a course in autoethnography: fostering reflective practitioners in occupational therapy

INSTRUCTIONAL APPROACHES

A Course in Autoethnography:Fostering Reflective Practitioners

in Occupational Therapy

Steve Hoppes, PhD, OTR/LToby Ballou Hamilton, PhD, MPH, OTR/L

Cyndy Robinson, MS, OT/L

ABSTRACT. This paper describes an academic course designed to laythe foundation for reflective practice in occupational therapy. In thiscourse, students conduct highly personalized research based on experiences

Steve Hoppes is Associate Professor, Rehabilitation Sciences, and Toby BallouHamilton and Cyndy Robinson are both Assistant Professors, all at the University ofOklahoma Health Sciences Center, Tulsa, OK.

Address correspondence to: Steve Hoppes, Rehabilitation Sciences, University ofOklahoma Health Sciences Center, 4502 East 41st Street, Tulsa, OK 74105 (E-mail:[email protected]).

The authors wish to express their gratitude to their students who have pioneered thiscourse with them (and given permission to excerpt from their autoethnographies). Theauthors have learned much from them and will always be indebted. They have openlyshared stories of their best, worst, happiest, and saddest moments in the clinic and intheir personal lives. The authors feel deeply honored by their trust.

The authors also wish to thank Dr. Beth DeGrace, who helped them create andfine-tune this course.

Occupational Therapy in Health Care, Vol. 21(1/2) 2007Available online at http://othc.haworthpress.com

© 2007 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J003v21n01_10 133

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in Level II fieldwork that leads to writing an autoethnography. The paperdescribes autoethnography, details its use in occupational therapy litera-ture, and discusses the design and outcomes of the course. Students’ ex-periences with this autobiographical genre of qualitative research areillustrated. In the writing process, students find clinical stories that mustbe told and learn to “move around” in their stories. The outcomes of thecourse include integration of personal and professional experiences, clo-sure to academic preparation, and deep reflection about what it meansto be an occupational therapist. doi:10.1300/J003v21n01_10 [Article cop-ies available for a fee from The Haworth Document Delivery Service:1-800-HAWORTH. E-mail address: <[email protected]> Website:<http://www.HaworthPress.com> 2007 by The Haworth Press, Inc. All rightsreserved.]

KEYWORDS. Qualitative research, occupational therapy education,reflective practice

INTRODUCTION

Occupational therapy educators seek active learning experiences toengage students in a “collaborative process that builds upon priorknowledge and integrates academic knowledge, experiential learning,clinical reasoning, and self-reflection” (American Occupational Ther-apy Association [AOTA], 2003, p. 1). A few years ago, the occupa-tional therapy faculty at the University of Oklahoma sought just thistype of learning experience for our entry-level Masters Degree students.We wanted to support students as they developed understandings ofthemselves as occupational therapists. We wanted to help them inte-grate qualitative research methods with experiential learning, clinicalfieldwork, and self-reflection. We dreamed of a new class that couldfoster reflective practitioners (Schon, 1983).

We believe we have created an ideal educational experience thatmeets all of these criteria. In the final semester of our program, studentswrite an autoethnography.

WHAT IS AUTOETHNOGRAPHY?

Autoethnography is a “postmodern form of ethnography” (Neville-Jan, 2003) and “an autobiographical genre of writing and research that

134 OCCUPATIONAL THERAPY IN HEALTH CARE

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displays multiple layers of consciousness, connecting the personal tothe cultural” (Ellis & Bochner, 2000, p. 739). The anthropologist DavidHayano (1979) first used the term to describe ethnographic researchdone on one’s “own people” through an insider’s perspective. A seconddefinition of autoethnography has evolved to include “autobiographicalwriting that has ethnographic interest” (Reed-Danahay, 1997, p. 2).While methods vary, an autoethnographer generally engages in note-taking, identification of categories and themes, emotional recall, discus-sion, and reflection to yield a narrative that affords both the inside viewof a research participant and the outside view of a researcher (Ellis,1998; Ellis & Bochner, 2000).

This qualitative research format has been used in occupationaltherapy to explore the experience of chronic pain and living withspina bifida (Neville-Jan, 2003, 2005), the impact of death of a family-member on occupation (Hoppes, 2005a), and meanings and purposesof caregiving (Hoppes, 2005b; Salmon, 2006). Although not called“autoethnography,” Dickie (1997), Thibeault (1997), and Hasselkus(1993) wrote autobiographical accounts examining the occupations ofmaking crafts, caring for a father with dementia, and caring for a motherat the end of her life, respectively. While still limited in its use in occu-pational therapy, autoethnography fits well with the profession’s valu-ing of narrative reasoning (Mattingly, 1994; Schell, 2003).

Autoethnography is a tool to find meaning and purpose in the midstof life’s challenges by placing the writer in dual roles of researcher andresearch participant. In our class, students write an autoethnography ex-amining their experiences of being student-therapists during level IIfieldwork. What are their strengths and weaknesses? What have theylearned about themselves and their clients? What does it mean to be anoccupational therapist? How does one become an occupational thera-pist? How do personal experiences influence the occupational therapistthey will become?

The process of writing an autoethnography grounds students in nar-rative reasoning as an essential component of occupational therapyreasoning. Mattingly characterized narrative reasoning as a “centralmode” that is “fundamental” to occupational therapists’ clinical rea-soning (1991, p. 998). In practice, occupational therapists use narrativereasoning to make sense of clients’ particular circumstances, prospec-tively imagine the effect of illness, disability, or occupational perfor-mance problems on their daily lives, and create a collaborative story toguide intervention (Hamilton, in press). In the process of writing their

Instructional Approaches 135

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autoethnographies, students explore, refine, and enrich their narrativereasoning.

Storytelling and storymaking are established therapeutic methods inoccupational therapy. Occupational therapists tell stories to understandthe unique experience of a person (Crabtree, 1998), what is meaningfuland purposeful to a client, and the uniqueness of one’s experience of oc-cupational dysfunction. As the profession began to value the impor-tance of narrative reasoning, occupational therapy texts and journalsfeatured narratives that therapists tell about clients and clients tell aboutthemselves (e.g., Bruce & Borg, 1997; Crepeau, Cohn, & Schell, 2003;Larson & Fanchiang, 1996). We impart the art of occupational therapythrough stories, notably (1) Peloquin’s use of story to warn about thedangers of depersonalizing clients (1993); (2) Yerxa’s story from her1967 Eleanor Clarke Slagle lecture telling of a woman reaching for aglass of water illustrating the role of meaning and purpose; (3) Clark’suse of story motif to tell of Penny Richardson’s recovery from a cere-bral aneurysm through occupation and personal narrative (1993); and(4) Wood’s tale of Betty’s bath in which occupation affords a welcomerespite from dementia (1995).

Writing an autoethnography affords students the opportunity to ex-amine, appreciate, and express the norms and values of the professionthey are about to enter. Autoethnography deals with the very “stuff” ofnarrative–human belief, desire, and commitment (Bruner, 1990, p. 52)and knowledge of intention, motive, and action not only imparts mean-ing but also makes sense of it (e.g., Bruner, 1990; Mattingly, 1994,1998; Polkinghorne, 1988). Writing an autoethnography allows stu-dents time and opportunity to move back and forth in time to integratetheir student experiences and define the ideals of their future practice.The ability to negotiate and renegotiate meanings through narrative is“one of the crowning achievements” of a person’s development and ofthe development of humanity and culture (Bruner, 1990, p. 67). We feelthat the autoethnography is the crowning achievement of our students’academic studies.

DESIGN OF THE COURSE

After a level II fieldwork in the fall semester of their final year,our students return for a spring semester that includes the autoeth-nography course. Prior to fieldwork, we introduce them to the assign-ment by describing autoethnography and by having students read an


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autoethnography written by a student the previous year. During field-work, students keep a “Reflections and Stories Journal” to record theirexperiences, reflections, and stories about the practitioners and clientsthey encounter. This journal provides data and sets the stage for theautoethnography.

Students are assigned to groups of four to six with a faculty facilita-tor. Groups meet three hours per week for seven weeks. The course be-gins with a brief lecture introducing autoethnography. Early in thesemester, students read and participate in class discussions of outstand-ing examples of autoethnographies, from occupational therapy (e.g.,Hasselkus, 1993; Hoppes, 2005; Neville-Jan, 2003; Thibeault, 1997) aswell as other disciplines (Ellis, 1993; Ronai, 1996; Tillman-Healy,1996). These models help students think about how they might shapetheir manuscripts. At the same time, they re-read their own journals toselect their most compelling stories and to identify unifying themes thattie their stories together.

The majority of class-time is spent telling and listening to students’stories and discussing their drafts in small groups with a faculty mentor.Often a student begins a story by saying, “This really isn’t the story Iwant to write about, but . . . .” They often tell the story without aware-ness of the story’s meaning or significance or that the story itself hasbegged to be told. Frequently, peers encourage the student to pursue acompelling story, even though no one may yet appreciate the story’smeaning. As the story unfolds, monitoring genuine reactions mirroredin the faces of peers during storytelling allows students to speculate onthe story’s meaning and significance.

During a class meeting, one of our students found that her story couldnot wait. Typically prefacing it as “not the story,” she blurted it out tothe faculty facilitator during a break before the first storytelling session.Peers encouraged her to retell the dramatic story of seeing a televisionnews account of an accident involving a police officer whom she sawhours later near death in the hospital’s level 1 trauma unit. Enthusiasticpeer response and support helped her tell the story that eventually tookthe shape of an autoethnography exploring personal and professionalboundaries.

In the second week, students begin to write stories for weekly groupmeetings and peer-review. The first submission is typically one or twoshort stories and the group begins to ferret out meanings by speculatingabout why the student is telling that story at this time. Sometimes, stu-dents write stories that initially appear completely unrelated. As storiescluster and students steep themselves in their own stories and examine


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their peers’, meanings and themes gradually surface in the followingweeks. Our experience is that the faculty facilitator often intuits the sig-nificance and meaning of a story long before the group grasps it, withthe storyteller usually the last to perceive its significance. The groupsupports the storyteller in the discovery process, nudging deeper reflec-tion with questions and prompts. For example, students probed the storyabout the police officer by asking, “I wonder if your reaction to the offi-cer’s wife at the hospital has anything to do with your recent marriage?”or “What was it about seeing his face in the hospital and his picture onthe newscast that caused your reaction?”

As the autoethnography takes on written form and the due datelooms, peer feedback gains renewed value. Feedback transcends copy-editing to consider narrative organization and effective ways to tell thestory. Many students follow examples from required readings by itali-cizing their unspoken thoughts, fears, and hopes and positioning them atkey points within the story.

Throughout the process, we ask students repeatedly to think aboutthe importance of their stories and themes in light of research questionsthat their autoethnographies might address. Sometimes, this is one of thelast puzzle pieces to fall into place. Our students’ autoethnographieshave addressed research questions such as:

• How does an occupational therapist define boundaries betweenpersonal and professional lives?

• How does an occupational therapist learn to deal with losses thatclients and their families experience?

• How does adversity in an occupational therapist’s life influenceempathy and understanding of clients?

We think these are important research questions for our students toconsider and autoethnography facilitates this exploration.

STORIES THAT MUST BE TOLD

We ask students, “Is it possible that, instead of choosing a set ofstories to tell, the stories will choose you?” We mean to suggest that cer-tain clinical stories must be told because they are uniquely and person-ally instructive. Students often tell us that, at first, this notion seemspreposterous. Nonetheless, they begin the process of writing their


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“autoeth-what?” “kicking and screaming,” as one student puts it, oftenwondering what purpose it can possibly serve. One student wrote:

An autoethnography? What is that? I am supposed to write anautoethnography when I have never even heard of one before?What I soon learned was that it was harder to explain what anautoethnography was than to actually write an autoethnography.

Although students may initially be unaware of their stories’ mean-ings and purposes, the interaction between writing and group discus-sions helps them look for their stories’ roots, unearth meanings, anddeduce lessons for their professional and personal lives. After muchwriting, rewriting, discussion, and feedback, powerful stories and stu-dents who are ready to learn from them gradually find each other, andautoethnography becomes the medium for reflection, expression, andintegration.

MOVING AROUND IN A STORY

An effective autoethnography, “fluently moves back and forth, firstlooking inward, then outward, then backward, and forward, until thedistinctions between the individual and social are blurred beyond recog-nition and the past, present, and future become continuous” (Ellis, 1997,pp. 132-133). Often, we have found that students do not know why cer-tain clinical events, such as the death of a patient or working with a childwith severe disabilities, hit them with such force. In telling these stories,they acknowledge that they became overwhelmed and “stuck,” unsureof how they wanted to respond, both personally and professionally. Atthis point, we ask a few gentle questions to help students move aroundin their stories: Why was this patient special to you? What do youthink you meant to this patient, and what did this patient mean to you?What would your clinical instructor say about your interaction with thispatient? What would someone, outside of OT, who knows you reallywell, say about your interaction with this patient? What do you thinkyou learned from your encounter with the patient?

These questions help students to move around in their stories. They be-gin to tell their stories not only from their own perspectives, but also fromthe viewpoints of others–clients, families, and fieldwork educators, forexample. They consider how their pasts shaped their clinical stories,and speculate about where their stories may lead. “Inward-outward/


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backward-forward” storytelling, demanded by autoethnography, helpsstudents understand that their personal stories are, in fact, tiles in a largermosaic that is the culture of becoming an occupational therapist.

STUDENTS’ STORIES

Students have shared remarkably compelling stories and lessons intheir autoethnographies. Three examples must suffice.

To break down the resistance of getting started on their writing, thesecond author (T.B.H.) gave a group of students 10 minutes in class towrite whatever came to mind. Writers often find that such “free writ-ing,” without regard to style frees them to write deeply. “You meanright NOW?” one student queried, as if writing in public was unspeak-ably difficult, even indecent. In less than 10 minutes, he outlined hisautoethnography using the concept of building a house as a metaphorfor building his career. The final product, “Becoming an OccupationalTherapist: A Groundbreaking Experience,” has sections titled “Settingthe Foundation: The Cornerstone” (stories about his experiences withhis grandfather and uncle with disabilities); “Reviewing the Blueprints”(stories of three patients who helped him understand the meaning andpurpose of occupational therapy); and “Building in Progress” (blue-prints for his career).

Another student explored the personal and professional parts of herlife, which she imagined as a line representing the threshold of theclinic’s door to the outside. With encouragement to explore the “line”further, she concluded,

I know the line, this line that separates my personal life and profes-sional life, will always exist to some extent. The depths willchange. At times, it will be as deep as the Grand Canyon, daringme to try and jump over, all the while not knowing what is on theother side. . . . Other times it will be as shallow as a stick scrapingacross hard dirt. . . . I realize that I always want to be cognizant ofthe line, knowing where it is at all times. I want to be able to decidewhen and if I should cross it. I will want to cross it at times; othertimes I will not. I want to define the depth, and I want to decidewhen I will cross it, even though I know that will not always bepossible. The line brings together my professional life and per-sonal life, which both define me as a person.


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A third student explored the unexpected emotional jolt that sent herreeling when a favorite patient died during fieldwork. After spendingsome time “stuck” in her story, we asked her, “Why do you think thisparticular patient affected you so deeply?” Without hesitation, she an-swered, “Because he reminded me of my grandfather,” something shehad not previously realized.

Through her autoethnography, she came to understand the genesis ofher clinical crisis: She had not thoroughly grieved her beloved grandfa-ther’s death a few years earlier. With this understanding in place, shewent on to skillfully analyze her nascent abilities to both bond and drawboundaries with patients, and described the type of therapist she wantedto become.

I learned that occupational therapy is not just about helping a pa-tient get better. It also has to do with helping patients make transi-tions, such as dying. I also learned how that affects me. Until I satdown and wrote, I never thought about it. It was just somethingI had to do at the time, and I did it. The autoethnography made mestop and think about it and figure out what it meant to me, how Iwas able to do it, and what it meant to the family and the client.I learned that it is not always good to keep feelings bottled up. Ialso learned that death is scary, very scary, to me, but I learned thatI can facilitate the process and make it a little easier on the familyand the client.

Despite initial hesitation and resistance, our students are, invariably,proud of their autoethnographies at semester’s end. One student com-mented that this work “gave closure to the whole program, made me re-flect on everything I’ve learned, and reflect and realize why I’m in thisprofession.” Another commented that she

[N]ever felt so good about a paper in all my life. I have alwaysthought that writing was one of my weaker areas and never felt realconfident with the paper I wrote. I am truly proud of the paper thatI produced (with lots of help and deep reflection).

Autoethnography has moved our students through impasses, taughtlessons in survival, and given them tools and meanings to build careersas reflective practitioners.


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REFERENCES

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Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press.Clark, F. (1993). Occupation embedded in a real life: Interweaving occupational

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doi:10.1300/J003v21n01_10


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a course in autoethnography: fostering reflective practitioners in occupational therapy

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