This article was originally published in the 2015 Spring Issue, and can be read here.
Authors: Maria Harewood, Caroline Storr, Matthew Hunt, Erin A. Douglas, Virginie Tousignant
Abstract
Increasing numbers of Canadian occupational therapy (OT) students participate in fieldwork in low and middle-income countries during professional training. There are a few studies investigating the perceived benefits and challenges of international fieldwork (IFW).
The aim of this study was to better understand the learning experiences during international fieldwork from students’ perspectives. 11 practicing occupational therapists who had completed an IFW experience as a part of their required professional education were interviewed, and data were analyzed using an interpretive description methodology. Collectively, participants had completed their OT training at four Canadian universities and undertaken IFW in eight different countries.
Four themes were identified: living in a new cultural context; learning about different approaches and contexts of occupational therapy practice; supports and resources for carrying out IFW; and perceptions of how IFW affects students, clients, institutions, and host communities.
The findings of this study can inform the best practice preparation and planning for IFW by students, university programs, and host institutions so that learning and sustainability can be optimized.
This study was conducted with a small group of participants. More research is needed on the perspectives of partners in IFW from a sustainability and resource viewpoint. Moreover, a comparison of different student debriefing strategies would be useful in informing best practices.
Introduction
There is a growing trend in health care professional training in many countries to expand teaching about global health issues and develop opportunities for international fieldwork for students (IFW; Barker, Kinsella, & Bossers, 2010, Drynan, 2013). These developments are also taking place in occupational therapy (OT) programs. As the role of OT in the field of global health expands, more students from high-income countries are participating in IFW in low- and middle-income countries (Barker, et al., 2010). Researchers have begun to investigate the impacts of participating in IFW for health care students (e.g. nursing; Lee, 2004, physiotherapy; Crawford et al., 2010, medicine; Petrosoniak, McCarthy, & Varpio, 2010), but there are still relatively few studies specifically investigating the perceived benefits and challenges for OT students (Barker, et al., 2010; Kinsella, Bossers, & Ferreira, 2008; Humbert, Burket, Deveney, & Kennedy, 2012). IFW provides the opportunity to experience different models of health care, gain an appreciation for culturally-informed understandings and practices related to health and rehabilitation, and acquire a better understanding of the impact of globalization on these issues. (Whiteford & McAllister, 2007; Champin, 2008; Broberg et al., 2003).
Benefits and Challenges of IFW
Researchers in nursing, physiotherapy, social work, and medicine have provided emerging evidence of positive outcomes of IFW (Clampin, 2008; Barker et al., 2010; Crawford et al., 2010). These experiences are associated with the development of coping skills, adaptive thinking, cognitive development, and the ability to think critically about professional issues (Cameron, Bednar, and Valade, 2003; Standeven, 1998; Frisch, 1990). Crawford et al. (2010) examined the experiences of Canadian physical therapy students who undertook IFW. They reported positive learning opportunities, the chance to experience a different health care delivery system, and the development of enhanced cultural competence. These findings support earlier empirical research in which participants reported becoming more culturally sensitive and aware of other cultural contexts (Lee, 2004). Alappat et al. (2007) also noted that furthering training opportunities for therapists within other cultural contexts in entry-level education could greatly improve the transfer of knowledge, adaptive skills, and awareness of global health issues.
A range of challenges associated with IFW has also been described in the literature. Some challenges relate to planning and preparation such as site selection, paperwork completion, and availability of funding (Crawford et al., 2010; Reisch, 2011). Other administrative challenges, including availability and timing of fieldwork within their curriculum, and procedural issues, such as insurance and immunizations, were reported (Kinsella et al., 2008; Crawford et al., 2010). Crawford et al (2010) and Reisch (2011) describe challenges during IFW related to adapting to cultural differences, experiences of culture shock, adapting to local practices and health care systems, and situations of widespread poverty. Students may also encounter language barriers, requiring a translator or alternate methods of communication in order to communicate with patients (Whiteford & McAllister, 2007). Crawford et al. (2010) also reported that students felt the need for additional follow up and debriefing from their home institutions after the completion of their IFW experiences.
Experiences Specific to Occupational Therapy
Commentators such as Champin (2008) and Barker et al. (2010) have argued that OT programs should integrate further opportunities for students to learn about global issues. As well as learning about global health in classroom settings, many OT students already participate in IFWs. Several research teams have conducted empirical studies to examine IFW in OT from diverse perspectives. Simonelis, Njelesani, Novak, Kuzma, and Cameron (2011) explored the experiences of supervisors, on-site staff, and OT students on IFW programs. They highlighted three themes: collaborative learning, cultural negotiations, and self-reliance. IFW program benefits included opportunities to learn collaboratively and build verbal and non-verbal communication skills (Simonelis et al., 2011). Humbert et al. (2012) conducted a study of culture and cultural learning within IFWs based on interviews with OT students. Their findings emphasize the dynamic and relational nature of IFW and identify these experiences as potential sources of increased cultural awareness and flexibility, leading to a broader worldview for students (Humbert et al., 2012). These studies make important contributions to better understand IFW for OT students. Nevertheless, there remains uncertainty about the range of benefits and challenges associated with IFW from student perspectives. We thus undertook a qualitative study to explore the perceptions of Canadian OT students regarding the benefits and challenges of having conducted IFW in a low- or middle-income country and how they perceived the longer term effects of these experiences.
Methods
Research Design
Given the experiential and exploratory nature of this inquiry, a qualitative design based on an interpretive description methodology was employed (Berg, 1989; Thorne, 2008). Interpretive description takes into consideration variability as well as patterns and commonalities between individuals, and has been used effectively in smaller scale qualitative studies (Thorne, Kirkham, & MacDonald-Emes, 1997; Thorne, Reimer, Kirkham, & O’Flynn-Magee, 2004).
Participant Recruitment
A purposive sampling strategy was used to recruit a diverse set of participants. Sampling dimensions included: university in Canada where participants received their professional OT training; current area of professional practice; country and region in which the IFW took place; and 1-5 years of practice experience since graduation. Participants were recruited by email invitations through referral from the Association of Canadian Occupational Therapy University Programs (ACOTUP), the Committee on University Fieldwork Education (CUFE), the Global Health Initiative (GHI), and investigator contacts.
Participants
Participants were English- or French-speaking licensed occupational therapists that had completed IFW within the last 5 years in a low- or middle-income country (as defined by the World Bank, 2011) during their Master’s level professional training. 11 occupational therapists participated in the study, and they had received their OT degree at four Canadian universities (the number of participants drawn from each university ranged from 1 to 5). Collectively, the participants completed their IFW in the following countries: Bolivia, Columbia, Kenya, Mali, Philippines, South Africa, St. Vincent and the Grenadines, and Thailand. The participants completed their IFW in the following areas of practice: community rehabilitation, mental health, orthopedics, pediatrics, and physical medicine.
Interviews
In-depth, one-to-one, semi-structured interviews (lasting approximately 40-60 minutes) were conducted with each participant following a semi-structured interview guide. Interviews were audio recorded and then transcribed. Interviews were either conducted in person or over Skype. Field notes were written following each interview.
Data Analysis
Analysis of the transcripts began as each interview was completed, with two members of the research team conducting initial coding of each transcript. Constant comparative techniques were used to compare within and between transcripts. All team members reviewed and contributed to refining the coding structure. The second level of analysis focused on the relationships between codes and involved the aggregation of codes into categories. Themes were then developed, communicating the core elements of the analysis.
Ethical Considerations
The study was reviewed and approved by the Institutional Review Board of the Faculty of Medicine of McGill University. All participants signed an informed consent form.
Results
Four main themes were developed: living in a new cultural context; learning about different approaches and contexts of OT practice; supports and resources for carrying out an IFW; and perceptions of how IFW affect students, clients, institutions, and host communities. Selected verbatim quotations are included to illustrate the four themes.
Living in a new cultural context
Participants described the cross-cultural nature of their IFW as both rewarding and a source of challenges. Most participants related specific encounters and experiences that offered opportunities to engage with and learn about cultural values, practices, and worldviews in their IFW setting. Such experiences were described as leading to greater awareness of and sensitivity towards local cultures. For example, a participant reflected on the community-oriented values that she encountered during her IFW: “…since then it really made me realize how much community is important and not just the immediate family but getting everyone implicated in the… form of groups … it made me realize the importance of the whole network or social network and how important that can be for anyone really…” (P5)
In describing the cross-cultural dimensions of their IFW, participants discussed factors that facilitated their learning and integration within these cultural settings, such as preparatory activities that they had completed individually or in groups prior to the IFW, as well as connections that they could draw between their own cultural background and the host culture, which some participants reported as helping them better understand these perspectives. Along with these stories of cultural learning and engagement, participants also shared experiences and offered reflections about how the cross-cultural aspect of their IFW challenged them and was sometimes frustrating or unsettling. A participant reported her struggle to understand local expectations and practices regarding the use of limited healthcare resources, and she related these to the differences in cultural values:
“I can see why [locals] want to put more resources into someone who has a very, very minor disability as opposed to a more severe disability, but that’s the culture saying that we want to normalize, we want to be normal and making, labeling a child as mentally retarded just because they can’t speak. That’s the culture.” (P8)
The participant went on to describe the struggle she felt between respecting what she saw as the local perspective and advocating for her client. Other participants reported experiences where particular cultural perspectives prompted them to reflect on some of their own assumptions and values.
Another facet of living in a different country and cultural context were communication barriers that were experienced by several participants. Such barriers had implications for clinical practices as well as for developing relationships with clients, co-workers, and others in the community. A participant described limitations related to her lack of knowledge of local languages:
“Of course there’s some things that I would have liked to do with the patients, but I couldn’t because of the language barrier, and some assessments that I would have liked to try but I couldn’t… That was really limiting.” (P6) Several participants reported that various individuals provided translation depending on the context. They also sought creative approaches to address communication: “We painted murals on the side of the schools with all the kids. So that was our like break-in, sort of get to know the kids, get them to know us. It was like ‘play’ was the sort of the translator, you didn’t need language. You could just play with the kids to get them to trust you.” (P4) Creative approaches enabled participants to make connections cross-culturally despite language barriers.”
Experiences related to cultural learning, including experiences that were viewed as troubling and challenging, were described as crucial aspects of IFW by participants and also important learning opportunities.
Learning about different approaches and contexts of occupational therapy practice
A common goal among participants for taking a part in IFW was to learn about their chosen profession within another healthcare environment. In describing their experiences during IFW, participants frequently noted similarities and differences between OT practice in Canada and in the host country. Differences in practice elements, such as charting, evaluations, and treatment modalities, were identified, as well as practice values, beliefs, working conditions, and the life experiences of patients. Roles of health care professionals were also discussed by participants in terms of differences in values and perceptions within the work setting, including relations between different professional groups. For example, a participant reported that occupational therapists in the IFW setting had less professional autonomy than in Canada. She reported that a major difference was how “the hierarchy is very pronounced in [country]. The doctors decided, and we just do.” (P6)
Faced with different role definitions, working styles, and resources, participants reported that they had to develop skills such as being flexible, creative, and adaptable. They also gained knowledge and skills related to treating a different set of clinical conditions and needed to account for the different realities for clients in terms of their activities, occupations, home environments, and social contexts. Participants associated these experiences with improved clinical reasoning due to the necessity of taking into account a wide range of factors and moving beyond some of the “taken-for-granted” nature of clinical practice in their home communities. According to one participant, “the biggest sort of educational component for us was that it challenged our clinical reasoning beyond any of my other placements that I had…” (P7).
IFW allowed participants to learn about the role of OT practice in another healthcare system and develop transferable skills and attitudes that they viewed as beneficial for their future practice.
Supports and resources for carrying out IFW
Participants experienced challenges and aids related to available resources and supports. Supports included assistance from their university to prepare for their IFW, such as planning and developing communication channels with the host institution, orientation sessions, and developing a detailed placement organizational plan. Some institutions assisted the participants to find a location to complete their IFW by providing participants with a list of destinations where students from the university had previously completed IFW or supported them in finding a partner in a new country. Other participants reported that their institutions did not provide support in finding a location, leaving them to find and coordinate with a prospective site on their own. In addition to the organization of the details of the practicum, other aspects of preparation included legal requirements, travel arrangements, health insurance, and orientation to the local context once they arrived in the IFW site.
During their IFW, several participants emphasized that mutually supportive relationships with other students, local professionals, and their OT educators were key sources of support. The importance of these relationships is reported by a participant in relation to ongoing supports in the IFW setting: “…we had a lot of support … and they were really eager to have us there. In the morning we’d all get together …we would debrief from our last time and we’d make our plans for what would come up the rest of the [rotation] but also we’d make our daily plans everyday almost like our long-term and short-term goals.” (P9)
In contrast, several participants found that the support from the educator or administration at the host institution was limited. A lack of feeling supported by the local partner represented an important challenge for these participants.
Participants also reported challenges related to the availability of materials and clinical resources such as assessments, equipment, books, and articles, which contrasted with availability in their home nations. A participant reported that “[t]he resources were very limited, we often found that we had to adapt whatever we could to the kids that we were treating.” (P8) Participants reported that the lack of resources challenged them to adapt and apply previously learned clinical skills to match the new realities encountered during their IFW.
Many of the participants highlighted the richness of the social resources and community connectedness in host communities, seeing these as resources that also supported their IFW experiences. A participant described the social supports that existed in her IFW setting: “In terms of people resources, there is this huge community spirit and everybody is helping each other and the staff is very devoted to the children and the adults there. They [have] a lot of volunteers as well just to help them.” (P5)
Overall, the participants associated the availability of supports in preparing and carrying out their IFW as playing a key role in the degree of success of their IFW.
Perceptions of how IFW affects students, clients, institutions, and host communities
Participants described a range of ways that they had benefited from IFW. They also reflected on whether their IFW affected clients, institutions, and members of host communities. P8 reported that the presence of international students was a source of “pride for them, kind of to see us there… They were really happy, and it gave them a little bit of hope.” Several participants described the opportunity to exchange information and experiences with clients, preceptors, and other health professionals as a more tangible benefit of their IFW. However, other participants felt that they had not made a contribution to the local community, institution or patients. One participant stated, “Well, it might be pessimistic, but I think I had almost no impact at all, because I was there only 5 weeks, and they have a type of living that’s really different from here.” (P1)
Several participants reported wishing that it was possible to create and manage a sustainable project within the host institution as part of their IFW. Obstacles to doing so were reported in relation to the student role “…but you need to be contributing to something that is already established, because otherwise it’s not sustainable, so that’s sort of, so the other responsibilities, I guess, was to set up systems that could be sustainable.” (P4)
Such feelings also led many participants to discuss struggles and potential recommendations for institutions on how they could improve IFW, clinical sites, and institutional programs. Some examples identified that would contribute to enhancing IFW included better pre-departure preparation and planning by the university, and longer duration of the IFW experience. Participants discussed the short length of their IFW, with time ranging from five to eight weeks. One participant expressed that “I think that any international placement should be 12 weeks at least…” (P7). She asserted that longer IFW would greatly enhance learning opportunities.
Participants also recommended that students taking part in IFW in the future ought to have enhanced language learning, more support for financial planning, and increased advanced preparation such as learning about the local cultural and social context. Participants also emphasized the attitudes that students need for a successful IFW that would be beneficial for the students themselves, as well as clients and local communities. According to a participant, future students need to be flexible and open-minded about the differences they will encounter on their IFW: “make sure you’re open, make sure you’re flexible, and [that] you don’t go in [with any prejudices].” (P4)
The importance of the attitudes of the students embarking on IFW was highlighted alongside suggestions of how best to organize or implement the learning experience.
Participants discussed how participating in their IFW has impacted their future plans. A participant reported that her IFW experience “has given me the interest to go work internationally, eventually” (P10). Another participant reflected on how the IFW influenced her career goals: “I would like to eventually teach and maybe like teach courses in community development, to work on that level. [IFW has] provided me with the hands on experience of what I would like to keep on doing professionally.” (P4)
Other participants made comparisons with how the IFW helped them for clinical practice in Canada: “Sometimes you see different cultures in the home, so it has helped me to adapt to you know what you have, to what you have in the home. And here it’s really multicultural…it helped me in this way.” (P2) In these ways, the experiences and learning that participants acquired during their IFW were seen as influencing their professional plans and future clinical practices.
Discussion
The present study highlights how the process of living in another country and experiencing field-work provides opportunities for personal development and learning about OT within another cultural context. Participants shared stories that described their international experiences as rich in learning, not only about themselves, but also about what their chosen profession meant within this new context. These stories also connected how practicing as an OT student in a different cultural context could create situations where they were required to use critical thinking, creativity, and problem solving in order to effectively treat a client. Participants were also confronted, sometimes to their surprise, by different approaches to healthcare and different expectations and conceptions of health, illness, community, and disability. Some participants discussed how they struggled to understand and accept healthcare norms and systems created within a different set of cultural traditions, beliefs, and values. In these ways, IFW prompted several of the participants to critically reflect on aspects of how they understood their chosen profession, their own worldview, and familiar models of care provision.
Benefits and challenges to participants on IFW
The benefits of IFW as reported by participants in this study were consistent with those reported in the literature. Personal growth, development of professional skills, and clinical reasoning were among the top benefits highlighted. Participants felt that they gained a deeper understanding of clinical reasoning than they did during their Canadian fieldwork courses. Enhanced learning may have been fostered by the confidence-building experiences of situations that required more independent thinking and flexibility (Simonelis et al., 2011).
Other benefits included increased appreciation and awareness of cultural contexts, with participants reportedly gaining a more developed sensitivity towards other cultural perspectives regarding health, illness, disability, and wellbeing. Other authors have also reported that cultural immersion of students on IFW led to critical assessment of personal skills and an increase in awareness of values and beliefs that shape other systems of healthcare delivery, particularly within OT practices (Horton, 2009; Odawara, 2005).
Challenges faced by participants ranged from culture shock to language barriers, and also encompassed administrative and organizational difficulties. Such struggles of adaptation are also reported for other health care trainees on IFW (Crawford et al., 2010). One aspect of IFW that is particularly highlighted by the current research is how the student learning experience was also influenced by the model of teaching. Many students reported distant supervision from an off-site OT, sometimes back in their home country, or relying heavily on their local preceptor for language support.
Administrative and institutional challenges were experienced by many participants, with students facing responsibilities such as planning and organizing the entire practicum, struggling to find suitable accommodations and local transportation, and acquiring sufficient personal funding. Many reported that the associated costs prevented them making the most of their opportunity to explore and learn about the region or country in which they conducted their IFW.
Influence of IFW on students’ future career
The study also aimed to explore students’ perceptions of how their IFW experience influenced their own career trajectory. Participants were directly asked if participation in IFW was linked to their career goals. However, the majority of information related to this question came from other seemingly unrelated questions, where participants discussed their increased confidence, independence, and problem solving skills, as highly influential in their chosen area of work, such as private practice or in resource poor settings. The perception of personal growth as a direct result of the experience has, by definition, a longer-term impact on professional and personal competencies. Of note, our sample was restricted to practicing OTs with less than 5 years of experience, which may not be enough time for participants to reflect upon their career aspirations. If clinicians with greater experience had been sought, a greater number of participants may have had the opportunity to conduct international work. In addition, while some participants reported that they were inspired to continue international work or to work in underserved areas of Canada, the current study did not formally assess or explore the extent of these desires. Further research into the development of career goals for OT students and the influence of participating in IFW on these goals is needed.
Recommendations for students and institutions for future IFW
The study findings suggest avenues for improving IFW. Many participants stated that they felt unprepared for the cultural differences when they arrived in their host countries for their IFW. From these experiences and the expressed desire for more extensive advance preparation, several steps seem promising. Students should proactively learn about the host culture, language, and healthcare system before embarking on IFW. This preparation should include research on local values and customs, health policy and healthcare models, and traditional medicine, amongst other topics. As well, many students mentioned pragmatic difficulties when arriving in their host country. Some of these issues might be minimized with better pre-travel planning, discussions with past students, and more interaction with community contacts and institutions prior to departure.
The majority of students stated that they were individually responsible for choosing the location for their IFW and initiating contact with host institutions. This proved to be a large barrier for some students, with delayed paperwork, lack of supervision, and safety and pragmatic concerns. Given the importance of these challenges, it seems reasonable to suggest that institutions wishing to optimize IFW experiences should seek to collaborate more closely with host communities to organize a structured program or only permit students to go to locations where this is possible. Students’ IFW experiences will also be enhanced with careful attention to the establishment of learning objectives and sustainable student projects prior to departure, and having a tentative schedule set for formal updates. In order to address language barriers and improve cross-cultural learning, institutions could also require that students have a minimum proficiency in the host language, as well as provide enhanced cultural education training.
The development of sustained and robust field-work programs in low- and middle-income countries may contribute to the further development of local rehabilitation capacity through knowledge transfer and resource building (Whiteford & McAllister, 2007). However, both institutions and students must be aware of the disparities between the settings. Attention to equity and justice concerns should prompt students and institutions to avoid treating the host setting as an educational “commodity.” This arises where students are sent to learn and immediately leave (Whiteford & McAllister, 2007), creating a drain on local resources for the benefit of students from more affluent countries but providing little or no local benefit (Elit et al, 2011). Greater institutional investment in creating sustainable training and service programs that include reciprocity of learning opportunities and exchange of knowledge would help to address these concerns. An important step towards these goals would be to partner more closely with host institutions so that they are an integral part of the planning process and thereby contributing to viable sustainability.
There are a number of limitations to the present study. It was conducted with a small group of Canadian occupational therapists. Though participants came from four universities, the purposive sampling strategy was only partially achieved as five of the 11 participants were from a single university, which resulted in a heavier representation of experiences from one institution. The researchers sought to be attentive to this situation during analysis to avoid experiences from one institution overshadowing other institutional contexts. One of the challenges to recruitment for this study was that graduated occupational therapists often did not reply to alumni or alma mater generic emails. A possible solution to this situation in future studies of this type would be to attempt to recruit participants directly through associations or colleges of OT professionals.
Conclusion
This study aimed to address gaps in the literature for OT students who participated in IFW in low- to middle-income countries. Participant experiences were captured in four main themes of living in a new culture context, learning about different approaches and contexts of OT practice, supports and resources for carrying out IFW, and perceptions of how IFW affects students, clients, institutions, and host communities. The findings suggest that IFW can lead to increased awareness of cultural perspectives on health, illness, disability, and wellbeing. Some students who participate in IFW also associate their IFW experience with the development of improved clinical reasoning skills.
Important considerations in planning, organizing, and implementing IFW include pre-departure preparation, funding, choice of collaborative learning service models, realistic project objectives, commitment by the host institution, and flexibility amongst stakeholders. The findings reported in this article are broadly consistent with findings in the literature for both OT and other professional groups, such as nursing and physical therapy, and also highlight some distinctive facets of the experience of IFW for Canadian OT students (Taylor, 1995; Barker, Kinsella, & Bossers, 2010; Petrosoniak 2010; Crawford et al., 2010, Drynan, 2013). The results of this study can help inform universities as they plan components of pre-IFW preparation and ensure that funding and site selection are addressed with adequate resources for a successful learning experience. Participants in this study also expressed that IFW should be associated with sustainable projects that could benefit localities. Collaborative partnerships between sending and host institutions represent an important opportunity to facilitate knowledge exchange and sustainable contributions, thus enhancing international fieldwork education. Opportunities for future research include better understanding the needs and expectations of these key partners.
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