Marieke Bosgoed and Miranda Pijl June 2003
Trial and Error in Ward 30
Preface and Acknowledgements In this bachelor thesis we studied the experiences of nine occupational therapy students from Linköping University in Sweden. The focus was on the effect of teamwork within ward 30 (a student ward) and on the OT students’ role in team decision making. This research was carried out by order of Linköping University. After a one – month preparation in Amsterdam, the Netherlands, we went to Linköping for three months to complete our research. For us as Dutch OT students from the Hogeschool van Amsterdam it was very instructive to get insight into the occupational therapy education in Linköping. After three months abroad, we had one month left to finish our study in Amsterdam. These five months in total are a precious experience for us and we are proud to be able to present this research report. We could not have done this thesis without the help of others. Therefore, we would like to express our acknowledgements to several people and institutes who contributed to our research in different ways. All the occupational therapy students who have been willing to share their experiences with us. You made this research possible. Emma Eliasson, our main supervisor and client, for all your support, effort and critical feedback. Hopefully we will meet you again in the future. All the employees of the occupational therapy program of the Linköping University in Sweden for your hospitality, helpfulness and for providing us all the supplies we needed in order to complete our research. Iet Dalewijk – Kropff for your positive feedback and support. The institute of occupational therapy of the Hogeschool van Amsterdam for giving us the chance to complete our final thesis in Sweden. Alexander Griekspoor for providing us the computer program InterviewEdit and for your motivational and critical feedback. Ross Harmer for your support and critical feedback, especially on the English spelling and grammar.
Tack så mycket allihopa! Thank you all very much!
Marieke Bosgoed and Miranda Pijl June 2003 Hogeschool van Amsterdam
Linköping University
Marieke Bosgoed and Miranda Pijl June 2003
Trial and Error in Ward 30
Contents 1 Introduction.............................................................................................................1 1.1 Background ......................................................................................................1 1.2 Ward 30............................................................................................................2 1.3 Coming to a query ............................................................................................3 1.4 Query ...............................................................................................................4 1.5 Operational definitions of the query..................................................................4 1.6 Aim ..................................................................................................................5 2 Method.....................................................................................................................6 2.1 Research design................................................................................................6 2.1.1 Research approach ..................................................................................6 2.1.2 Literature review.....................................................................................6 2.1.3 Onlooker observation..............................................................................7 2.2 Data collection..................................................................................................7 2.2.1 Informants ..............................................................................................8 2.2.2 Description of the informants..................................................................8 2.2.3 Interview setting .....................................................................................9 2.2.4 Ethical considerations .............................................................................9 2.3 Data analysis ....................................................................................................9 3 Findings ..................................................................................................................12 3.1 Teamwork ........................................................................................................12 3.1.1 Extensioned Problem Based Learning (PBL) ..........................................12 3.1.2 View of professional roles of other students ............................................12 3.1.3 Importance of presence of both the occupational therapist and physiotherapist .......................................................................................13 3.1.4 Importance of feedback ..........................................................................13 3.1.5 Responsibility to explain OT role............................................................13 3.1.6 Learning about own role .........................................................................14 3.1.7 Effect of auxiliary nursing jobs ...............................................................14 3.2 Team decision making......................................................................................15 3.2.1 OT part in team decision making.............................................................15 3.2.2 Equal team decision making....................................................................16 3.2.3 Team decisions were often more medical ................................................16 3.2.4 Learn to prioritise....................................................................................17 3.2.5 Time taking team decision making..........................................................17 Hogeschool van Amsterdam
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3.3 Others...............................................................................................................17 3.3.1 Too sick patients for OT .........................................................................17 3.3.2 No presence of tutors during the first days ..............................................17 3.3.3 Lack of information ................................................................................17 3.3.4 Two – week placement too short .............................................................18 3.3.5 Too much auxiliary nursing jobs .............................................................18 3.3.6 Influence of placements before................................................................18 4 Discussion ................................................................................................................19 4.1 Discussion of findings ......................................................................................19 4.2 Discussion of method .......................................................................................20 4.2.1 Trustworthiness ......................................................................................20 4.2.2 Credibility ..............................................................................................21
5 Recommendations for practice ...............................................................................22 6 Conclusion ...............................................................................................................24 References....................................................................................................................25
Appendices I
Glossary
II
Interview guide
III InterviewEdit
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Introduction
In this introduction the background of the research problem and its context are formulated. In addition, the research query and aim are introduced. Chapter 2 describes the method, data collection and the data analysis. Chapter 3 presents the findings and chapter 4 the discussion. Chapter 5 contains recommendations for practice. This report ends with a conclusion and appendices. This report contains some italicized words that are included and explained in the glossary (see appendix I).
1.1
Background
In 1988, the World Health Organization (WHO) published a report about multiprofessional education of health personnel. The idea behind this report was to stimulate teamwork in primary health care. It described the importance of multiprofessional education during all phases of the education of health personnel. The WHO Expert Committee had already noted a worldwide trend towards teamwork in 1977. It appeared that health workers could carry out numerous tasks and responsibilities more efficiently if they were members of carefully composed teams of people with various types and degrees of skill and knowledge. A team as a whole had an impact greater than the sum of the contributions of its members (WHO, 1988). Likewise, Benders and Van Amelsvoort (2000) describe a team as a group of people who want to achieve a common result that is greater than the sum of individual efforts. Decision making is one of the main aspects of multiprofessional teamwork (Oudenhoven, 1989; Remmerswaal, 1998). In team decision making, all concerned team members verbalize the wishes of the client from their profession specific angle. Occupational therapists aim at enabling occupations of their clients. To appropriately pursue this specific objective of the client, it is important that an occupational therapist participates adequately in team decision making (Higgs & Jones, 2000). As a result from the promotion of teamwork by the WHO, several educations worldwide started programs to train the teamwork skills of students. The WHO called attention to the fact that team effectiveness is not ensured by training team members individually, but rather by approaching problems together with different professions. By multiprofessional training, the different professions would become aware of their different ways of thinking and acting. In addition, they would gain experience in coordinated teamwork, where each individual has an essential role to play. Also, the team members would need to find ways to prevent or solve conflicts that can arise in teamwork. The basic educational principal of multiprofessional education is therefore called ‘learning by doing’ (WHO, 1988). Linköping University (LiU) had a long history of practical multiprofessional education. First only organized between nursing and medical students, and between physiotherapists and medical students, discussing patient problems and programs together in hospital wards. Later the LiU intended to arrange a similar type of education in primary health care centres (WHO, 1988). Hogeschool van Amsterdam
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Although the WHO focussed specifically on teamwork in primary health care, teamwork itself seemed to be important in the total chain of health care. Therefore, the LiU developed a new work experience program for medical, nurse, physiotherapy and occupational therapy (OT) students: ward 30.
1.2
Ward 30
Ward 30 was started in Linköping in January 1996. This students’ ward serves as a role model for teaching health care students. It provides opportunities for students to learn how their roles interrelate, and how the quality of care and rehabilitation for their patients can be optimised. In Linköping, this team of students makes its own decisions about treatment of patients. A qualified nurse is always attending to supervise. Other members of the permanent staff are the tutors: a registrar (a doctor training to specialize), a physiotherapist and an occupational therapist. These tutors take part in the meetings and can be consulted when needed (Wahlström & Sandén, 1998). The medical tutor, registrar, is nowadays more often a specialist. Although the tutors are responsible for the overall care of the patients and have a monitoring role, they leave the practical elements and the planning to the students. If needed, a medical / geriatric consultant and an orthopaedic consultant can be consulted (Wahlström & Sandén, 1998). Besides increasing students’ understanding of the whole care of the patient and developing their practical experience of medical care and rehabilitation, multi – professional teamwork is an important goal of ward 30 as well. This is emphasized in the following goals of ward 30. Goals of ward 30, concerning teamwork: • Students will develop skills for cooperation in a team. • Students will increase understanding of each other’s profession. • Students are able to develop their own professional role, and by cooperating with others, obtain a perspective on this role (Wahlström & Sandén, 1996, 1998). Ward 30 is a ward with eight beds. Patients with hip fractures and orthopaedic problems, who require care and rehabilitation, are treated here. The students form teams and work in shifts during a two – week period. A student team consists of 1 – 2 medical students, 2 – 4 nurse students, 1 occupational therapy student, and 1 physiotherapy student. The work consists of joint care tasks, and profession specific tasks. Each student team starts on an evening shift followed by a morning shift and then has the third day off (Wahlström & Sandén, 1998). The members of the student team plan the distribution of tasks themselves in a meeting. In addition, a meeting is held where every patient is discussed from the students’ specific profession point of view. In this meeting, the nurse, the OT, the physiotherapy tutor and the registrar are present, but in an unobtrusive role. Thus, the students fulfil both general and specific tasks. Each morning shift concludes with a reflection, where after the shift, the student team reflects on, and discusses, cooperation and practical details with the nurse tutor. The period is concluded with a
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care conference at which the outgoing student team hands over to the incoming student team (Wahlström & Sandén, 1998). The occupational therapy students receive information in a syllabus at the start of the concerning semester. This syllabus contains goals, care philosophy, responsibilities, profession specific competences and team competences. In addition, information about a day at the clinic, the patient, the diagnosis, the care process, and the schedule are described in this syllabus. Besides this, information about educational rules is given. Furthermore, the students receive information one day before they start in ward 30. This information is about their OT role in the team, demands, routines and a typical day at ward 30. Then the students have the chance to talk together in the team, meet the staff and they receive information about how to reach the staff at any time. An OT tutor is present at the ward during the meeting where the patients are discussed and during the transfer of information between the OT student of one team to the OT student of the next team.
1.3
Coming to a query
As early as 1988, the WHO had emphasized the need for evidence about undergraduate multiprofessional education of health workers. It was necessary to determine the specific ways in which multiprofessional education increased students’ abilities to solve health problems both individually and as a member of a team. Also, there was a need to determine if it resulted in a significant improvement in the quality of health care. The WHO underlined the need for research and evaluation of the effects of multiprofessional education on later professional practice and quality of care (WHO, 1988). Several completed projects have resulted of ward 30. First of all, a detailed description about the organisation of ward 30 was made. Furthermore, the effect of ward 30 is evaluated with questionnaires. In the questionnaires students have the opportunity to give their comments on several aspects of ward 30. However, this is not on a research level and no qualitative research, which reveals experiences, was found. This demonstrated the need for a study that reveals experiences of OT students. Thus, a qualitative research was needed. In January 2003, Emma Eliasson, occupational therapist and teacher at LiU (Sweden) visited the institute of occupational therapy at the Hogeschool van Amsterdam (HvA) to discuss a subject for a final thesis project. Two students of the HvA would do their final thesis by order of Emma Eliasson. Therefore, Emma Eliasson was the client of the project. After a conversation with Emma it was apparent that the experiences of occupational therapy students concerning the effect of teamwork in ward 30 on their confidence as an OT had not yet been examined. In addition, the client emphasised the importance of OT students taking place in team decision making, which was not yet evaluated either. Evaluation of these aspects is important, because occupational therapists need to develop an adequate role in teamwork. The experiences of OT students will tell what Hogeschool van Amsterdam
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aspects of ward 30 empower them to participate adequately in teamwork. Teachers of the OT program of LiU want to know if participation in teamwork, as practised in ward 30, influences their confidence as an OT. With this information the OT teachers have the opportunity to evaluate and to optimise the current OT program of LiU. This study will thus focus on teamwork and on how OT students experience their role in team decision making. Therefore the following query was formulated.
1.4 • •
1.5
Query How do occupational therapy students experience the effect of teamwork within ward 30 on their confidence as an occupational therapist? How do occupational therapy students experience their role in team decision making in ward 30?
Operational definitions of the query
Occupational therapy students Students who participate in the OT program at LiU. Part of this program is a two – week placement in ward 30 (described in section 1.2 ward 30). In this research we focus on students who participated in ward 30 this study year (2002 – 2003). Experience “Whenever we do something, a whole range of experiences are possible. We may, for example, feel pleasure, anxiety, comfort, challenge, or boredom. Moreover, we may have thoughts of self – doubt or confidence. We may proceed deliberately with solid convictions about why we are doing what we are doing or hesitantly, worrying that our actions are futile or meaningless. Experience refers, then, to such immediate thoughts and feelings that emerge in the midst of performance” (Kielhofner, 2002, p. 17). Effect A result, usually of a “cause” (Rittenhouse, Campbell, & Daltro, 2002). Teamwork “Coordinated action, carried out by two or more individuals jointly, concurrently or sequentially. It implies commonly agreed goals; a clear awareness of, and respect for, others’ roles and functions on the part of each member of the team; adequate human and material resources; supportive cooperative relationships and mutual trust; effective leadership; open, honest and sensitive communications; and provision for evaluation. Teamwork is a process rather than an end in itself and occurs whenever two or more workers interact to solve problems, whether in a formally constituted team or informally. It entails the ability to work as colleagues rather than in a superior – subordinate relationship” (WHO, 1988, p. 6). Ward 30 A student ward in which students of several professions treat clients (see for a detailed description section 1.2 ward 30). Hogeschool van Amsterdam
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Confidence as an occupational therapist Confidence is defined as secure believe in your abilities and in yourself (World Book Dictionary, 1987) Confidence as an occupational therapist is confidence as a professional occupational therapist. Role “A social or occupational identity, which directs the individual’s social, cultural, and occupational behaviour and relationships” (Hagedorn, 2001, p. 161).
1.6
Aim
The aim of this research is to acquire knowledge of and insight into student experiences during their placement in ward 30. This helps the occupational therapy program of Linköping University to evaluate if the goals of ward 30 are achieved. This information provides knowledge of how students experience the value of the learned skills concerning teamwork for their future practice. In addition, it gives them insight into the students’ role in team decision making in ward 30. With the experiences of occupational therapy students in mind this knowledge and insight can be used to optimise the occupational therapy program concerning skills in teamwork.
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2
Method
2.1
Research design
Trial and Error in Ward 30
2.1.1 Research approach The researchers studied the effect of teamwork on students’ confidence as an occupational therapist and the role of these students in team decision making (our phenomenon). Theory concerning this phenomenon had not yet been developed. In case no theory fits the phenomenon, knowledge – generating studies using inductive and abductive reasoning are appropriate. Inductive and abductive reasoning studies are qualitative research methods, which means that the researcher begins with shared experience and then represents that experience at increasing levels of abstraction (DePoy & Gitlin, 1998). This research focuses on particular personal experiences of individuals, the OT students in ward 30. The researchers tried to gain insight in these experiences and tried to assess which values OT students attach to these experiences. According to Migchelbrink (2002), qualitative research is a competent method to gain insight in and to understand (“verstehen”) the experiences of individuals. “Verstehen” is a phenomenological principal. The tradition of “verstehen” places emphasis on the human capacity to know and understand others through emphatic introspection and reflection based on direct observation of, and interaction with people (Patton, 2002). The researchers tried to reveal the meaning of OT students about the effect of a placement in ward 30. The foundation of phenomenology is to reveal the meaning, structure and essence of the lived experience of a phenomenon for a person or group of people (Patton, 2002). According to the phenomenological approach, only those who experience the phenomenon can understand its meaning (DePoy & Gitlin, 1998). Therefore, the researchers described the phenomenon from the perspective of those who experienced it, the OT students. It is important to reveal the essence, by understanding the core meanings of the phenomenon commonly experienced (Patton, 2002). This is also stated very clearly by Eichelberger (1989, p. 6): “A phenomenologist assumes a commonality in experiences and must use rigorously the method of bracketing to search for those communalities”. Thus, a qualitative research method with a phenomenological approach was the most appropriate to use in our study. In short, we had to view the phenomenon from the perspective of the OT students using the technique of “verstehen” and then search for communalities. 2.1.2 Literature review In qualitative research, theory is used to place boundaries on the study. Furthermore, researchers formulate smaller, concise sub questions that are then pursued. These smaller questions are called context – based questions (DePoy & Gitlin, 1998). In our study we refined our query (made it context – based) by studying literature, by having conversations with the client, and by doing an onlooker observation (see section 2.1.3 onlooker observation).
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In phenomenology, literature about the phenomenon should only be used to describe the importance of the study and to clarify and support experiences (DePoy & Gitlin, 1998). Thus, researchers cannot connect the theoretical information to the topics, which emerge from data, until the discussion. Before data collection we reviewed literature about teamwork, group processes, decision making, clinical reasoning, learning and multiprofessional training wards. The researchers did this to be able to understand the meaning of the experiences and to know when to take the topic into more detail using probing questions. By using probing questions, the researcher will attain rich and in – depth data (Patton, 2002). Bogdan and Biklen (1992, p. 162) stated: “The reading you do should provide you with stimulation rather than be a substitute for thinking”. Therefore, the researchers should bracket their pre – understanding about topics as much as possible. 2.1.3 Onlooker observation An onlooker observation is a process of observing that can be done separately from interviewing (Patton, 2002). Only to increase insight into and knowledge of ward 30, the researchers observed activities, interaction between professions and the timetable of the setting. This onlooker observation helped the researchers to understand the context in which the experiences of the students took place. A direct observation is a good way to gain knowledge about the context that is necessary to understand the different perspectives of the informants (Taylor & Bogdan, 1998). The researchers had to be aware not to use this observation as a data resource, because it might has given us too much pre – understanding. When using the phenomenological approach, researchers have to bracket pre – understanding as much as possible during data collection and data analysis (DePoy & Gitlin, 1998).
2.2
Data collection
To attain information about experiences, interviewing is an appropriate method. The advantage of interviewing is that by probing, in – depth information will be gained (DePoy & Gitlin, 1998; Kvale, 1996; Taylor & Bogdan, 1998). Qualitative research interviews can vary from open / unstructured, to semi – structured and structured (Migchelbrink, 2000). The phenomenological approach states to use an unstructured or open type of interviewing (Becker, 1992). The openness of this type of interview is also its power (Kvale, 1996). Its process is flexible and dynamic (Taylor & Bogdan, 1998). The researcher will ask one open – ended question and other questions will emerge through the conversation (Becker, 1992; Migchelbrink, 2000). By using probing questions the researcher stimulates the informant and will gain access to in – depth information about perspectives, experiences and situations as expressed in the informants’ own words. It is important that the researcher is the leader of the interview, but does not interfere in the interview process (Taylor & Bogdan, 1998). In research literature there are lot of other commonly used terms for “qualitative research interview” (Kvale, 1996) such as open interview (Migchelbrink, 2000), in – depth interviewing (Taylor & Bogdan, 1998), open – ended interview, non – standardized interviewing (Patton, 2002; Taylor & Bogdan, 1998), and non – directive and unstructured interviewing (Taylor & Bogdan, 1998). In this study, the researchers preferred to use the term “open – ended interview”. Hogeschool van Amsterdam
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During interviewing, the researchers used an interview guide (see appendix II). This guide served as a checklist and made sure that all the relevant topics were covered within the limited interview time. It could also be used to set up different start and probing questions to get people to talk. The guide must not be seen as a structured schedule or protocol (Patton, 2002; Taylor & Bogdan, 1998). 2.2.1 Informants As written before, the phenomenon can be understood only from the perspective of those who experience it (DePoy & Gitlin, 1998; Kvale, 1996; Taylor & Bogdan, 1998). In this study the OT students were the ones who experienced the phenomenon. Therefore, the researchers interviewed OT students of LiU who had participated in ward 30. Students who fulfilled to the following criteria were selected: The student is an / a: OT student; student who had participated in ward 30 in the study year 2002 – 2003. He or she does not participate in ward 30 at the moment of interviewing; student who can express him / herself comprehensibly in English; student who does not work as a qualified occupational therapist in real practice yet. Eleven students who met the requirements were asked by email to participate in this study. This email was send by Emma Eliasson. As a teacher at the OT program of the LiU she has access to the email addresses of the OT students. The researchers attached a letter to this email in which information was given about the study. Nine students responded, who all wished to participate voluntarily in this study. These students were the informants of this study. 2.2.2 Description of the informants Table 1 shows the details of the students who participated in this research. Gender
Age
Nationality (Time in Sweden)
Female
46
Estonian
Week numbers in which students participated in ward 30 9 & 10; 2003
Week numbers in which students were interviewed in 2003 14
7 & 8; 2003
16
7 & 8; 2003 9 & 10; 2003 9 & 10; 2003 42 & 43; 2002 11 & 12; 2003 5 & 6; 2003 7 & 8; 2003
14 14 15 13 14 15 13
(23 years)
Female
38
Female Female Female Female Female Female Female
27 26 24 24 22 22 21
Iranian (15 years)
Swedish Swedish Swedish Swedish Swedish Swedish Swedish
Table 1: description of the students Hogeschool van Amsterdam
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2.2.3 Interview setting The OT students were interviewed individually in a room that was free of distractive stimuli. Nobody could disturb during the interviews. The interviews were recorded on tape with a tape recorder. The researchers used two tape recorders in the room in case one of them failed. The OT students could use a Swedish – English dictionary, in case they could not explain themselves in English. One of the researchers, the interviewer, interviewed each OT student. The other researcher was the observer. The researchers switched roles between interviewer and observer every other interview. Before the interview started, the OT students were offered a cup of tea / coffee and a biscuit. This to become comfortable with the researchers and the interview situation. The first interview of both interviewers was regarded as a pilot interview. This was not made known to the participating students. 2.2.4 Ethical considerations In order to keep the data confidentially, no names were attached to the data that was used. Only locations and details were used. Before the interview started the OT students were informed about the aim, the procedure of the study and the voluntary and anonymous participation. The researchers explained how they had planned to use the data. They asked the students permission for this use. By doing these things, informed consent was reached.
2.3
Data analysis
After reviewing the advantages and disadvantages of qualitative data analysis methods, the researchers have chosen to follow the principals of phenomenological analysis as suggested by Patton (2002) and Tesch (1990), and meaning condensation as suggested by Kvale (1996). The researchers eclectically used several sources describing phenomenological analysis and meaning condensation. Phenomenological analysis seeks to grasp and elucidate the meaning, structure and essence of the lived experience of a phenomenon for a person or a group of people (Patton, 2002). Meaning condensation involves a reduction of large interview texts into briefer formulations (Kvale, 1996). Data analysis was started with transcription of all the interviews. Both researchers did a part of the transcribing. Unfortunately, due to time pressure the researchers could not review and optimise each other’s transcriptions. Because of very useful information from the pilot interviews, the researchers decided to include these in their data analysis. Both researchers analysed the nine interviews separately. At this stage, after transcribing the interviews, the researchers individually started the principals of meaning condensation and phenomenological analysis. It is important to be totally aware of the preconceptions about the phenomenon (Becker, 1992; Patton, 2002; Tesch, 1990), which is called epoche by Moustakas (1994).
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In the phenomenological approach, epoche is used to bracket all the preconceptions, and to approach the data as open as possible (Patton, 2002). After the researchers printed out all the transcriptions, they wrote down their own thoughts, feelings and prejudices about the phenomenon under study. Using this open view, the researchers were able to understand the experiences from a students’ point of view. To get sense of the whole, each interview should first be read in total (Becker, 1992; Kvale, 1996; Tesch, 1990). Then each researcher should read and reread the interview to determine the natural meaning units. A natural meaning unit is an abridgment of meanings expressed by informants (Kvale, 1996). The units should be represented in briefer statements (themes). To describe these themes, expressions of informants are used as much as possible. If any of the meaning units show similarities, they should be clustered together (Tesch, 1990). Patton (2002) calls this internal homogeneity. To this he adds the importance of external heterogeneity, where the researchers check whether each theme really differs from one another. The researchers then must go constantly back and forth between data and these isolated themes, in order to achieve the most appropriate theme. This is the theme that puts the experiences into words at the best (Tesch, 1990). Next is to find out, which themes and their natural meaning units correspond with the goals of the concerning research. When two or more researchers analyse the data separately, they should compare and discuss their found themes to choose the theme that fits the informants’ experiences best (Polit & Hungler, 1999). This cannot ensure the validity of the themes, but it can minimize any preconceptions (Polit & Hungler, 1999). Essential themes should be tied together into a descriptive statement (Becker, 1992; Kvale, 1996). This includes the specifics of one person’s experience (Tesch, 1990). It is recommended to let the concerning informants review his or her individual descriptive statement of essential themes. Then the informants are asked to give comments and corrections on this, in order to check whether the researcher described the experiences of the informants correctly (Patton, 2002). For this study, in the first part of the analysis the researchers followed the description above. In the beginning they both described their thoughts and prejudices about the phenomenon, to be able to approach the data as open as possible. Then they analysed the interviews separately in order to find themes. By comparing their themes together, the researchers wrote a descriptive statement for each interview, using the idiom of the students. To come to the descriptive statements the researchers used an analysing computer program, called InterviewEdit (see appendix III). The researchers emailed the students their individual descriptive statement and asked for their comments. One of the nine students commented on one sentence of her descriptive statement. Her descriptive statement was optimised with her comments. Then the researchers sent her the corrected version, which she approved. Next, the researchers again, continued the analysis process separately. Researchers should read through each descriptive statement, in order to compare them, identify common themes, and reorder themes into a structural description of the phenomenon. Doing this, researchers leave the particulars behind, and focus on the phenomenon itself (Becker, 1992). Phenomenologists call this process the Hogeschool van Amsterdam
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“identification of the fundamental structure” of the phenomenon (Tesch, 1990). In this study, the researchers followed this step, in order to reveal the core of the students’ experiences in a final structural description. The whole process of data analysis is illustrated in figure 1.
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Findings
Findings from this research are presented from the perspective of the participating students. It contains the two topics of this research: teamwork and team decision making. In addition, the students mentioned some issues that are not part of the phenomenon. However, since a part of the aim is that the findings of this research can be used to optimise the OT program, the researchers found these issues worth mentioning in section 3.3 others.
3.1
Teamwork
3.1.1 Extensioned Problem Based Learning (PBL) All of the students noted that the beginning of their placement in ward 30 was difficult, because they did not know exactly what their role was. It was new for them to receive full responsibility for real patients in a real environment. The first days (the weekend and evenings) the OT tutor was not present and the students did not have enough information about the routines in ward 30. Most of the students had not been in a similar orthopaedic field before. The students of the other professions were also new in this situation. Therefore they had to cooperate, which made them become closer. The students commonly agreed that these difficulties finally made them more secure and contributed to their development. One of the students called this process “extensioned Problem Based Learning”, because problems suddenly popped up in this real environment. Therefore it was necessary to think by themselves, to look in literature, to ask other people, and to share the knowledge in the team. They grew into their role by putting theory into practice: ‘I had the chance of trial and error. I had the chance of trying, I had the chance of failing, I had the chance of trying again and I had the chance of finding the right way.’ ‘We got the chance to practise it more in a practical way. [...] Because it was a very real situation, and during the education it’s just theoretical. We had the responsibility of these patients, to do things right and it felt very important to make things right.’ ‘The teamwork is much about PBL [...] it is more deep, you get to practise what you learn theoretical. [...] Here it is a further step in a way, since you don’t work besides a tutor.’
3.1.2 View of professional roles of other students OT students got a clear view of the professional roles of the other students and learned the importance of this. In ward 30 they did not always have a full schedule, so they had time to engage into each other’s work more. By observing, talking, discussing and good communication with others, they got a kind of holistic perspective, with which they could cover all the demands for the patient. The students found it very important to know the other professions’ fields, because then they knew who to go to for help. It was easy for them to do so, since they were all students and very open to each other: ‘If every profession knows or explains in the team his or her opinion you can make it together with the most efficiency. The best for the patient, so you get a kind of a holistic perspective. I think is very important in our future role too.’ Hogeschool van Amsterdam
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‘Since we are all students we are all very véry open to each other. I think teamwork is better there [...] We have time to do what we need [...] and therefore we can get engage into each other more.’
3.1.3 Importance of presence of both the occupational therapist and physiotherapist Many of the students mentioned that they had the most in common with the physiotherapist; together they formed the paramedical students. It made both professions feel secure by being together, because the medical professions (nurses and doctors) were represented more. Not all of the teams had a physiotherapist. One of the students said that it felt overwhelming to be the only paramedical student and to have the responsibility for the physiotherapist jobs as well: ‘It had been good if there had been a physical therapist there, so you could have someone to discuss the patient’s problem, cause we don’t have the same view. [...] It wasn’t my job. But I do understand it was very important so of course I did it for the patient. I do think that we have different views, so it is really important that there is a physical therapist and a occupational therapist.’ ‘Most of the times I helped out the physios, because it’s quite, you know, similar, we’re interested in the same things, more or less.’
3.1.4 Importance of feedback Two of the students mentioned the importance of feedback during the placement. First of all they got feedback from the patients. They had a good communication with the patients and the gratefulness that they experienced confirmed them that they were doing a good job. Secondly, one student underlined the importance of the feedback from the real personnel, because everything was discussed very professionally. Finally, the feedback of the other team members helped them: ‘I got feedback from the team members, from my supervisor and with good communication from the patients, good feedback. The most of them were very satisfied with our work. So, they show it by leaving us flowers and chocolates and cards and that they were very satisfied.’ ‘Well in other placements, you might have that feeling, that when you are with a patient and your supervisor is there, the patient álways turns to the supervisor. They don’t pay you very much attention. You have to be alone with the patient to get that attention. And in ward 30 you get that attention the moment you walk into the room. [...] That’s something that has helped me to build up my confidence and to feel secure with myself.’
3.1.5 Responsibility to explain OT role For all the students it felt very important to explain their field to the other professions, because otherwise their part would have been forgotten. They felt the responsibility to explain, because in Sweden a lot of people do not know what the role of occupational therapists is, and there are a lot of prejudices. In addition, one student saw it as an obligation to get the doctors and nurses to understand that the patient is thinking about the whole situation, and not only about his diagnosis. They felt more secure when they could explain their field and when they could erase the prejudices about OT:
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‘In Sweden it is like that and all people know maybe what a nurse is doing, but not all people know what the OT is doing, that’s why it is special important to show and tell other people what we are doing. [...] It is very important to say to others for myself also.’ ‘When I explain that we work with occupation and the daily activities and this assessments that we do there, I think they understood how important it was. Because they forgot it. [...] When I talked with the nurses they said that they, if I haven’t been there, they had forgot to do these things.’ ‘Not that I hád to promote, but I see it as a chance to promote, because as I said before, everyone is not aware of what our role is and what we can do. So, that’s a golden opportunity for us to promote ourselves.’
3.1.6 Learning about own role The students learned a lot of things about their own role, they got a clearer view of it. Some of them said that because their role in ward 30 was limited and obvious, they had the chance to get good at it. For the first time they were responsible for the whole process of the patient. Others thought that the environment was very clinical and only went into one part of occupational therapy. As a result one of them questioned her choice of being an occupational therapist. They got to know themselves and their own capacities. They learned to have trust in their own knowledge. They all learned to report to others: to other occupational therapists in the community and to their team members. They saw the importance of written information. Two students had some ethical considerations, concerning association with real patients and their family, and colleagues. They could practise their professional attitude towards these people they communicated with. The students could try out assessments and train the different aids with the patient. Finally they learned about different diagnoses, and they could explain to the patient why he was doing things: ‘Because my job was so limited, I got the chance, during these 2 weeks, get good at it [smiles].’ ‘I was thinking about some ethical considerations [...] it didn’t feel right to put the patients in this situation, to have all new staff around. Because we did make mistakes. [...] Mistakes are good to make to learn things, but it is not good for the poor patients [...] I don’t think that would have happened in another ward. So I don’t know if the educator should have taken more place or something.’ ‘So I report it [...] I never really had this experience before, to do it orally or written. To have somebody else do something for me, and to know what I’m supposed to say, what is important to this person to know.’
3.1.7 Effect of auxiliary nursing jobs Since there were no auxiliary nurses in ward 30, all the students were supposed to do the auxiliary nursing jobs together. By doing this, the students got to know the patient and understood their whole situation. One of the students mentioned that this part of the teamwork caused some problems, because not everybody had the same share in it. Especially the medical student did not always take part, which she thought was bad for the nurses:
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‘I think that was very good. [...] I was there as not occupation therapy, as human. [...] I learned some things and I say communication at this help me in future for whole understanding for another people in situation.’ ‘Me and the physiotherapist helped out a lot, and the doctor didn’t have the possibility to help out just as much, and maybe she didn’t want to [laughs], I don’t know. [...] I just feel bad for the nurses that the teamwork didn’t work, as good as it was supposed to, as far as auxiliary nurses jobs go.’
3.2
Team decision making
3.2.1 OT part in team decision making Big part in team decision making about going home The OT students had a big part in the decision making about people going home or not and if there was something needed to be done to enable this. One student said this part of decision making was the most concrete part. The OT students experienced their role as very important, but it was forgotten sometimes. Decisions were sometimes made without them, because the medical part was most important in this ward. Usually the patient was medically done, before he was rehabilitated enough: ‘I was taking part to saying if this patient could manage at home. If I thought it was possible to this patient to go home, or what was needed to be able to go home. I think that was the most, my most concrete part of the decision making.’
Other OT roles in team decision making It was the first time that the OT students were really independent and made their own decisions. It felt good for them that they could work on their own and to discover that they really knew something. Nurses and doctors had to work a lot together, but the OT students could work on their own. They said that they planned a lot in their head during the day, which one student defined as clinical reasoning. In ward 30 they also practised to make decisions more quickly, because they had to do it independently and on the spot in a real situation. They made decisions about which aids the patients needed and about training and activating people. They were the only ones with the training, occupation view. OT students had a big part in the team meeting by stating what they should do with the patients in their point of view. One of the students learned that you cannot always be right. Students often think that they have to know everything, but she learned that this is not possible: ‘But for me it felt good in some way that I could work on my own, that I wasn’t depended on anyone else and try to be independent [...] and make your own decisions.’ ‘You make this, [...] clinical reasoning, [...] but I, because sometimes they told me about the patient in his situation or his disease and how it worked and then you always had to think where are we now and where do you want to go and how much does it effect like the disease and the aids and yeah you plan a lot in your head.’ ‘Decision making is a huge deal in ward 30, and yeah it’s a good preparation for it, for what’s coming work as an occupational therapist. You háve to make decisions more quickly, so it’s a positive pressure that you have. I felt it that way.’
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Making small decisions in divided teams Two students mentioned their part in small decisions, which were not always for the whole team. Sometimes the teams were divided: ‘A lot of my decisions were just mine and maybe, I had help from the physiotherapist. And a lot of the medical decisions were done by the nurses and the doctors, so I mean the teams were sometimes divided a little like that.’
3.2.2 Equal team decision making One student mentioned that in the beginning her role was unclear. She did not know what the others expected of her as an OT. It influenced her in a positive way that the team learned to know each other and that the others were listening to her with respect. This openness and respect for each other in the team was something that most of the students mentioned. They agreed that decision making in ward 30 was very equal, everyone had the chance to participate and to have an opinion. The team members discussed until everyone agreed. Sometimes they had to compromise to solve a problem: ‘Due to the circumstances so my role was not so very clear in the very beginning, because I didn’t know it myself [laughs] [...], but later on as the other team members got more understanding about my profession and role, then I got more confidence in the work I was doing. The role in decision making was becoming stronger too.’ ‘We didn’t have any arguments, of course we had discussions, but everybody always ended up in that we agree. But of course everyone has their opinion on how to solve the problem, you just have to maybe compromise. And you have to to suit everyone [...] I think we were very equal in our team.’ ‘I could decision making. Yeah, I could because, other profession, everyones were there was a student, so communication was easy I mean. Nobody shamed for talk.’
3.2.3 Team decisions were often more medical In ward 30 the decisions were often more medical and the OT students did not have anything to say about this. Most of the OT students got the feeling that the doctors and nurses thought that the medical things are far above the paramedical rehabilitation. One student mentioned the gap between paramedics, and doctors and nurses as far as language and knowledge goes. Sometimes it was difficult to take the medical aim and put it towards rehabilitation. They understood that the medical things have priority, but had the opinion that occupational therapy comes right after. Therefore, they said it was important to explain their field to others and to have the self – esteem to tell that they have another point of view: ‘I mean there’s quite a difference between nurses and doctors and between the paramedics, like the physiotherapist and the occupational therapist. There’s quite a gap in between there, as far as language goes, and as far as knowledge goes. So sometimes it was difficult to take the aim of medical and put it towards rehabilitation. Take it from medicine, like drugs, to actual training, to abilities, so sometimes it was difficult to do that.’ ‘It is important to take place, because it is easy to be forgotten.’
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3.2.4 Learn to prioritise OT students learned to prioritise; to discuss which patient needed their attention most, because there was limited time. They had to plan what to do with patient. In addition, the OT students had to do auxiliary nursing jobs on ward 30. They had to leave the role of the OT. Every team member had to make decisions and take responsibility for these jobs: ‘There come the medical student and she said: ‘Can you help me clean up this room?’ And for a second I thought, I don’t want to I want to train this patient. What is the most important thing? Do you have time to do that now? So you have a kind of dilemma, and I thought okay I can train with him later. So I helped her to clean this room.’
3.2.5 Time taking team decision making One student found it difficult to really change something for the patient, since they were all students and therefore had to check everything by real personnel. This took quite a lot of time: ‘It’s quite difficult, when we’re all students. Especially the medstudents have to check with the doctor first. You know it’s a big thing, before you can actually do something [...] and it takes quite a lot of time. [...] I think for the patients, poor patients [laughs].’
3.3
Others
3.3.1 Too sick patients for OT The first thing is that two OT students agreed that some of the patients, the cancer patients, did not need so much OT. Doing their job was difficult, because the patients were very sick. Therefore, they believe that it is important to have a good selection of patients in ward 30: ‘But in the last week there were more patients that I thought didn’t needed so much occupational therapy, so I wanted maybe to have more patients with fractures and things like that. In the last week there were more patients with cancer and a lot of very sick patients. [...] I think that it is important to see what kind of patients are we going to have in ward 30.’
3.3.2 No presence of tutors during the first days Some of the students talked about the availability of tutors. They found it difficult that no tutor was physically present during the first days. Therefore one of the students suggested to start on a Tuesday or Wednesday, because then they could get verbal advice and practical help from the start of their placement: ‘The thing that they can correct is that the tutors should be there on the first time of every team on the Friday. Maybe they shouldn’t start on a Friday, maybe they should start on a Tuesday or on a Wednesday, in the middle of the week, cause then they are there on daytime. So the teams get a tutor on the first time they are there to ask the questions that they need to ask. Maybe that should make it a bit easier, to at least get verbal advice from the beginning and then maybe more in hand at the practical things.’
3.3.3 Lack of information One of the students experienced a lack of information about the routines. As earlier described this was mostly experienced in the first weekend when no OT tutor was Hogeschool van Amsterdam
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present. She did not know what was expected of her as an OT and without this information she could not prepare for this placement. Furthermore, there was conflicting information concerning whether she had to do the physiotherapist’s job or not. In the end it was apparent that the physiotherapist’s job was a task for the whole team, not only her duty: ‘[...] you need more information. What is expected of you as an OT student and as a team member about the routines on the ward 30? There was a quite lot of information, but not enough, because I think it is a waste of time if you come on the weekend and you don’t have the opportunity to do a good work, that you have to get this feeling of shocks, and it’s unnecessary.’
3.3.4 Two – week placement too short One of the students mentioned that the placement should be longer than two weeks, because just when she felt secure with herself and she knew all the team members she had to leave: ‘I think in other placements you can’t work as independent as you wish to do. And that’s why ward 30 is so great, because there we’ll get to work on your own. And students who haven’t been that independent in their placements they really need more time, so that’s a shame, that there only is two weeks.’
3.3.5 Too much auxiliary nursing jobs Two students agreed that there were too much auxiliary nursing jobs on ward 30. As a result, the nurses sometimes prioritized that work more and there was too little time to do the OT tasks: ‘I think maybe the nurses have a lot of things to do and they have some problems to be working as assistance nurses also [...] So we, me and the physical therapist, we did a lot of things as assistance nurses also, so sometimes the training have, the nurses prioritize maybe their work more than ours sometimes, [...] and then we have to take out the patient and do a lot of other things than we maybe wanted to do our fields more sometimes.’
3.3.6 Influence of placements before Two students mentioned that previous placements influenced their placement in ward 30. They had a more confident role, because they already had the chance to work in an orthopaedic placement and / or to work on their own: ‘I had my fieldwork at this orthopaedic session the semester before, so I felt that I had a more safe role. That I knew what to do.’
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4
Discussion
4.1
Discussion of findings
Trial and Error in Ward 30
The aim of this study was to reveal the experiences of OT students who participated in ward 30 in Linköping. The students were asked about their experiences of learned skills for future practice concerning teamwork and about their role in team decision making. The findings show that students experienced the beginning of their placement as difficult. Especially the new environment caused an insecure feeling. The first days, the OT tutor was not physically attending the ward and there was not enough information about the routines. This is underlined in the following sentences, quoted by Reeves, Freeth, McCrorie & Perry (2002, p. 342), and described in an article by Bloomfield (1997); “Learners in unfamiliar environments do experience some reduction in self confidence and increased anxiety and therefore tend to seek greater contact with their tutors. Once learners understand the demands of the new learning environment their confidence and competences are generally enhanced”. Still, the difficulties in the beginning made the students develop and more secure in the end. They experienced their placement as a more advanced way of Problem Based Learning (PBL). They learned to put theory into practise. According to Knowles (1975) and quoted by Parsell, Spalding, & Bligh (1998) people learn more deeply and permanently when new knowledge is directly and early connected to practice. They also describe that people learn more effectively by using a task – centred or a problem – solving approach. In ward 30 the OT students got a clear view of other professional roles and they learned its importance for their future practise. They now know which profession they can ask for help. Interaction with other professions provided them a holistic perspective with which they could cover all the demands of the patients. The study by Eva (2002) demonstrates that a more holistic approach through interprofessional teamwork might improve patient outcomes. Individuals have to work together as a team, because they do not have the time to become an expert in all aspects of patient care (Eva, 2002; Parsell, et al., 1998). The OT students mentioned the importance of explaining occupational therapy, because they noticed that not many people in Sweden know about this. Doctors and nurses sometimes forgot the occupational therapy part and therefore the OT students had to take place. Also, to get the doctors and nurses to understand that not only the diagnosis, but that the whole situation of the patient is important. Benders & Amelsvoort (2000) and West (1996) describe that obstructions in teamwork can arise when the medical angle is too dominant, status differentials appear and / or there is an unequal valuation for each profession. In ward 30 the students found it easy to communicate with others. Since they were all students and thus approximately on the same level, they were very open and respectful to each other. Everyone had the chance to participate and to have an opinion. For these reasons, students experienced an equal decision making and team members discussed till everyone agreed. In teams where every team member can give Hogeschool van Amsterdam
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an opinion and everybody accepts the final decision, there is decision making by consensus (Oudenhoven, 1989). In contrast, Reeves et al. (2002) describe that difficulties can appear in interprofessional teams when different groups of students are brought together. Learning can be slowed down when people experience status differentials and when the effect of professional socialization occurs. Although the findings of our this study show the opposite, some similarities with the theory of Reeves et al. (2002) were found. The OT students mentioned that the teamwork regarding the auxiliary nursing tasks was not always equally spread. Especially the medical students did not participate in these jobs. Furthermore, students mentioned a gap between the paramedical, and medical and nurse students concerning knowledge and language. They experienced that decision making in ward 30 was focused too much on the medical part. OT students did not contribute much to this. A final example of similarities with the theory of Reeves et al. (2002) is that the OT students mentioned they had most in common with the physiotherapy student. It made them feel secure to be with two paramedical students, because the medical professions were represented more. In this study, students mentioned the clinical reasoning process in ward 30; they learned to plan a lot in their heads during the day. Higgs and Jones (2000, p. 3) stated; “Clinical reasoning, or the thinking and the decision making processes associated with clinical practice, is a critical skill in the health professions and is central to the practice of professional autonomy. It is a thinking process directed towards enabling the clinician to take “wise” action, meaning taking the best judged action in a specific context.” Neistadt (1996, p. 676) links this to practice by stating: “A primary aim of occupational therapy education is to teach students how to think like practitioners, that is, how to engage in clinical reasoning.” Practising clinical reasoning is important for the future success of occupational therapy as a profession (Paterson & Adamson, 2001). Ward 30 offers opportunities to practise clinical reasoning. Thus, in this environment clinical reasoning by OT students should be stimulated.
4.2
Discussion of method
4.2.1 Trustworthiness In a study, researchers have to be aware of possible bias concerning the phenomenon under study (Polit & Hungler, 1999). In this study bias, or pre – understanding, might be caused by onlooker observation, literature review, and the personal background of the researchers. The fact that researchers are OT students themselves might have been of influence. However, the researchers tried to limit this bias by writing down their own thoughts and feelings about the phenomenon before starting the analysing process. This made it possible to bracket their pre – understanding as much as possible and to view the phenomenon with openness. On the other hand it was easier to understand the experiences of the students, since the researchers have had almost similar experiences. In addition, the researchers are familiar with doing interviews and creating an open atmosphere in a conversation due to their experiences as an occupational therapy student. Another way of creating a good interview environment for informants is to have the interviews in a familiar place (Taylor & Bogdan, 1998). The researchers choose to interview at the building of the OT program. Hogeschool van Amsterdam
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Another form of bias that might have influenced the researchers’ study is recall – bias This is caused by the fact that the students have had other placements before and / or after their placement in ward 30. It might have been difficult for them to connect the experience to the specific placement in ward 30. Other placements might have influenced their experiences. To limit this recall – bias – influence, the researchers of this study only interviewed students who participated in ward 30 in this study year 2002 – 2003. Before the interview started, the researchers showed the goals of ward 30 (see section 1.2 ward 30) to the students. These goals were not new to them and were showed to refresh their memories. However, it might have had influence on their thoughts. Another aspect that might have affected this study is the language difference. The students had to express themselves in English, therefore it might have been more difficult to verbalize their experiences. To reduce this difficulty, the researchers decided to provide the students with a Swedish – English dictionary. Another aspect worth mentioning is that the interviews were cross – cultural. Some findings might be cultural specific for Swedish occupational therapy students. For this reason and because of the limited number of participating students, this study is not transferable to other countries. However, other OT programs can use these findings to optimise their training ward or when starting up a new one. 4.2.2 Credibility Polit & Hunglar (1999) describe the principle of data saturation within sampling. They describe that phenomenological studies are generally based on samples of ten or fewer study participants. In this study nine students were interviewed, therefore almost perfect saturation was reached. In addition, the findings of each interview showed common themes. The researchers think that further investigation would not bring up any new information and would reveal the same common themes. To create a reliable study the techniques of “triangulation analyst” and “theory triangulation” were used. Triangulation analyst is having several analysers to analyse the same data independently and compare their findings (Patton, 2002). Migchelbrink (2000) calls the use of multiple analysers “peer – check”. Theory triangulation is using multiple theories to interpret data (Patton, 2002). In this research the theory of phenomenological analysis and meaning condensation were used eclectically. Another way of increasing credibility is to apply a member – check. With a member – check researchers let informants comment on among others a descriptive statement (Migchelbrink, 2000). The researchers of this study let the students comment on their descriptive statements. By doing this, the researchers were convinced that they had expressed the experiences of the OT students correctly.
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5
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Recommendations for practice
Since part of this research aim is to give the LiU the tools to optimise their OT program, the researchers choose to give some recommendations. These recommendations are either concluded from this study by the researchers or given by the interviewed students. OT students mentioned the need of a physiotherapist in a team. They experienced a more confident and stronger role when they had the support of a physiotherapist in the paramedical part. In addition, they could view and discuss the patient’s problem from different rehabilitation angles. If is not possible to have both an occupational therapist and a physiotherapist in one team, then it should be clear, who has to fulfil the job of the absent profession. OT students mentioned that other team members expected them to do the physiotherapist’s job as well, when in fact it turned out to be a task for the whole team. In the first few days of the placement, the OT tutor was not physically present on the ward. One of the students mentioned the option to start on a day and time when the tutors are physically available; i.e. the beginning of the week. This might help the students to be more secure in the beginning. Another cause of why students felt insecure in the beginning was that they experienced a lack of information about both organizational and profession specific aspects. They did not know exactly what was expected from them. A function description about their role as an occupational therapist and about the auxiliary nursing tasks might prevent this. Students, who participated in an orthopaedic fieldwork before, experienced a more secure role in ward 30. It is important that these differences in experience and knowledge are considered, before they are going to participate in ward 30. Some of students might need extra information about the possible tasks of an occupational therapist in an orthopaedic ward. The clinical environment caused a limited role for the OT students. They could only complete the first part of the patient’s rehabilitation process. Therefore, some of the students questioned their own choice of being an occupational therapist. This feeling became stronger, because several patients, especially cancer patients, were too ill to be treated by an occupational therapist. Thus, to let the OT students experience the importance of their role in a team, it is essential to have a good selection of patients in ward 30. Ward 30 offers opportunities to practise clinical reasoning in a real environment. Since this is a primary aim of present occupational therapy education, the researchers believe the OT program of LiU should stimulate clinical reasoning in ward 30 and make the students more aware of this skill. Explicit for the placement in ward 30 was that the students had to fulfil auxiliary nursing jobs next to their profession specific job. Sometimes the auxiliary nursing Hogeschool van Amsterdam
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jobs were prioritized more than the profession specific jobs, whereby the OT students could not proceed their own tasks. In addition, all team members did not equally share the auxiliary nursing tasks. Therefore, it should be stimulated that students discuss and compromise about the division of duties. One of the students mentioned that the placement should be longer than two weeks. At the end of the two weeks she experienced a confident feeling, because she knew all the team members and the routines in the ward. At that moment she was convinced she could function optimally. However, she could not practise this further, because her participation within ward 30 was to its end. To make this placement more effective for this student, it should have been longer than two weeks. Further research, in order to identify the optimal learning time in ward 30, can be recommended.
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Trial and Error in Ward 30
Conclusion
The findings from this research are encouraging. Students were generally positive about their placement in ward 30. They all emphasised that ward 30 is a good way of learning teamwork skills. As a result of learning through trial and error they became a more confident OT student. However, some issues can be optimised. The medically focussed environment, for example, caused that the OT role was limited and forgotten sometimes. With these findings, the OT program of LiU has the opportunity to optimise their education. Finally, other OT programs can learn from these experiences when starting up or optimising a training ward.
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References Becker, C. S. (1992). Living & Relating: An introduction to phenomenology. Newbury Park, London, New Delhi: SAGE Publications, Inc. Bloomfield, D. (1997). Actuarial examinations: What can be learnt from the students' perspective [PhD thesis]? London: Institute of education, University of London. Bogdan, R. C., & Biklen, S. K. (Eds.). (1992). Qualitative research for education: An introduction to theory and methods. Needham Heights: Allyn and Bacon. DePoy, E., & Gitlin, L. N. (1998). Introduction to research: Understanding and applying multiple strategies (Second ed.). Danvers: Mosby. Eichelberger, R. T. (1989). Disciplined inquiry: Understanding and doing educational research. New York: Longman. Eva, K. W. (2002). Teamwork during education: the whole is not always greater than the sum of parts. Medical education, 36, 314 – 316. Hagedorn, R. (2001). Foundations for practice in occupational therapy (Third ed.). Edinburg, London, New York, Philadelphia, St Louis, Sydney, Toronto: Churchill Livingstone. Higgs, J., & Jones, M. (2000). Clinical reasoning in the health professions (Second ed.). Melbourne: Butterworth Heinemann. Kielhofner, G. (2002). Model Of Human Occupation: Theory and application (Third ed.). Baltimore, Philadelphia: Lippincott Williams & Wilkins. Knowles, M. S. (1975). Self – directed learning: A guide for teachers and learners. Chicago: Follett. Kvale, S. (1996). InterViews: An introduction to qualitative research interviewing. Thousand Oaks, California: SAGE Publications, Inc. Migchelbrink, F. (2000). Praktijkgericht onderzoek in zorg en welzijn (Fifth ed.). Amsterdam: uitgeverij SWP. Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks: CA: Sage. Neistadt, M. E. (1996). Teaching strategies for the development of clinical reasoning. American Journal of Occupational Therapy, 50(8), 676 – 683. Oudenhoven, J. P. v. (1989). De groep onder de loep: Een inleiding in de groepsdynamica (Third ed.). Groningen: Wolters – Noordhoff b.v.
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Parsell, G., Spalding, R., & Bligh, J. (1998). Shared goals, shared learning: evaluation of a multiprofessional course for undergraduate students. Medical education, 32, 304 – 311. Paterson, M., & Adamson, L. (2001). An international study of educational approaches to clinical reasoning. British Journal of Occupational Therapy, 64(8), 403 – 405. Patton, M. Q. (2002). Qualitative research & evaluation methods (Vol. Third). California, London, New Delhi: Sage publications, Inc. Polit, D. F., & Hungler, B. P. (1999). Nursing research: Principles and methods (Sixth ed.). Philadelphia: Lippincott. Reeves, S., Freeth, D., McCrorie, P., & Perry, D. (2002). 'It teaches you what to expect in future...': interprofessional learning on a training ward for medical, nursing, occupational therapy and physiotherapy students. Medical education, 36, 337 – 344. Remmerswaal, J. (1998). Handboek groepsdynamica: Een nieuwe inleiding op theorie en praktijk (Third ed.). Baarn: Uitgeverij H. Nelissen. Rittenhouse, T., Campbell, J., & Daltro, M. (2002). Dressed – down research terms: A glossary for non – researchers. Rockville: Center for mental health services. Taylor, S. J., & Bogdan, R. (1998). Introduction to qualitative research methods: A guidebook and resource (Third ed.). New York: John Wiley & Sons, Inc. Tesch, R. (1990). Qualitative research: Analysis types and software tools. New York, Philadelphia, London: The Falmer Press. Wahlström, O., & Sandén, I. (1996). Training ward 30: Syllabus for the 2 – point integration phase at the faculty of health sciences and orthopaedics clinic at the university hospital in Linköping. Linköping: Linköpings universitet – Hälsouniversitetet, Universitetssjukhuset i Linköping. Wahlström, O., & Sandén, I. (1998). Multiprofessional training ward at Linköping University: early experience. Education for health, 11, 225 – 231. West, M. (1996). De dynamiek van een team. Baarn: Uitgeverij H. Nelissen. World Book Dictionary. (1987). Chicago, IL: Doubleday. World Health Organization. (1988) Learning together in to work together for health. Technical Report Series 769, Geneva, Switzerland.
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Appendix I:
Trial and Error in Ward 30
Glossary
Abductive study “Patterns and concepts that merge from an examination of information or data, which in some cases may relate to available theories and in other cases may not” (DePoy & Gitlin, 1998). Epoche A Greek word meaning to refrain from judgement, to abstain from or stay away from the everyday, ordinary way of perceiving things (Moustakas, 1994, p.33). HvA Hogeschool van Amsterdam Inductive study “Human reasoning that involves a process in which general rules evolve or develop from individual cases or from observation of phenomenon” (DePoy & Gitlin, 1998). InterviewEdit Computer program to analyse transcribed interviews. For more information see appendix III. LiU Linköping University Onlooker observation An onlooker observation is a process of observing which can be done separately from interviewing (Patton, 2002). OT Occupational Therapy Probing: “Skill that comes from knowing what to look for in the interview, listening carefully to what is said and what is not said, and being sensitive to the feedback needs of the informant” (Patton, 2002, p. 374). WHO World Health Organization
Hogeschool van Amsterdam
Linköping University
Marieke Bosgoed and Miranda Pijl June 2003
Appendix II:
Trial and Error in Ward 30
Interview guide
Checklist • 4x tapes • 2x taperecorder testen • Batterijen + reserve • Woordenboek • Koffie / thee, koekjes, koffiemelk • Interview guide • Pennen, collegeblok Welcome, thank you for participation, tell who we are: OT student Amsterdam Hand over blanco paper to write on demographic questions Explain: we won’t use your name in this study, only age, nationality etc. Name: Date of birth: Female Nationality: If not Swedish; time of stay in Sweden: When participated in ward 30:
INTERVIEW GUIDE • Explain role of observer, who doesn’t participate in the interview; interviewer writes down notes • Take away coffee cups before the interview starts • Ask to turn of mobile phone INTRO (explain the purpose of this interview / study) We do this research by order of the OT program of Linköping University. Emma Eliasson is our client. We do this research as a final thesis project. This research is about your placement in ward 30 (In Swedish: undervisningavdelningen). We try to gain insight in your experiences. We will focus on teamwork. Ward 30 has certain goals regarding to teamwork, which are the following: (HAND OVER PAPER) Read out loud and slow: • Students will develop skills for cooperation in a team. • Students will increase understanding of each others’ profession. • To enable students to develop their own professional role, and by cooperating with others, obtain a perspective on this role. We want to know if these goals are attained by your placement. Therefore we want to talk with you about your experiences. It is very important that you tell what you think or feel. Keep in mind that there is no correct answer. Everything you say is valuable, because it gives us knowledge and insight which can be used to optimise the OT program concerning skills in teamwork. We observed the organisation and daily routines of ward 30: student doesn’t have to explain these aspects of ward 30 in detail.
Hogeschool van Amsterdam
Linköping University
Marieke Bosgoed and Miranda Pijl June 2003
Trial and Error in Ward 30
The findings of this study will be written in a report, which will be given to Emma Eliasson and will be placed in the library of the Hogeschool van Amsterdam. Is this okay by you? • Explain dictionary • Explain and test tape recorders Do you have any questions, before we start? (TAKE AWAY HANDOUT WITH GOALS)
First question teamwork (working together with other professions) QUESTION: • What did you learn of teamwork within ward 30, either positive or negative things? What did ward 30 taught you about teamwork, either positive or negative things? • And what is the effect of this (summary) on your confidence as an occupational therapist? How did this (summarize) influence your professionality? What was it, out of all the things you mentioned, that influenced your confidence as an occupational therapist? And in what way?
First question decision making INTRO: I would now like to introduce the final topic: team decision making. Decision making is an important aspect of teamwork. I would like to know more about your experiences about team decision making within ward 30. QUESTION: • Could you describe in as much detail as possible how you experienced your role in team decision making in ward 30? Can you tell me about team decision making in ward 30? How did you experience your role / participation in it?
Query (for ourselves: to keep in mind) • How do occupational therapy students experience the effect of teamwork within ward 30 on their confidence as an occupational therapist? • How do occupational therapy students experience their role in team decision making in ward 30?
Hogeschool van Amsterdam
Linköping University
Marieke Bosgoed and Miranda Pijl June 2003
Trial and Error in Ward 30
Probing questions • • • •
Can you tell me something more about …/that? That’s helpful. I’d appreciate a bit more detail. I’m beginning to get the picture. Do you have further examples of this? What do you mean by that?
Detailed question • When did it happen? • Who else was involved? • Where were you during that time? • What was your involvement in that situation? • Where did that happen? Ask for clarification • I’m not sure if I understand what you mean by that. I think it would help if you could say more about that. • You said it was (difficult)…What do you mean about ‘difficult’? Check whether you understand it correctly • You then mean that … • Is it correct that you feel that… • Does the expression…cover what you have just expressed? Nonverbal • Silence… • Hm, hm. • Nod Stimulating words • That’s very helpful. • I’m beginning to get the picture. • Thank you. • You explained that very clear to me.
Final closing questions • That covers the things I wanted to ask. Is there anything you would like to ask or add to this? • Are there any more things you would want to say before we end the interview? • Okay thank you very much for your cooperation. • Is it okay to your that we contact you again, if we need some extra information about what you said? • Ask telephone number. • Tell about / invite for presentation in Linköping for the end of May.
Hogeschool van Amsterdam
Linköping University
Marieke Bosgoed and Miranda Pijl June 2003
Trial and Error in Ward 30
Appendix III: InterviewEdit InterviewEdit is a free computer program for the Apple Macintosh* that helps researchers analyse transcribed interviews. Based on a simple texteditor called TextEdit, the program has a number of extensions that allow researchers to define themes, color mark text according to these themes, and automatically generate summaries containing all marked pieces of text (see figure 2). Multiple themes can be merged, to further condensate the text into a limited number of common themes. Furthermore, multiple sets of themes can be created in case the researcher has different projects running in parallel, and these sets can be shared among co – workers. InterviewEdit is available as a free download at: http://www.mekentosj.com/interviewedit The author would like to acknowledge the kind people at Apple for making the source code of TextEdit freely available. Figure 2:
*InterviewEdit requirers an Apple Macintosh computer running MacOSX 10.1 or higher
Hogeschool van Amsterdam
Linköping University
