being and becoming a competent practitioner.

Developing Competence

Short (1985) recognized the vital importance of how the term competence is interpreted in education. Different interpretations of competence are concerned with what people can do (performance and behaviours), what they know (knowledge and skills) and how they are (a state of being). It can be difficult to make judgements about whether competence has been achieved in any of these interpretations. For example, performance and behaviours may be more quantifiable and observable than a state of being, which could be judged in a more qualitative and subjective way.

Short’s critical analysis will be used to structure further exploration of the development of competence within occupational therapy education.

Competence in Performance and Behaviours

Competence in this context refers to the demonstrable ability to do something correctly or to a sufficient standard. Acts of this kind are often independent of an ongoing purpose or intent. For example, students may know what to do when an office telephone rings in a placement setting. They may have been instructed to pick up the phone, give a greeting, take a message and/or pass the caller to another person. They are either able to do this or not. The ability to achieve isolated tasks, such as this, is essential in indicating a baseline level of communication skills and professional conduct.

However, it is rare that student therapists perform purely isolated tasks that have no relation to what follows. They are expected to deal with more complex levels of behaviour and performance, which require them to exercise judgement and make decisions. For example, referring back to the telephone call, if the student decides to pass the call on to a more appropriate person, then they have to understand the issue to be passed on and to decide who the most appropriate person is to deal with it. The student also has to have the skill to communicate effectively and courteously with the caller and, if taking a message, know how to detail accurately what the message is.

Replicated, learned acts of purely doing something are uncommon in occupational therapy by the very nature of working with individuals and organizations. Occupational therapy requires more than a technical approach to doing things, although technical skills may still be required.

Competence in Using Knowledge and Skills by Thinking and Reasoning

Creek (2009), in an unpublished lecture (‘The art of occupational therapy’), identifies the different types of knowledge used by occupational therapists (see also Ch. 3). There are universal theories that inform the student about such things as basic sciences, medical and mental health conditions, professional frames of reference and social policy, which can be learned through such things as lectures and private study. There is also contextual knowledge, which is gained when students work with people in their own context. For example, the student will have to seek knowledge about a particular individual’s health condition and circumstance. Creek also identifies practical knowledge where students learn not just what to do but how to do something, such as how to make an individual feel welcome and how to communicate to facilitate a person’s engagement in an activity (Creek 2007).

Short’s (1985) explanation of competence in knowledge and skills complements Creek’s view. The application of knowledge and skill, whether universal, contextual or practical, is purposeful. It requires critical thinking to make judgements and choices about the most appropriate and pertinent course of action, for and with a person.

To develop the capacity for critical thinking and decision-making, students need firm foundations for professional practice. In particular, they need to develop competency in using universal knowledge about the philosophy of occupational therapy and theories that inform practice and approaches to intervention. Practical knowledge will enable students to feel secure and grounded. They will be able to explain their interventions in the context of their professional knowledge and skills, and an individual’s needs. Being able to clearly explain to others about the nature and intention of occupational therapy should be a focus of learning in every educational setting, including placement settings. Therefore educators and practitioners should make sure that every student can explain how occupational therapy can address identified individual, group and community issues. Occupational therapists need to be able to persuasively explain their practice and vision in every new encounter to each new person who needs occupational therapy, as well as for initiatives in settings where occupational therapy has been previously unknown.

Learning how to explain the practice and vision of occupational therapy requires awareness of the underlying professional reasoning, which takes different forms (Schell and Schell 2008). Practice educators can facilitate learning through sharing their own reasoning, modelling and encouraging the application of professional reasoning to and in practice. Professional reasoning is important in developing individualized interventions, which are informed by evidence. It is necessary to ensure that protocols are not applied indiscriminately to all individuals. Evidence-based practice is not about providing a specific recipe for intervention in every case (see Ch. 9).

The Art of Being a Competent Practitioner

Short’s (1985) fourth concept of competence is defined as a ‘state of being’ (p. 5), implying the quality of a person. This state of being competent includes such subjective elements as their values and attitudes. This particular concept is difficult to define and also difficult to measure, having a fundamentally holistic nature, linked to therapeutic use of self. The qualities of a competent therapist are expressed not just by what they do and what they know, but how they go about their work. We know when we encounter competence in a person, and it is this state of being competent that educational programmes and placement educators strive to develop in their students.

Understanding this concept of competence as professional artistry has been explored by Creek (2009), using the Dreyfuss and Dreyfuss model of skill acquisition (Benner 1982). This offers insight into the expert practitioner who tacitly knows what to do, based on a synthesis of understanding, experience and expertise. From the outside, this expert way of working can look accidental or coincidental, but is probably more accurately described as alchemy – the magical power of changing something that is common into something of value. This power is a synthesis of different elements of competence, uniquely adjusted for each situation and thus appearing to have a magical quality.

This degree of expert practice is of course difficult to achieve within the timescale of pre-registration programmes, especially when opportunities to apply and rehearse knowledge and skills in practice are time-limited. Yet, professional artistry is an important part of developing confident practice in less familiar and more unpredictable situations (Fish 1998). The role of placement or practice learning is crucial in the development of both professional competence and artistry; it is where the art of occupational therapy develops through the application of professional knowledge and skills. Future graduates will need to be competent to continue to work in the prevailing settings of health and social care and also in other employment contexts which continue to emerge as the result of policy changes.

To achieve this, students will need to be exposed to varied placement experiences where occupational therapy has a legitimate role. This involves balancing established placement settings such as acute inpatient units, with other settings, such as those which use therapeutic horticulture with many different groups of people. These alternative settings require development by practitioners and educators, in partnership with relevant organizations. The next section develops this theme further.

SITUATED LEARNING AND THE SIGNIFICANCE OF PLACEMENT LEARNING

Encountering Risk

Programmes of occupational therapy education require students to undertake a minimum of 1000 hours of assessed fieldwork placement experience, as identified earlier. Often, such experience takes place in established medical or rehabilitation centres for people with physical illness and disability and mental health issues. Many student placements rightly still take place in these settings, as individuals with acute illness or impairment have difficulty fulfilling their chosen occupations and activities. There continues to be, therefore, a well-founded and legitimate role for occupational therapists in health and social care.

However, in the context of changing health and social care policy worldwide, there is increasing emphasis on the prevention of ill-health and the promotion of health-improving behaviours (WHO 2008), to make better use of scarce financial and professional resources. One of the consequences has been a greater emphasis on community-based interventions with increased social relevance. In response to this trend, many occupational therapy programmes have been including role-emerging and non-traditional placements in their curricula for a number of years. Role-emerging placements usually take place in settings where there has been no previous occupational therapy service (Totten and Pratt 2001) or where there is no established occupational therapy role (COT 2006). ‘Non-traditional’ refers to the fact that many of these placements are outside the statutory medical or social setting of current practice and are found within private, voluntary or charitable organizations.

Initially these placements were used in the UK to address a foreseen shortfall in placement opportunities for students. More recently, role-emerging placements have been seen as a means of exploring new opportunities for employment and to enhance learning opportunities. These placements have grown in number and frequency and have taken on a new meaning through the language of occupational science (see Ch. 3). Such placements occur where there is evidence that individuals and communities have unmet occupational needs, often due to societal or policy consequences, such as homelessness and unemployment, and which may or may not relate specifically to illness or impairment (see Ch. 29). These types of placements often provide an opportunity for students to design what they think occupational therapy can offer in the given context. However, this means that students have to learn to use their knowledge base confidently, investigate the context and the needs of the people within it, and are appropriately supported in their learning and developing practice.

Exposing Students to Risk; from the Known to the Unknown, the Predictable to the Unpredictable

Role-emerging placements could be seen to expose some students to greater risks, as not all students have the life experience or confidence to accept their insecurities about a situation and learn their way through it. Cooper and Raine (2009) raise the issue of whether students who are thought likely to struggle should be exposed to the additional pressure of a role-emerging placement. This is an issue that is debated often and while one would not wish to see students fail placements unnecessarily, the debate needs also to encompass the evolving nature of occupational therapy practice and be clear about how competence is interpreted. The issue could be about why students should not be exposed to role-emerging placements if the aim is for them to achieve competence for current real-world practice and future practice in evolving contexts. When students work in the real world of practice, there are some core expectations of what practice learning will help them to develop. Barker et al. (2010) identified core learning attributes achieved on international placements, which are often role-emerging:

■ Thinking outside the box

■ Adaptability/flexibility

■ Cultural sensitivity

■ Recognizing the value of interpersonal relationships

■ Gaining confidence by working outside one’s comfort zone

■ Increasing autonomy

■ Critical reflection on the appropriateness of occupational therapy practice.

These attributes indicate what students can achieve through core learning. Similarly, Tanner (2011) identified three threshold concepts to indicate student learning about the realities of practice:

1. Person-centred practice and use of self: including overcoming a fear of the setting, which was often based on a lack of understanding of people with a disability rather than seeing the person as a real person in a real world. Students often expected that they would tell patients what to do rather than engage them in making choices

2. Developing a professional identity: including thinking and acting like a professional and being able to explain their role to others

3. Practising in the real world: including the need to understand the reality of practicing in a world with all its policies and systems that impact on service delivery and, inevitably, on patient choices. This threshold also identified the importance of a student’s ability to apply learned theory.

These core learning attributes and threshold concepts are echoed in a small, qualitative study by Fieldhouse and Fedden (2009), where person-centred practice, therapeutic use of self, linking theory with practice and developing a professional identity also featured strongly. Taken together, the core learning attributes and threshold concepts support situated learning – that is, learning in the real world of practice, familiar and unfamiliar, where the integration of professional knowledge and skill are facilitated and mastered to a level of proficiency. While these findings are drawn from international, health and role-emerging settings, it is clear that this core learning would be a desirable outcome from any placement – national or international, role-emerging or traditional.

Different placement contexts are likely to expose different expectations and different levels of familiarity with the situation. For example, most students may have some generalized expectations of what is expected of them in a hospital setting. Students are likely to have previously visited a hospital to see a relative or for personal treatment. However, being a student practitioner is less familiar, because of the expectation to demonstrate competence to practice in very specific and measurable ways. Unfamiliar situations, such as working with a prison population, being attached to an employment centre or undertaking an international placement, potentially create more challenges. This might expose students to an increased risk of failing. Conversely, an unfamiliar placement setting may also heighten the students’ awareness of their learning needs, creating an enhanced opportunity for learning.

It is possible that the enhanced opportunities of a role-emerging or unfamiliar placement setting enable student learning and professional development to a higher level, justifying the possibly increased risk. Anecdotal evidence from students suggests that role-emerging placements are where many, although not all, identify their most significant learning; where their professional identity becomes more secure; where they feel most autonomous and where they are able to use a greater range of their professional skills. Somehow, intentionally placing students in these settings sharpens their perspective on what occupational therapy is and what occupational therapists can do. Role-emerging placements seem to create a greater sense of ‘work excitement’ where the learning environment fosters individual growth and development (Lickman and Simms 1993). They define work excitement as ‘personal enthusiasm and commitment for work evidenced by creativity, receptivity to learning, and ability to see opportunity in everyday situations’ (p. 211).

Vickers (2007) identifies the transformative nature of learning when students are exposed to ‘dynamic and fundamental learning experiences as opposed to a simple enlargement of knowledge (and skills)’ (p. 38). She defines ‘transform’ as a ‘significant change from the learner’s established way of thinking and acting, and towards a new way of understanding their world and their place within it’ (p. 38.). Role-emerging placements may help students to consolidate what they know and understand but also change the way they think and act in less familiar situations where the learning environment enables work excitement to emerge. Achieving new understandings requires strategies for managing risk and facilitating transformation, which will be discussed next.

Managing the Risk and Facilitating Professional Development

Strategies for managing role-emerging placements have been identified (COT 2006; Fieldhouse and Fedden 2009; Lorenzo et al. 2006). To prepare, a robust infrastructure needs to be established: for example, how to identify appropriate placements; identifying learning opportunities in the placement; establishing day-to-day supervision roles; ensuring that professional supervision is available; creating links between the university, professional supervisor and day-to-day supervisor; establishing robust communication channels; frequency of supervision and so on. Much of this is well-documented with guidance, for example, from the College of Occupational Therapists in the UK (2006). While the preparation and infrastructure to support role-emerging placements is vitally important and should not be underestimated in managing risk, it is the process of supported learning through the placement that will further mitigate risk for the student and for service users.

Lorenzo and Buchanan (2006) have adopted an action learning approach to support students working with disadvantaged communities in South Africa. This approach facilitates reflection in and on practice, enhancing the relevance of practice learning by encouraging sitting, listening, observing, questioning and reflecting on everyday practice and experiences, with the potential to bring about real change and real learning. The approach is an educational process, not a therapeutic process, and is concerned with creating a learning environment in which all participants benefit. Lorenzo and Buchanan (2006) argue that it is an inclusive way of learning for students, service users, placement educators and supervisors and university teachers. Our focus here though is on the students, their learning and developing competence and their particular relationship with their supervisor(s) and service users.

Galvaan (2006) comments on how students manage being in an unfamiliar and unknown situation. She identifies that students are aware that they are working outside their comfort zone, where their attitudes, values and assumptions are challenged, often where their knowledge and skills do not seem to fit. Using the work of Savin-Baden, she acknowledges that this results in a sense of disjunction where the student’s sense of self becomes fragmented as they venture on a journey of self-discovery. The students use their previous knowledge to build on their emerging experiences within the role-emerging context. Equally, they use their lack of knowledge and skill in that context to discover what they need to know, at a point when that knowledge is needed, so it can be applied. This is an inductive way of working, enabling the student to come to an understanding of what occupational therapy can offer, rather than jumping to a conclusion that there is a problem to be fixed.

So that competence can be achieved and demonstrated, the student’s process of self-discovery should be supported by the placement educator. Through supervision, students should be encouraged to admit their fears and feelings of powerlessness in the placement situation, as it is this honest exposure that creates the right environment for growth (Galvaan 2006; Lorenzo et al. 2006). They propose a number of specific strategies for supervision, which placement educators could use with the student:

■ Allow opportunity to deconstruct occupational theory and literature so that it can be reconstructed to provide appropriate meanings in the placement context

■ Investigate the literature and identify the evidence base that informs why the role-emerging placement works as it does, so that the student can value the work done by the placement

■ Help the student to recognize the application of their knowledge and skills in this context

■ Facilitate student understanding that the issues presented by the placement are serious enough and legitimate for intervention with an occupational focus

■ Help the student to create a structure in the placement to control any feelings of being overwhelmed

■ Facilitate the students’ organizational and management skills

■ Identify personal coping strategies

■ Develop the students’ sense of, and confidence in, being able to take informed risks and to act on identified needs

■ Create and harness a sense of work excitement and agency.

In adopting the strategies above, placement educators need to be secure in their own role as an educator in the workplace. This is quite a different approach to the more traditional apprenticeship model, where students learn by modelling the core professional skills of their supervisor in a particular practice environment. The latter is about skill development and ‘cloning’ for a given situation; the former is concerned with enabling students to learn and develop the new knowledge, skills and thinking required to re-position or re-define occupational therapy in unfamiliar situations and in which cloning, based on accepted practices, may have limited application.

In creating role-emerging opportunities for students, we are in fact also creating role-emerging opportunities for placement educators and academic staff. All the actors in this scenario will be working outside their comfort zone to a greater or lesser degree but the strategies identified above place responsibility on academic staff and institutions, placement educators and students, to ensure optimal success through risk management, rather than risk avoidance.

SUMMARY

This chapter has identified and discussed the political, professional and educational contexts that impact on the practice and education of occupational therapists. It has described the current process of occupational therapy education and the factors that influence the process from professional and regulatory perspectives and the subsequent effects on professional development. The different aspects of competence and their contribution in creating a competent practitioner were explored, before considering how role-emerging placements can be used to further enhance competence in the changing context of health and social care. The chapter concluded with a discussion of why exposing students to risk may be desirable with strategies for how academics, placement educators and students can mitigate against failure while working for success.