*Nancy E. Krusen
Pacific University, School of Occupational Therapy, USA
Clinical education, or fieldwork, is a required part of learning in many healthcare professions. Successful fieldwork indicates readiness for practice. Failure during clinical education has seldom been examined from the viewpoint of the student. The purpose of the study is to investigate adaptive strategies following fieldwork failure of occupational therapy students in the United States, to understand the meaning associated with the experience, and contribute to professional clinical education. This phenomenological study examines failure with an Occupational Adaptation perspective. Data are collected through open-ended, semi-structured interviews. Twelve occupational therapy students reveal a broad range of adaptive behaviours, strategies and categories without a predominant pattern. Three themes emerge: I need to tell my story not passing is not the same as failing, and convergence, supporting the concept of learning from what goes wrong. When academic or clinical education challenges are greater than a student’s ability to adapt, he or she may fail. The investigator recommends the inclusion of student voices for research in teaching and learning about failure. Future research could apply the Occupational Adaptation theoretical frame of reference to name and frame adaptive strategies in clinical education and intervention across professions and cultures that support professional growth.
Keywords: clinical education; fieldwork; occupational adaptation; phenomenology; professional development; scholarship of teaching and learning
Clinical education, also called fieldwork for the purposes of this study, is a required part of the learning process in many healthcare professions around the world. Though the requirements differ, physicians, nurses, psychologists, and therapists each complete clinical education. Occupational therapy students in the United States must complete fieldwork successfully to be eligible for graduation, for the national certification examination, and for employment as a practitioner. When students fail fieldwork, the experience may have significant consequences. There is a need to examine the process of adaptation following failure, from the student’s perspective, to provide insight into the art and science of professional education.
An unidentified proportion of students across health professions fail fieldwork, prompting investigation into the process of failure and the implications for education. The investigator has worked as an academic and a clinical educator, and has been in the difficult circumstance of failing students. The investigator has also served as mentor to several students who had previously failed a fieldwork placement. This study examines the stories of occupational therapy students who have failed fieldwork, to improve our understanding of their adaptive strategies and to gain insight into the process of learning from what goes wrong. A phenomenological design supports examination of the experience through the voices of the students to more clearly understand the meaning associated with the events, contributing to understanding of professional clinical education.
The review of the literature addresses foundational information regarding fieldwork in occupational therapy, current research surrounding fieldwork failure and the Occupational Adaptation theoretical frame of reference. The Accreditation Council for Occupational Therapy Education (ACOTE®) of the American Occupational Therapy Association (AOTA) sets Standards for educational programs in the United States. ACOTE states that fieldwork is a ‘crucial part of professional preparation’ and must be carried out ‘under supervision of a qualified occupational therapy practitioner’ (ACOTE 2011: 32). Level I fieldwork is integrated into classroom education and introduces students to practice. Level II fieldwork is designed to ‘develop competent, entry-level, generalist occupational therapists’ (ACOTE 2011: 34). Occupational therapy students must complete a minimum of 24 weeks of supervised full-time level II fieldwork. Students receive formal evaluation of their performance during Level II fieldwork through completion of the AOTA Fieldwork Performance Evaluation for the Occupational Therapy Student or an equivalent measure (ACOTE 2011: 36). An overall final score indicates student performance as passing or not passing.
Researchers in the profession of occupational therapy have examined many factors related to fieldwork failure in an effort to promote success, including examination of individual, academic and clinical environmental characteristics as noted below. Historically, researchers confirm the findings that success in the classroom is not a predictor of success in the clinic (Anderson and Jantzen 1965, Lind 1970, Ford 1979, Katz and Mosey 1980, Mann and Banasiak 1985, and Best 1994). Mitchell and Kampfe (1990) described individual coping strategies of students needed for fieldwork; students used Problem-Focused and Seeks Social Support more than Blamed Self, Wishful Thinking or Avoidance. James and Musselman explored commonalities across Level II fieldwork failure. They documented that supervisors most commonly report poor problem solving skills, poor clinical reasoning skills, difficulty ‘getting the big picture’ and poor academic preparation as reasons for fieldwork failure (2005: 67).
Sands (1995) and Scheerer (2003) gathered data directly from students to examine the students’ perceptions of their professional behaviour as contributors to classroom and fieldwork success. Students described the importance of being asked to participate in research about them and believed that telling their stories enhanced an understanding of their learning needs. Lew, Cara and Richardson (2007) identified several factors as contributing to negative experiences, including: (1) the role of the supervisor, (2) poor supervisory characteristics, (3) the fieldwork infrastructure, (4) misconceptions in the fieldwork experience, (5) student coping strategies, (6) student responses, (7) positive outcomes, (8) negative consequential outcomes, and (9) cycle of the ineffective fieldwork experience (105).
The investigator applied Occupational Adaptation (OA) as a theoretical framework to examine adaptive responses of students experiencing fieldwork failure (Schkade and Schultz 1992, Schultz and Schkade 1992). Adaptation is a process by which a person makes sense of and interacts with her or his environment to respond to occupational challenges, in order to move toward relative mastery. The transition from student to novice practitioner is often a time when performance demands outstrip a student’s ability to adapt (Garrett and Schkade 1995). OA provides one view of explaining the interaction between a person and the environment, such as fieldwork. Occupational adaptation is a normative process during which people exhibit many types of behaviours as they respond to and master occupational challenges. Three systems, sensorimotor, cognitive and psychosocial, contribute to adaptive responses. Further, adaptive response behaviours may be primitive (hyperstable), transitional (hypermobile) or mature (blended stability and mobility). Relative mastery may be examined through an individual’s sense of effectiveness, efficiency and satisfaction to self or others. In contrast, skill mastery describes literal accomplishment of a task by an external measure: a fieldwork performance evaluation indicates a level of skill mastery.
The process of Occupational Adaptation is most apparent during life transitions. Csikszentmihalyi (1990) described flow as the circumstance when high challenge is matched with high skill, a theoretical foundation for the concept of relative mastery in OA. When both challenge and skill are high, people experience a sense of time suspension; of being ‘in the groove’ or ‘in the flow.’ When the occupational challenge is greater than the ability to adapt, the person may experience occupational dysfunction. Major life transitions, such as illness, marriage, divorce, moving or job change, are events when the challenge may exceed the ability to adapt. At these times a person may experience a diminished adaptive capability, demonstrating performance that does not meet expectations to self or others. A variety of assessment measures of student performance are used to determine entry-level competency of occupational therapy students. No current measure explicitly addresses adaptability and flexibility, skills that cross competency categories.
Research design
Phenomenology is an accepted method of inquiry focusing on understanding lived experience from the perspective of the participant (van Manen 1990). The author used student voices to reveal student perspectives on the phenomenon of failure during clinical education and the phenomenological approach to illuminate how the students make sense of the experience. Phenomenology incorporates a variety of data collection methods, for example, interviews, textual analysis, video or art. The investigator used this method to uncover the essential elements of the experience, as well as interpret their meaning and usefulness in the practice of education.
The University Institutional Review Board registered the study prior to commencement of the research (Ref: #074-10). The investigator reviewed the Informed Consent to Participate document with each prospective participant prior to enrolment in the study. Each participant returned an electronic Consent before commencement of the research. The primary ethical concern was potential emotional distress of participants. Each was directed to contact support resources with whom she/he originally worked at the time of the failure.
Participant selection
The investigator selected a purposive sample of occupational therapy students who had failed a Level II clinical fieldwork experience in the United States within 12 months prior to enrolment in the study. There was no conflict of interest. The investigator had no previous acquaintance with any participant. There were no limitations by gender, age, location or type of facility. Study participation required English fluency. The investigator posted recruitment information on physical communication boards at professional conferences, and virtual communication boards via national listserv. The posting also made its way to social websites, spontaneously and without the investigator’s intent.
Data collection
Each participant completed an open-ended, semi-structured interview via telephone or SkypeTM voice calls with the investigator. Interviews ranged from 40 to 110 minutes. Participants were each interviewed once. The investigator asked participants to describe their experiences of fieldwork failure using four questions as a guide to semi-structured interviews (Table 1). The investigator developed these items from previous research concerning fieldwork framed by Occupational Adaptation theory.
Table 1. Interview guide
· After you first learned that you would not pass your fieldwork, what did you do?
· How did you deal with the experience on a day-to-day basis?
· What did you do to deal with the experience on a long-term basis?
· What advice would you give to other students who might face a similar experience?
Free-flowing conversation around these four central questions characterized interviews. The investigator provided prompts intermittently, to redirect participants as needed, or request additional information. Interviews were audio-recorded and transcribed. The investigator wrote memo notes simultaneously with, and immediately following each interview, recording insights obtained during the course of the conversation.
Data analysis
Because of the direct connection to the theory of Occupational Adaptation, analysis proceeded through multiple levels. First, the investigator identified action verbs in the transcribed text, grouping verbs into three systems, sensory motor, cognitive, and psychosocial categories. This first pass enabled the investigator to determine whether participants used a range of systems during the experience of failure. Second, the investigator noted descriptive words and phrases from the text, revealing exemplar adaptive response behaviours to answer the question whether participants demonstrated patterns during the experience of failure. Next, the investigator coded the transcribed text line by line, giving codes to words and phrases, using constant comparison to previously coded sections. The investigator used iterative data collection, constant comparative analysis, and sampling to saturation, consistent with phenomenological methods. An iterative process involves analysis of each case and then moving back and forth between individual cases. Boeije (2002) noted that while constant comparative analysis is most closely associated with grounded theory (Glaser and Strauss 1967), it has value for the creative researcher to interpret social phenomena in other qualitative methods. The investigator compared codes for similarities to and differences from previous data as each case was added. The investigator analysed transcriptions until no new codes or themes arose, referred to as saturation. Next, the investigator identified major themes or axes, connecting central points or themes. Axial coding took place within a single interview and also across each new interview with its predecessors. The investigator then compared axis points to clarify core themes related to the experience of fieldwork failure. The investigator compared transcript codes until no new axial codes emerged and compared axes until no additional core themes appeared. Table 2 shows an example of coding. The investigator followed van Manen’s method of reflection, reading, writing, re-writing (van Manen 1990).
Table 2. Sample coding. I need to tell my story
|
P’ticipant |
Transcribed text |
Open Code |
Axial code |
|
June |
L27. I don't mind talking about it now. It ought to be OK to talk about. I’m glad someone asked. |
OK to talk, Glad asked |
Tell the story |
|
|
L242. It has to be OK to talk |
OK to talk |
Talk taboo |
|
|
|
|
|
|
Beth |
L45. It helped to talk to the next site supervisor |
Help to talk |
Tell the story |
|
|
L184. I am glad to have someone to tell |
Glad to tell |
Tell the story |
|
|
|
|
|
|
Maria |
L167. It has to be OK to talk about failing |
OK to talk |
Tell the story |
|
|
L171. No one talks about it. It’s like it might be catching |
No one talks
|
Talk taboo
|
|
|
|
|
|
|
Jessica |
L213. I can tell my patients I understand and tell them why |
Tell understand |
Tell the story |
|
|
L216. No one wants to talk about depression or why you failed a FW. Talk about a double whammy |
No one talks |
Talk taboo |
|
|
|
|
|
|
Sonia |
L30. I needed to tell my story |
Need to tell |
Tell the story |
|
Olivia |
L11. I needed to tell somebody |
Need to tell |
Tell the story |
The investigator has a long-term interest in student adaptation following fieldwork failure and its implications for OT education that prompted the research reported herein.
Trustworthiness
Application of several techniques assures the trustworthiness of the study (Creswell 2009). Member checking clarified participants’ beliefs, giving credibility to interpretation of data (Lincoln and Guba 1985, Miles and Huberman 1994). After interviews were completed and transcribed, the investigator sent a preliminary summary of the data analysis to each participant, asking them to consider whether it was reflective of their experience. Five of twelve participants responded, each with only brief comments such as ‘Looks good’ or ‘Yes, you got it’.
Direct quotations from participants provide authenticity. They are the means to provide rich descriptions of the participants’ conversations in this study. Much non-verbal communication is missing in audio-only dialog. Memo notes are supplements describing intonation, phrasing, volume, tempo and what participants did not say. As in music, rests or pauses in language imparts shape and meaning. Listening to the music in participants’ conversation and describing these elements enable the listener to ‘hear’ the voice of the participant more clearly (Lincoln and Guba 1985). The investigator also kept memo notes during the process of analysis to make links across participants and codes. Dependability is supported by maintenance of an audit trail, author notes, transcripts, and codes.
Two expert occupational therapy peers reviewed the data. One reviewer currently serves as an academic fieldwork coordinator and one serves as a practitioner and clinical supervisor. Both are also educators for the regional American Occupational Therapy Fieldwork Educator Certificate Workshop. Each peer examined the audit trail of transcribed documents, basic and axial codes, field notes, and preliminary summary of data analysis. Each served as ‘devil’s advocate’ during the data analysis, offering comments and suggestions according to her own experiences with fieldwork students. This peer review provides an external check of the research process and a fresh perspective to the analysis of data.
The investigator conducted interviews with an initial purposive sample of 4 participants. Analysis of these data suggested that continued sampling should occur to gain information about the phenomenon under investigation. Initial interviews also contributed to refinement of questions. The final sample consisted of 12 occupational therapy students, 2 men and 10 women. Participants ranged in age from 23 to 49 years. At the time of the study, 9 participants had graduated and 3 were still actively enrolled in an occupational therapy curriculum. All participants subsequently passed their respective fieldwork placements.
The investigator asked participants not to identify their educational institution, fieldwork placement or geographic location. Participants chose pseudonyms to maintain confidentiality. Two participants had not failed any fieldwork placement, yet experienced such strong emotions about failure, that they contacted the investigator in response to the recruitment, expressing a desire to tell their stories. Though these participants were outside the original parameters of the study, the investigator believed these participants provided a different perspective of the phenomenon of failure, enhancing trustworthiness of the research.
Participants described a broad range of behaviours used following fieldwork failure. These behaviours confirm the all three systems (sensorimotor, cognitive and psychosocial) are engaged in responding.
Sensorimotor adaptation
Participants described familiar sensorimotor activities post-failure as a way to adjust to their changed circumstances: cooking, walking, cleaning, grocery shopping, exercising, and completing home repairs. Beth eloquently related making use of her previous background as a horseback-riding instructor to illustrate sensorimotor activity as an adaptive strategy:
After I failed I just taught and rode until I thought I could go back [to fieldwork]. [Laughs] I taught a lot. […] So I kept teaching and training during my next fieldwork. I found balance on a horse until I was balanced on the inside.
Most participants described changes in sensorimotor activity before and after failure. Some participants described feeling lethargic, having appetite changes and having difficulty sleeping. Others described ‘just needing to move’, ‘just needing to do something’. Mark stated he resumed a healthy diet and a workout routine, things that he had ceased in the busy-ness of fieldwork. Jessica experienced sensorimotor changes during fieldwork failure as part of a larger loss of health during her rotation. She reported being unable to move, describing her loss of motion as ‘textbook catatonia’:
I was up for the next new patient and when the next new patient had a diagnosis like my mother, I just lost it. My mom had just died in the last year. I couldn’t do anything. I just sat. I couldn’t even say what was wrong. My dad had to drive out to pick me up and come drive me back home.
While Jessica’s sensorimotor response was outside the typical experience of fieldwork students, unexpected major life events during fieldwork are not so atypical. Participants described a broad spectrum of life circumstances with which they contend during fieldwork, including births, marriages and deaths.
Cognitive adaptation
Participants described engaging in familiar cognitive activities after learning they would fail, as a way to resume a routine. Participants described activities to focus and to distract: reading, studying, bill paying, organizing, watching videos, playing on the Internet, listening to music, and helping their kids with homework. Almost all participants described a change in cognition shortly after they learned they would fail; ‘I just couldn’t think for a while’. They related initially engaging in activities requiring limited executive function and in activities done in solitude, as best illustrated by June:
I went home and I watched repeated episodes of Xena, one after another after another. There must be over 100 episodes and they are all free online. [Laughs]
I cried a lot, too. I mean a lot. [Pause] Besides Xena […] [Laughs] Let’s see, I spent lots of time by myself. That wasn’t very good for me but I couldn’t stand to talk to anyone. Eventually – I guess about a week later – I went to talk to the academic coordinator and we put together a plan of remediation, but I still watched a lot of Xena when I needed to escape. I was pretty much cried out by then.
The Internet served constructive purposes for some participants as well as an escape; ‘I watched a lot of YouTubeTM videos of people. You know, treatment, assessments and stuff. Not sneezing pandas’. Almost all participants related initial difficulty planning, isolation from other people, a combination of not knowing what to do next, and not wanting to talk to other people. Participants reported limited cognition and withdrawal after having to leave their fieldwork, ‘I didn’t tell my classmates’; ‘I didn’t talk to anyone. My clinical coordinator kept calling and I wouldn’t answer the phone’. Participants reported that after a few days they resumed connections and organizing, stating, ‘Mostly I wanted to be by myself. And then it was OK (to be) with my family’, ‘I withdrew at first’, ‘[…] I finally called my ACC [academic clinical coordinator] back’ to make plans.
Several participants related not knowing how to perform when asked to change their behaviour by their supervisor. They described limited ability to identify adaptive strategies. Justin related having concerns about his performance and his finances during clinical fieldwork but not knowing how to manage. ‘I just couldn’t see how to do it any differently’. He reported that afterward he made use of financial counselling, additional financial aid, mental health counselling, and academic services to develop strategies before resuming his fieldwork. Each participant eventually met with academic advisors, counsellors, and talked to family and friends. Each described creating an academic plan of remediation with these resources. Plans identified specific objectives that included familiar and new resources, and completion of the Fieldwork Experience Assessment Tool (FEAT) (Atler et al. 2001). The FEAT evaluates the demands of the fieldwork environment, the fieldwork supervisor, and the student. Supervisors and students may use the FEAT for discussion and problem solving.
Psychosocial emotional adaptation
All participants described strong emotions though not all subsequently related feeling resolved. Many participants described being tearful and fragile in response to failure. Mark stated, ‘When I failed I actually cried. I didn’t tell my classmates that. [Long pause] I am not a tough guy anymore. [Pause] I went home from [site] and cried.’ After becoming ‘cried out’, many participants described finding strategies to soothe painful feelings, including spending time alone, prayer, meditation, and eventually reaching out to family and friends to decrease their sense of isolation. (For the purpose of this study, spiritual adaptive strategies are included in the emotional category.) Most participants had moved past extreme emotions at the time of the interview, describing relief that the raw state was passed. Several participants, but not all, made a connection between adaptation and using strategies to change and to grow: ‘I kept thinking I must be stupid. I kept thinking I’m not OK. Eventually I got busy and worked it out’. Lisa described the literal and metaphorical ‘housecleaning’ necessary to get a fresh start:
[Laughs] I cleaned the house. Literally. Then I went to counselling and did some more housecleaning. The counselling helped a lot and I met with my advisor at school and the [academic] fieldwork coordinator. Once I got a plan, after that things went fine.
Adaptive response behaviour
Garrett and Schkade (1995) illustrated adaptive response behaviours of occupational therapy students during fieldwork. Primitive or hyperstable responses are those in which a person may appear stuck, unable to implement a strategy or persistently repeating a strategy that has previously been unsuccessful. Transitional or hypermobile responses are disorganized and scattered, in which a person moves quickly from one strategy to another. Mature responses blend stability and mobility in a well-considered approach. People use all three behaviours, representing typical attempts to adapt to challenges based on past and current experience. In this study, a few participants remained stuck or hyperstable in response to failure, having difficulty recognizing their complicity in the circumstance or having difficulty moving past the initial event. Ann’s response expressed this hyperstable adaptive behaviour:
I thought I could balance everything and I couldn’t. I was getting married and it was all I could think about instead of my fieldwork. I was just in la-la land. I sort of knew that, but thought I was covering up pretty well. [Pause] I had to tell my family and my wedding party and stuff why I had so much time all of a sudden and that was really embarrassing. [Pause] I didn’t know that getting married would be so stressful. [Pause] I still think they could of just passed me anyway. It wouldn’t have been a big deal. I’m still kind of mad.
While Ann summarized, ‘I’m still angry’, other participants, such as June, Beth, Mark and Zoe articulated about being stuck and then moving forward. Mark recognized his dysadaptation (Schkade and Schultz 1992) and his inability to change during the fieldwork:
I was just nervous at the site. Not that bad, but not like myself. I would screw up something and then it didn’t seem like I could recover. I didn't juggle very well. I didn’t know how to do it differently.
Mark described the time following failure as necessary to regroup, review and move on.
Each of the two participants who passed fieldwork (skill mastery), Olivia and Sonia, also described a sense of failure or dysadaptation (Schkade and Schultz 1992). They each noted circumstances in which skill mastery and relative mastery were dissonant. Sonia said:
They thought I was wonderful and said I made all these changes, but I was just an automaton. I hid myself and I smiled.
She related modifying her behaviour to fit in but not having the sense that she learned therapeutic skills. She saw her performance as having been likable instead of effective, ‘I learned to be a chameleon. I probably should have failed, but I didn’t.’ Olivia described adapting in a high challenge environment in which she felt she could not seek support without risking failure:
‘[clinical supervisor] just kept saying how worthless students were. […] I have no idea what I did or didn’t do: if I was any good at evals or treatment or not. I dared not ask. I was afraid of calling attention to myself […] I still don’t know what I learned. [Pause] I learned to be quiet and accept feedback regardless of my thoughts. [Pause] Maybe I should have failed.
Olivia and Sonia each depicted using a narrow set of strategies, primarily adapting by viewing the challenge as ‘time limited’ and ‘fitting in to survive’. Each also expressed an overwhelming need to tell her story to make sense of the experience. These two participants passed their respective fieldwork, thereby exhibiting skill mastery by the metric of the Fieldwork Performance Evaluation (FWPE) (American Occupational Therapy Association 2000). They described using adaptive strategies sufficient to pass, but had no sense of relative mastery; indeed each believed she should have failed. These two participants reported feeling neither effective nor satisfied; instead describing a fervent wish that such a circumstance ‘never happens again’.
Themes
The final step of data analysis, after examining systems and adaptive response behaviours, was to determine the meaning of the experience for participants. Three themes emerged from the data casting new perspectives on fieldwork failure that are not addressed by current literature; I need to tell my story, not passing is not the same as failing, and convergence. Almost all participants related storytelling as one means to make sense of their experiences, regardless of their opinions about the circumstances. Their experiences of dysadaptation were so powerful; they contacted the investigator, stating, ‘I need to tell my story’. Participants described relief that someone listened to their perceptions about failing. Telling stories was more than a recounting of the event or a description of adaptive strategies; storytelling was a means to make sense of the events, to tell others that ‘I am OK’ as a person, and that failure is acceptable. Many participants also indicate a common theme that ‘Not passing is not the same as failing’. While none describe failure as desirable, participants indicated failure itself should be acceptable, and acceptable to talk about; that growth results from failure. ‘There is nothing wrong with me.’ ‘I may have failed my fieldwork, but I am not a failure’.
Convergence, a coming together of circumstances, may be positive or negative. In addition to revealing a variety of adaptive strategies, participants’ narratives indicated the importance of convergence as a contributor to fieldwork failure. Zoe’s story epitomized the three identified themes. She clearly stated that multiple factors must come together at the same time for fieldwork to be successful, that people need to know the story, and that failure is not failure:
My fieldwork was doomed from the beginning. [Laughs] You asked me what I learned, and I learned its OK to fail. […] It’s OK sometimes to just let things be the way they are. We started out fine. We knew the fieldwork would be close, ’cause I was in a school and it was near the end of the year. Well, first we had storms that shut down the school, but that was OK and they reopened soon. But then the storm had made it flood and they shut the school again a couple of times because of the roads and the water around the foundation and the wires. They finally reopened, but in between, I was worried about my family and I couldn’t concentrate. And my supervisor couldn’t be there ’cause storm stuff happened with her family. [Laughs] G-d it was crazy. We both learned a lot. At the end, I didn’t have enough hours or enough skill. So I didn't exactly fail but I couldn’t pass.
If there are some times where everything comes together, then there must be some, where they don’t. You know our clients, our patients, fail all the time and we just keep going. They come see us because something failed. And it has to be OK. [Pause] This was it for me. What a disaster. Sometimes things just can’t turn out the way we want them to. It’s no one’s fault. I couldn’t have done anything any better or any different. And neither could my supervisor.
You know how people say things just click sometimes? Well this was the opposite. [Laughs] My clinical just went to s---. My Mom said ‘It went to Hell in a hand basket’ and neither I, nor my supervisor, could have changed the outcome. So how did I change? People need to know that it is OK to fail. That not passing is not the same as failing. We fail at little stuff all the time and it’s no big deal, it’s just part of it, you just try again. Fieldwork is a really big deal, but I wouldn’t trade what I learned. Nobody had an experience like I had.
The three themes reflect process and product of adaptation. Some circumstances simply have too much turmoil for successful convergence, despite all efforts to make things work. Failure may not be a lack of skill, but a combination of circumstances for negative convergence. Jessica (whose mother had died within the previous year) was also articulate in her recognition of the relationship between convergence and failure. Her description is an insightful example of the divide between environmental demand and adaptive skill, as well as the growth that springs from adversity and failure, the need to tell the story, and to find a sense of being alright as a person.
[After failure] I had months of inpatient and outpatient therapy. And I returned [to OT school] with the view that I had something unique to offer. I have insight that nobody else has. And it’s not just for clients who had a diagnosis like my Mom; it’s for the world […] So many students just don’t get what a big deal it is when everything crashes. It really is like your whole world collapses. I can tell my patients I understand, and tell them why. From both sides. [Pause] I have insights into myself as a client and a daughter and an OT. […] It just takes the time it takes. I am OK, just the way I am.
Examination of participants’ stories supports adaptation as a core element in professional development following fieldwork failure, consistent with the findings of Garrett and Schkade (1995), Ferraro, Coates and Crist (2004), and Gutman et al. (1998). Analysis indicates that participants use all three categories of behaviour, sensorimotor, cognitive and psychosocial. Analysis also showed exemplar adaptive response behaviours established by OA, hyperstable, hypermobile, and mature responses. Analysis of the data identified no single category or pattern of behaviour as predominant to deal with fieldwork failure. From further analysis of interviews emerged themes of fieldwork failure with unique perspectives and insights. Participants in this study expressed a desire to be heard, supporting narrative as a means to make sense of actual or perceived failure. Hamilton (1999, 2008) and Frank and Polkinghorne (2010) described narrative approaches as central to the research tradition in occupational therapy, suggesting it as one tool for use to explicate human experience. Participants’ experiences illustrated a lack of congruence between skill mastery (passing fieldwork) and relative mastery (effectiveness, efficiency and satisfaction to self and others). In some circumstances participants who exhibit skill mastery did not describe effectiveness, efficiency or satisfaction. Neither did they describe a repertoire of adaptive strategies or mature response behaviours. Conversely, some participants who described effectiveness, efficiency or satisfaction did not necessarily pass their fieldwork experience. McGregor described a disconnection for nursing students who feel compelled to hide, ‘wearing a chameleon cloak’ (2007: 507). Further, McGregor noted students’ perceptions of powerlessness, fear, and hyperstability while identifying a need for mutual respect in the ‘context of mutual sharing’ (508). Schkade and McClung (2001) stated that learning from things that go poorly during adverse life events are often a prompt for adaptation, also referred to as negative relative mastery (Schultz and Schkade 1997, Krusen 2001, Seery et al. 2010). Participant stories of growth from real or perceived failure confirmed the OA concept of negative relative mastery, the need to adapt in response to a traumatic life event or distressing outcome. Study participants summarized the concept of learning from what goes wrong, ‘People need to know that it is OK to fail.’
The three themes suggest a means to support student adaptation and subsequent professional development. Csikszentmihalyi (1990) described flow as a just-right fit between high challenge and high skill levels. With poor convergence, the just-right challenge between student and fieldwork setting does not occur. Failure may be inevitable despite the efforts of all involved parties and may serve a benefit for learning beyond the field of occupational therapy. Most human service professions require an experiential education component. Insight from the participants in this study may support professional development in other fields. Sayer et al. (2002) described a method of individual educational diagnosis and intervention for undergraduate medical students. While the individual structured assessment, problem identification, action plan and academic support is labour and cost intensive, it does enable students’ success as they move forward in the program. Nelson (2003) advocated that open, communal inquiry, including student voices, would support the scholarship of teaching and learning, ultimately for improved education. Teaching and research could be combined to target ways in which we can support students to adapt to failure. This could include student perspectives across professions and cultures, examining convergence, exploring teaching adaptive strategies in academic or clinical settings, examining the long-term impact of failure on practitioners, and including students in the data analysis phase of the scholarship of teaching and learning.
Study limitations
The purposive sample was limited in the number of participants. There was no existing database of participants who fit the enrolment criteria from which a random pool could be selected. There was undoubtedly a bias in this study: participants who were willing to discuss their experiences. The investigator believes this to be of no significant effect. The instructor believes the participants and their responses to be representative of students who fail fieldwork. The investigator further believes that the fieldwork settings at which the participants failed also are typical. Another limitation of this study is that there are no participants who failed a fieldwork education experience and subsequently withdrew or were dismissed from their programs. Their adaptive strategies, or lack thereof, would no doubt enrich and enliven this discussion. In addition, there was no opportunity for repeated time sampling, for protracted engagement or for interviewing all students who failed a clinical education experience. Despite some limitations, the investigator concludes the themes to accurately reflect students’ perceived experience of failure. The perspective conforms to that of current researchers in the field.
When academic or clinical education challenges are greater than a student’s ability to adapt, he or she may fail. Participants in this study used a broad variety of adaptive strategies and adaptive responses following failure. Analysis of student voices conveys the power of their experience. If adaptation is a core element in professional development, then the Occupational Adaptation theoretical frame of reference has utility beyond the profession of occupational therapy to name and frame the means through which everyone adapts to life challenges. OA is currently being applied to patients and clients in practice as well as in education. Academic and clinical educators may enable students to grow professionally through the development of adaptive strategies or response behaviours, as well as enabling fieldwork students to facilitate adaptive skills with clients and families. The basic question about how people adapt to failure is worthy of additional study. The investigator recommends the inclusion of student voices for the scholarship of teaching and learning, or voices of clients and families in shared decision-making. Future research across professions and cultures could support learning about adaptation during professional development or client intervention.
References
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