Integrating the Centennial Vision Into anEvidence-Based Fieldwork-Learning Experience

Steve Van Lew, MS, OT/LNandita Singh, MPH, OTR/L

ABSTRACT. Occupational Therapy’s Centennial Vision includes the concept ofevidence-based practice (EBP) as a core mechanism to move the profession forward.The literature reveals that although EBP has become an expected norm by occupationaltherapy consumers and payers, it is difficult to implement secondary to a variety ofissues. The implementation and use of an EBP fieldwork experience within the phys-ical disabilities context require problem-based and collaborative learning approaches.Fieldwork students complete 15 practitioner-facilitated EBP modules regarding per-formance approaches specific to the fieldwork site. The response of the participantssuggests that EBP can have a positive impact on new knowledge acquisition and itsapplication to new clinical skills. Future program goals include the development ofmore in-depth outcome measures to ascertain the effectiveness of a fieldwork clinical-learning module program.

KEYWORDS. Evidence-based practice, fieldwork education, problem-based learn-ing, collaborative learning

INTRODUCTION

The Occupational Therapy Centennial Vision is a blueprint for present and futurepractice, education, and research. According to American Occupational Therapy Asso-ciation (AOTA, 2007), it states that “by the year 2017 we envision occupational therapyto be a powerful, widely recognized, science driven, and evidence-based professionwith a globally connected and diverse workforce meeting society’s occupational needs.”An integral part of the educational aspect of the centennial vision is the fieldworkexperience. The purpose of the fieldwork experience is to provide occupational therapy

Steve Van Lew, MS, OT/L, is Associate Director of Occupational Therapy, NYU Langone MedicalCenter/Rusk Institute, New York, NY, USA.

Nandita Singh, MPH, OTR/L, is Program Manager of Occupational Therapy, NYU LangoneMedical Center/Rusk Institute, New York, NY, USA.

This is a sole submission to the Occupational Therapy in Health Care Journal.Address correspondence to: Steve Van Lew, Associate Director of Occupational Therapy, NYU

Langone Medical Center/Rusk Institute, 400 East 34th Street, Room RR310, New York, NY 10016-4998, USA (E-mail: steve.vanlew@nyumc.org).

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Occupational Therapy in Health Care, Vol. 24(1), 2010Available online at http://www.informaworld.com/OTHC

C© 2010 by Informa Healthcare USA, Inc. All rights reserved.doi: 10.3109/07380570903410852

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students with the opportunity to apply the knowledge learned in the classroom topractice in the clinical setting (Costa & Burkhardt, 2003). The fieldwork experience isa dynamic learning process in which students experience firsthand the responsibilitiesand rewards of practicing occupational therapy.

The practice of occupational therapy during the fieldwork experience should be basedupon evidence-based knowledge. The need to search out and find evidence to supportthe efficacy of occupational therapy interventions has been driven in part by the risingcosts of health care, shortened hospital stays, prospective payment systems, and theincreased accountability of all health care professionals in providing the clients with themost efficient and effective services (Stube & Jedlicka, 2007). Although evidence-basedpractice (EBP) is expected, it has experienced difficulty in fully penetrating the fieldof occupational therapy. The ability or inability of therapists to embrace EBP has nosimple explanation (McCluskey, 2003). The reasons for this difficulty are numerous,from ambiguity of what constitutes evidence to the skills necessary to transfer researchknowledge into clinical skills. For example, in a qualitative study by Welch and Dawson(2005), the researchers analyzed the responses of the subjects about how they usedEBP. All respondents identified the need to develop their skills in EBP, specifically inthe analysis and implementation of research. Interestingly, this trend can be seen evenafter professional training in EBP. In a study by McCluskey and Lovarini (2005), theinvestigators examined the behavioral change as it related to implementing EBP afterparticipants engaged in a 2-day EBP workshop. Although the results demonstrated EBPknowledge acquisition, it failed to demonstrate any significant EBP behavioral changeamong the participants.

This article introduces the reader to EBP principles and the current challenges andrewards for use in fieldwork educational programs. Problem-based learning (PBL) andcollaborative learning are implemented as effective mechanisms in the developmentof fieldwork-learning experiences for both fieldwork educators and their students.A description using EBP in the creation and implementation of fieldwork-learningmodules is provided followed by deceptive evidence regarding the EBP moduleapproach. This innovative fieldwork experience demonstrates how an educationalapproach like EBP can be integrated into everyday fieldwork and practice to promotea science-driven profession.

OCCUPATIONAL THERAPY FIELDWORK-LEARNING MODULES

Keeping these challenges in mind, the authors wanted to create EBP-learning modulesfor students during their fieldwork experience. The clinical learning modules were re-formatted from existing didactic lectures into a collaborative model to include evidence-based practices. The clinical learning modules were designed to supplement and supportour 1:1 supervisory model for Level 2 fieldwork students. These modules are integratedinto the 12-week physical disability occupational therapy fieldwork at the Rusk Insti-tute of Rehabilitation Medicine. Students attend 15 modules, which are highlighted inTable 1 during the first 4 weeks of their Level 2 fieldwork experience. On the firstday of the fieldwork, students are presented with a resource binder containing the pre-arranged learning module schedule as well as information and resources required foreach module. The students are instructed to read each section prior to the module andcomplete all evidence-based assignments where indicated. These assignments includean evidence-based case study and a presentation at the end of the fieldwork experience.

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TABLE 1. Clinical Learning Modules for Fieldwork Level 2 Student Program

Clinical LearningModules Brief Description

Learning objectives andfieldwork assignments

Students are informed of site-specific fieldwork 2 objectives, 12-weekguidelines, case study, and in-service requirements

Vital signs and medicalprecautions

The role of occupational therapy in the acute care setting is discussed.Students practice monitoring vital signs. Students are exposed to commonlines, drains, and tubes associated with patients in the ICU and learnprecautionary handling skills. Students research unfamiliar diagnoses andcurrent evidence-based treatment interventions

Functional independencemeasure (FIM/WeeFIM)

Students learn guidelines and parameters to assess and grade thisstandardized evaluation. Case studies including practice scoring sectionsare completed and checked for accuracy

ADL principles—orthopedic protocols

Common orthopedic conditions including total hip and knee replacementsand spine surgeries are reviewed. Precautions and use of assistivedevices are demonstrated and students practice instructing patients in itsuse

Transfer and handlingtechniques

Students participate in an interactive hands-on session with an emphasis onbody mechanics, positioning, and patient safety. Several transfertechniques are performed

Assistive technology An overview of electrical aids to daily living, computer access, switch training,and environmental control units is presented and demonstrated. Studentsdiscuss case studies and review evidence-based practices in this field

Shoulder principlesanatomy/palpation

Shoulder anatomy and common conditions are discussed. Students areengaged in a critical review of assessment protocols and treatmentoptions. Journal articles are reviewed and evidence-based practices arediscussed

Horticulture therapy atRusk

Students are given a history and tour of the Rusk Glass Garden andparticipate in a horticulture group therapy session. Horticulture therapyresearch is disseminated and discussed

Neurological motorevaluation

Brain hemispheres, effects, and complications associated with neurologicalconditions are reviewed. Students participate in a practical assessment ofperformance components (i.e., tone, positioning, sensation) of the upperextremity. Journal articles are analyzed

Barrier-free design Common accessibility environmental obstacles and options for homemodifications are explored. Students learn to measure for bathroomequipment, home accessibility, and ramps

Cognition and perceptionassessment andtreatment

Terms and descriptions associated with cognition and perception aredefined. Students observe patient performance of ADL tasks throughvideo case studies and learn to functionally screen for deficits. Journalarticles are reviewed and analyzed

Neurological motortreatment

Treatment protocols for positioning, splinting, handling and facilitatingmovement, and patient education are discussed. Current evidence-basedpractices in topics, such as motor learning and functional electricalstimulation, are discussed

Splinting principles andfabrication

Students compare evidence-based options for splinting both orthopedic andneurological conditions. A variety of splints are fabricated

Seating and mobility Mat assessments, anatomy, seating principles, and options for seating andmobility systems are examined. Students experience operating manualand power wheelchairs. Current evidence-based trends in seating arecompared and analyzed

Vision therapy Eye anatomy, cranial nerves, ocular motor skills, and eye conditions arereviewed. The role of occupational therapy in the assessment andtreatment of visually impaired patients is discussed and studentsexperience the functional impact of these deficits through simulation.Evidence-based practices in the area of functional vision restoration andlow vision are reviewed

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Depending on areas of expertise and interest, clinical specialists, senior or staffoccupational therapists facilitate these clinical learning modules. They are interactive,clinically practical, and dynamic in nature and cover a variety of topics appropriate foran acute rehabilitation of physical disabilities experience. All fieldwork-learning mod-ules address the areas of occupation, client factors, performance skills and patterns, aswell as activity contexts and demands (AOTA, 2008). Most importantly, critical reviewsof practices and current trends are emphasized during these learning experiences.

These clinical learning modules were developed using a combination of PBL andcollaborative learning mechanisms in order to facilitate optimal transferability of learn-ing into clinical occupational therapy skills. PBL is an andragogy type of learning,which is based upon constructivist theories in which learning occurs in small groupsdiscussing real-life clinical problems (Costa, 2004). Overall, occupational therapy stu-dents educated in the PBL format have reported positive benefits from this style ofteaching (Stern, 1997). In an attempt to objectify these benefits, Scaffa and Wooster(2004) used a quasi-experimental pre-test–post-test design. Subjects participated in a5-week, 30-hr PBL course with the administration of the Self-Assessment of ClinicalReflection and Reasoning prior to and following the participation in the PBL course.The results indicated that the PBL course had a statistically significant effect on thestudents’ self-perception of their clinical-reasoning skills and behaviors.

The other learning type used in the development of the EBP fieldwork learning mod-ules was collaborative learning. The learning modules are group based and facilitatedby two occupational therapists. Collaborative learning is an extension of constructivisttheory in which groups of learners collaborate, or work cooperatively, to construct newknowledge (Costa, 2004).

EVIDENCE-BASED PRACTICE AND THE LEARNING MODULE

The integration of EBP into the learning modules is an ongoing process that enablesboth students and therapists to learn the latest in EBP. The authors believe that thisprocess enables a cross-fertilization of EPB knowledge acquisition among the studentsand therapists. Clinical staff offer and share their clinical experiences with students andfoster reflection on clinical decisions and interventions. The modules were designed tobridge the academic learning with clinical practice and encourage EBP. Patient videoanalysis, case studies, reading assignments, critical reviews of related journals, anddiscussion on current practice trends further enhance the use of EBP. One of the maingoals of these modules is to assist in the development of practical evidence-based clinicalskills from EBP knowledge acquisition. This is accomplished by cumulative learning,where themes are introduced in increasing complexity. Cumulative learning reinforceskey principles and allows for gradual proficiency with higher-level skills and processing(Scaffa & Wooster, 2004).

An example of this process in action can be explored using our Neurological Motormodule. All modules include a problem-based knowledge-acquisition segment alongwith a practical group skills-acquisition segment. With the Neurological Motor modulethe PBL segment is based upon the latest research in motor rehabilitation related toneurological conditions. The majority of this evidence can be categorized within motorlearning, constraint-induced movement therapy, functional electrical stimulation, andtask-specific therapy. Using the motor-learning literature as an example, the facilitatorsfirst engage the students in basic motor-learning principles, then the application ofthese principles to real clinic scenarios. Although the main goal of this first section

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of the module is knowledge acquisition, the development of clinical reasoning skillsis introduced into the clinical scenarios. The second segment of the module addressesthe application of this knowledge to the development of practical clinical skills. Thistheory–practice bridge at times can be difficult for students to first navigate, consideringtheir lack of experiences in the real work clinical setting. The modules are an attemptto assist students in this theory to practice transformation.

Data from student-focus groups revealed that 95% of the students who participatedin the learning modules had a positive experience. We also examined data from theStudent Evaluation of the Fieldwork Experience (SEFWE). Out of 35 SEFWE surveys,80% of the respondents reported that they believed the learning modules added to theirprofessional knowledge and skills during their Level 2 fieldwork experience. Subjectivefeedback from the clinical instructors indicated that they believed that the students werepositively influenced by their participation in the learning modules, specifically withregard to their synthesis of evidence-based knowledge and its appropriate applicationto an acute rehabilitation setting.

Future plans include the creation and implementation of a more objective measure-ment tool to assess the students’ learning. Through this new tool we also hope toascertain constructive feedback from the students to improve the learning modules. Inaddition, future plans include the use of an inventory of students’ learning styles to betteradapt the modules to meet the unique needs of the students. Another future programoutcome goal is to implement a longitudinal outcome procedure to measure the actualEBP of both the clinical instructors and students as they progress through their fieldworkexperience.

CONCLUSION

The success of the Occupational Therapy Centennial Vision will be highly depen-dent upon the integration of EBP principles in both the academic and clinic settings.Because clinical reasoning, additional clinical knowledge, and client-centered practiceare learned within the clinical context, the contributions of fieldwork to EBP skill build-ing among occupational therapy students cannot be underestimated (Stube & Jedlicka,2007). Clinical settings that assume the responsibility of fieldwork student must dili-gently investigate and implement EBP principles into their existing clinical educationalstructures in order to move this exciting vision of occupational therapy forward.

Declaration of interest: The authors report no conflict of interest. The authors aloneare responsible for the content and writing of this paper.

REFERENCES

American Occupational Therapy Association. (2007). AOTA’s centennial vision and executive sum-mary. American Journal of Occupational Therapy, 61(6), 613–614.

American Occupational Therapy Association. (2008). Occupational therapy practice framework:Domain & process 2nd Edition. The American Journal of Occupational Therapy, 62(6), 625–683.

Costa, D. M. (2004). Clinical supervision in occupational therapy (pp. 69–70). Bethesda, MD: AOTAPress.

Costa, D. M., & Burkhardt, A. (2003). The purpose and value of occupational therapy fieldworkeducation (2003 statement). The American Journal of Occupational Therapy, 57(6), 644.

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McCluskey, A. (2003). Occupational therapists report a low level of knowledge, skill, and involvementin evidence-based practice. Australian Journal of Occupational Therapy, 50(1), 3–12.

McCluskey, A., & Lovarini, M. (2005). Providing education on evidence-based practice improvesknowledge but did not change behavior. BMC Medical Education, 5. Retrieved February 3, 2009,from http:/www.biomedcentral.com.

Scaffa, M. E., & Wooster, D. M. (2004). Effects of problem-based learning on clinical reasoning inoccupational therapy. The American Journal of Occupational Therapy, 58(3), 333–336.

Stern, P. (1997). Student perception of a problem-based learning course. The American Journal ofOccupational Therapy, 51(7), 589–596.

Stube, J. E., & Jedlicka, J. S. (2007). The acquisition and integration of evidence-based concepts byoccupational therapy students. The American Journal of Occupational Therapy, 61(1), 53–61.

Welch, A., & Dawson, P. (2005). Closing the gap: Collaborative learning as a strategy to embedevidence within occupational therapy practice. Journal of Evaluation in Clinical Practice, 12(2),227–238.

Received: 02/01/2009Revised: 08/30/2009

Accepted: 08/30/2009

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