PROFESSIONAL FORMATION: EXPLORATION INTO THE IMPACT OF AN INTERNATIONAL SERVICE-LEARNING EXPERIENCE ON OCCUPATIONAL THERAPY STUDENTS
Occupational therapy (OT) is a profession that focuses on helping people with or without disabilities engage in daily life (AOTA, 2008). The goal of OT intervention is to promote the participation in life to an individual’s fullest capabilities and desires. Occupational therapy practitioners work directly with individuals with disabilities to facilitate participation in activities of daily life including basic daily tasks like dressing and grooming, work related tasks and leisure activities. The profession values the whole person, designing interventions for each person’s unique needs focusing on their individual pursuits, context, and life demands. Essentially, occupational therapy practitioners collaborate with clients to identify how to accommodate disabilities to maximize engagement in all life activities.
The profession of occupational therapy was born out of the importance of ensuring that war veterans were engaged in important tasks to avoid mental illness and promote healing. Occupational therapy practitioners, then called Reconstruction Aides, engaged veterans from World War I in occupations that absorbed them in an effort to ensure these individuals felt a part of and could continue to contribute to society despite the experience of war. The importance of engagement in meaningful activities is the cornerstone of the OT profession. This value of meaningful activities and goals to help veterans reintegrate into society after World War I ties the profession very closely to principles and practices of social justice and OT practitioners often report feeling “called” to serve others (Quiroga, 1995).
As occupational therapy students learn of the origins of the profession during their didactic educational experience, the tenets of social justice are emphasized as a foundation to the profession. Occupational therapy students are educated to understand that everyone has the ability to contribute to society and the role of the OT practitioner is to work with the client to ensure full participation (AOTA, 2009). Due to the values of the profession of occupational therapy, students and OT professionals look for opportunity in disability, whether it be physical, mental, or contextual, to find the chance for each person to engage in what occupations he or she find most meaningful. OT educators are tasked with ensuring that OT students enter the workforce with a strong sense of identity, both personally and professionally, to purse the justice for each person they will encounter as a professional.
Paulo Freire in his famous work “Pedagogy of the Oppressed” (2000) refers to the concept of conscientization that calls upon health care providers to develop a critical consciousness which “posits that the thinking subject does not exist in isolation but, rather, in relationship to others in the world” (Kumagai & Lyspon, 2009, p. 783). Freire’s pedagogy emphasized that in order to avoid the promotion of oppression, individuals must develop a “reflective awareness of the differences in power and privilege and the inequities that are embedded in social relationships” facilitating a commitment towards social justice (Kamagai & Lyson, 2008, p. 783). Freire’s pedagogy offers a foundation for the development of coursework for OT educators to facilitate the development of OT practitioners that have a strong commitment to social justice.
Since, human beings are complex, influenced by family, culture, environment, personal beliefs, and other factors, it is critical that occupational therapy practitioners develop a strong understanding of how human beings work (Galvin, Wilding & Whiteford, 2011). Health care, the context of OT practice, is, in itself, a complicated venture. Health care professionals must go beyond understanding the disease and disability to develop the ability to deliver patient care focused on social justice. More and more, occupational therapy practitioners are being called to provide quality care to those with limited resources (Bass-Haugen, 2009). Focusing on health care that promotes justice, in the field of occupational therapy referred to as occupational justice, requires practitioners to have a strong understanding of social justice in addition to their health care knowledge (Bass-Haugen, 2009; Hansen, 2013; Kumagai & Lypson, 2009).
Furthermore, the focus on social justice has become viewed as a critical method for trying to eliminate health disparities and address discriminatory practices by health care providers (Schiff & Rieth, 2012). Teaching skills beyond health care knowledge places demands on educators to prepare health care providers that not only implement skilled intervention but do so with a consciousness of the person to provide holistic and thoughtful care (Clingerman, 2011). Educators are challenged to teach beyond practice skills and promote professional formation to enable the development of professionals who can provide quality care in a sometimes unjust world (Furze, Black, Peck & Jensen, 2011).
Service-learning can act as a pedagogy that facilitates an in-depth understanding of how humans function in an authentic environment (Eyler & Giles, 1999). In order to understand the core concepts of occupational therapy, students must develop an understanding of the lived experience of the people they plan to serve. Living and being among individuals in community and partnership teaches students to think in a holistic and broadened scope considering world views beyond their own (Braveman & Bass-Haugen, 2009; Lattanzi & Pechak, 2011). International service-learning (ISL) “combines aspects of conventional study abroad with aspects of conventional service-learning, offering an exceptional degree of integration into a target culture and an intensive experience of community service” (Tonkey & Quiroga, 2004, p. 131). ISL firmly challenges one’s beliefs by placing a student in a different cultural context that allows for reflection and questioning of one’s personal and health beliefs. It promotes critical consciousness and helps students develop a deeper understanding of those who they will provide services to both currently and into the future (Kumagai & Lypson, 2009). According to the literature, ISL experiences promote the development of skills for health professions students in “communication, education, recognizing individual and cultural differences, prevention and wellness, professional behavior, professional development, and social responsibility” (Lattazini & Pechak, 2011:103). It is important to emphasize that these skills are required for any occupational therapy practitioner to be successful in practice and that research strongly supports ISL as a pedagogy to lay a strong foundation of these skill sets (Lattazini & Pechak, 2011).
The profession of occupational therapy was “founded on a social vision of justice” (Nilsson & Townsend, 2010, p. 57). The occupational therapy literature discusses the opportunity of service-learning as a pedagogy to help OT students understand the importance of social justice and consider the holistic needs of the people OTs serve (DeGrace, 2005; Flecky & Gitlow, 2009; Hansen, et al., 2007; Hoppes, Bender). Hoppes, et al. (2005), show that service-learning activities teach OT students about diversity, the ability to understand the community perspective and the ability to engage in reflection. Flecky and Gitlow (2009) demonstrate the opportunity for service-learning to help OT students learn about disability, increased awareness of the impact of the environment on disability and advocacy, all tenets of social justice. Beck and Barnes (2007) discussed how a service-learning experience on the Texas Border with children allows students to engage in exploring the ethical principles of practice which includes occupational justice. Other literature focuses on the successful implementation of international service learning which calls on educators to consider social justice in the design and implementation of ISL (Hansen, et al., 2007; Lattanzi & Pechak, 2011). Since service-learning is a pedagogy grounded in the concepts of social justice, it easily serves as a foundation for transforming students from solely knowledge providers to caring citizens (Cuban & Anderson, 2007).
This study focuses on the experience and transformation of occupational therapy students from an international service-learning experience in the Dominican Republic. The goal of the experience is to engage in the professional formation of caring occupational therapy practitioners who will provide quality care with a strong sense of social justice throughout their careers (Mu, Coppard, Bracciano, Doll & Matthews, 2010). In an effort to understand the depths and meaning of such an experience, the researchers asked students to reflect upon their service-learning experience and report how the experience impacted their world views.
1. INTERNATIONAL SERVICE-LEARNING PROGRAM
A Jesuit, Catholic university in the Midwest of the United States has a partnership with a mission in the Dominican Republic. Through this partnership, multiple disciplines participate in immersion experiences in the country, including occupational therapy. Occupational therapy students participate in a 3-week cross-cultural service-learning experience in the Dominican Republic focusing on the aspects of occupational therapy treatment in an international setting (Mu, Coppard, Bracciano, Doll & Matthews, 2010). A major emphasis of the experience is exploration of the role of occupational therapy in an underserved global health setting to gain a deeper understanding of how social justice and health impact one another. Implementation of intervention, patient education, reflection and discussion are the main methods used to promote student learning during the experience. Students have the chance to engage directly with individuals across the lifespan with a plethora of different disabilities to explore the cultural and health beliefs of the Dominican people. The OT students are encouraged to reflect on their beliefs as practitioners trained in the United States and consider how the experience in the Dominican Republic is challenging those beliefs. Students are further challenged to explore the definition of health from a global perspective and to try to understand how cultural context influences health beliefs and practices. The students are expected to practice occupational therapy with the resources available in the country, promoting the ability to practice in disparate conditions and offer intervention strategies that match the cultural and health beliefs of the people they are serving.
The academic faculty who instruct the course are experienced occupational therapists who have prior involvement in international occupational therapy practice and international service learning. Students participate in the service-learning experience in the Dominican Republic as an elective course. Each year, students apply and must complete an interview process to be accepted into the experience. Enrollment is competitive and the program is a strong draw for many OT students, demonstrating the desire of many students to deepen their understanding of social justice. Approximately ten students are accepted each year into the program. Prior to the experience, students participate in a series of preparatory meetings encouraging them to explore the culture, health beliefs and social justice issues of the country. The preparatory meetings are reflective in nature with the intention to help students get into the practice of reflection and to help alleviate culture shock in the transition to the Dominican Republic.
Students engage in live discussion-based reflections throughout the ISL experience. These reflections are not formally documented but help students get into the practice of reflection, which is a critical aspect of service-learning experiences (Bringle & Hatcher, 1999; Deeley, 2010). The reflective practice is not only meant to be a tool for the ISL experience but to build reflection as a daily activity with the hope the students will carry the skills of reflection into their professional life. After the completion of the ISL experience, students are asked to engage in a written reflection answering a series of questions focused on the meaning of the experience. The students are asked to address the following questions:
Why did you choose to participate in this experience?
What did you gain from this experience?
How do you think this experience will impact you as an occupational therapist?
What did you observe about the culture that was different than you expected?
How did you grow and change from this experience?
What has this experience meant to you? How have you been changed because of this experience?
The questions are provided through an online survey tool and responses are confidential. The students were sent a link to the survey after their return to the United States. Students were asked to address these questions within two weeks of the ISL experience.
After approval from the university Institutional Review Board (IRB), the researchers used the reflection survey questions and collected data over several years of the service-learning course (2010-2012). The results include the reflections of 22 (all female) participants over three years of the program. Attendees apply for the experience and applications are reviewed in a competitive manner. Student participants range from 5 to 12 participants each year across the three years. Upon obtaining the results, qualitative analysis was performed. In order to avoid results representing only one experience or cohort, data was collected and analyzed after three cohorts participated in the program. The intention of this approach was to give a longitudinal perspective from the international service learning program discussed in this manuscript. The purpose of the reflection questions were to assess students’ beliefs about the transformation that took place from the ISL experience focusing on the development of skills to practice OT infused with a strong emphasis of social justice.
As mentioned above, the reflection questions were completed confidentially through an online survey post-experience and compiled into a database offered through the survey software for analysis. The two researchers involved in collecting the data, each reviewed the data independently. After the independent qualitative analysis, the researchers identified key words or phrases that exemplified points of the student’s reflections explicating themes from the data. Subsequent evidence supporting each theme was also compiled. After the individual theme analysis, one of the researchers merged the themes compiling co-identified themes. The two researchers then met and prevalent themes were discussed by the researchers. From this point, student quotations were selected to illustrate the themes that synopsize the research outcomes.
3. STUDY LIMITATIONS
The individualistic nature of the experiences of students while immersed in this type of setting is challenging to quantify. Students provide individualized written reflections that begin to show a glimpse of the changes that they experience but may be limited in ability to truly capture the essence of the transformation. Students are also aware that the information they provide on their reflections, although anonymous, is reviewed by course instructors. Studies have shown that students may provide reflections that instructors want to hear rather than their true experience. This could be a limitation when using the student reflections as the main source of data (Hutchings, 2002).
Another limitation of this study is that it is based on the immediate reflections from the students who participated in the experience. This does show the impact the experience had on them in this snapshot of time but does not reflect the long term growth that may occur as well in students. Long-term growth from the experience may occur long after they have processed through the lessons learned along with the reintegration into their home environments.
As described previously, international service learning uses the principles of service-learning in an international setting. According to Crabtree (2008), ISL allows students to focus on developing skills in cultural brokering, collaborating with community partners in a developing country, and understanding the complexities of health and justice on community members. In this study, the results of the survey from this ISL experience yielded four predominant themes that support the growth in understanding of social justice by the occupational therapy students. These themes include: stepping outside my comfort zone, growth, cultural sensitivity, and simplicity and being present. Each theme will be described in detail along with supportive qualitative data.
Figure 1. Themes from ISL occupational therapy experience
Source: Prepared by the authors
The first theme from the post-experience reflections is stepping outside my comfort zone. Students reported they chose to participate in the international service-learning experience in order to experience being pushed out of their comfort zone through the immersion in another country. The theme coincides with the work of Kiely who identified multiple levels of transformation that occur due to ISL including “political, moral, intellectual, personal, spiritual and cultural” (2004, p. 5). He further discussed that students who experience transformation from ISL possess a desire to change (Kiely, 2004). The importance of preparing students to assess their desire to step out of their comfort zone is critical to the success of ISL to avoid the danger of promoting stereotypes and health disparities (Grusky, 2000).
The theme of stepping outside one’s comfort zone was recurrent throughout the student reflections. Prior to even participating in the experience, students reported sentiments of the desire to step out of their comfort zone as exemplified by the following quotation:
I knew it would challenge me professionally and personally by being out of my comfort zone in a different country.
These insights are important to consider in the recruitment and selection of students to international service-learning experiences such as the exemplar here. A student’s attitude prior to an experience can influence the outcome and the student’s transformation. Along with benefits to service learning come risks, especially with ISL, where students may perceive the experience as a vacation and not focused on the intention of the experience (Parsi & List, 2008). This attitude can be avoided through an application and consideration process inviting students to attend who come to such experiences with passion and intention towards transformation (Grusky, 2008). Per the experience of the instructors of the ISL experience, student attitude prior to the experience not only can positively impact the individual but also the entire group. In the authors’ opinion, promoting students to reflect and think about the experience before it happens is critical to ensure they enter the experience with an open mind and heart.
A student also reported,
I chose to come to the Dominican Republic because it was something that was out of my comfort zone, and yet something I thought I would become passionate about.
Students expressed the benefits of being pushed out of one’s comfort zone after the experience as well, as exampled here,
After being immersed in another culture, I think it'll be easier for me down the road to jump into other opportunities where I will be pushed out of my comfort zone because I know that I can get through it and become a better person because of it.
The preceding quotation represents the intent of the experience, which is to engage students in a transformative experience that develops the skills necessary to provide future care to individuals from diverse backgrounds and health beliefs. The insight of the student to remove the fear of experiencing something different is critical to develop the critical consciousness occupational therapy practitioners need to be effective at helping clients engage in daily life to their fullest ability (Kumagai & Lypson, 2009). This reflection also insinuates the value of international service-learning experiences as an opportunity to not only expose students to diverse experiences but also build confidence in handling future situations. Kiely (2005) refers to this concept as the transformative experience of dissonance, which alludes to the experience of stepping out of one’s comfort zone by exploring one’s perception with the realities of the ISL experience. According to the Transformational Service-Learning Process Model developed by Kiely (2005), in dissonance, students have the opportunity to learn and change.
A second theme reported by the students is growth. Students reported individual, professional and spiritual growth throughout their reflections of the experience. The students identified growing in areas of self-confidence, appreciation of their life at home and recognizing the kindness of others, meaning the Dominican people. This theme was recurrent throughout the student reflections.
Students expressed concerns about preconceived notions prior to the experience that were dispelled due to the experience as evidenced by the following statement:
I was hesitant in being accepted in the culture, based on a previous conversation. I was told that I would not be accepted and treated poorly based on my skin color. Based on my skin color it would be assumed that I was Haitian. The thing is that I have been told that since I was very young. I prepared myself for the same thing while in the Dominican Republic, except I was happily misinformed! My growth came in the form of not having to prepare for the worst in people's actions or words.
Recognizing that the “other” does not mean something negative will be important when the students as practitioners work with clients he or she views as different. Being surprised by the sameness of “others” is another step towards appreciating all people as individuals and increasing one’s conscientization to others (Freire, 2005).
Participants also reported growth in their own self-concept and professional formation as an occupational therapist due to the experience. This response corresponds directly to the previously mentioned Transformational Service-Learning Process Model identifying it as Personalizing, essentially an emotional response to the ISL experience (Kiely, 2005).
I gained confidence in my own skills and sense as a therapist. I learned that many parents and caregivers, as well as interventionists have an innate therapeutic sense!
The above statement alludes to the transformation of the student viewing the “other” as one always in need of help. Recognizing that those who seek services are not innately helpless is an empowering principle of social justice (Freire, 2005).
Students also reported personal growth including spiritual growth as evidenced by the following quotation.
I learned more about myself as a spiritual being, and how I can bring back with me things have learned in the DR to my life back home.
This experience by students aligns with the spiritual transformation identified by Kiely (2004) as one of the core aspects of transformation that occur as part of ISL. To engage in social justice, the occupational therapy practitioner has to know oneself deeply (Freire, 2005, Kumagai & Lypson, 2009). Spiritual transformation, as defined by Kiely, is described as “a movement toward deeper (un)conscious understanding of self, purpose, society and greater good” (2004, p. 11). As described by Kiely (2004), this theme of growth and understanding of the self and increasing one’s self-awareness ensures that the occupational therapy practitioner will practice in a more engaged and thoughtful manner integrating the tenets of social justice into daily practice.
Another predominant theme reported by the participants was cultural sensitivity. After the experience, students acknowledge increased cultural sensitivity including awareness of similarities and differences across the Dominican and American cultures seen in client interactions and in the health care beliefs and systems. Health care is riddled with health disparities but the literature indicates that if health care providers seek cultural knowledge and skills, individual health care providers can avoid culturally insensitive practices, which contribute to health disparities (Abreu & Peloquin, 2004; Glazner, 2006). Increased cultural sensitivity by providers can directly reduce the promulgation of health disparities promoting equal and just health care provision (Abreu & Peloquin, 2004). The theme of increased cultural sensitivity was recurrent throughout the student reflections. Evidence of this theme includes the following quotations:
I loved learning about the different culture, how to interact with the people of the Dominican Republic, and learning about their ways of life.
I believe I will be more patient when working with different people who are from different cultures and who speak different languages. Having an experience like this will forever remind me what it is like to feel frustrated, esp. when not being able to relate to ideas and communicate phrases.
I gained all that I set out to and so much more. This experience gave me an understanding of the Dominican culture and helped me realize that there are reasons why people do the things they do. Americans place values on different things than Dominicans but who's to say which values are ‘best’?
A forth theme emerged focused on simplicity and being present. Students reported a desire to live more simply and live in the present after the cross-cultural international service-learning experience. These sentiments align directly with the teachings of Paulo Freire (2005) and are supported by personal transformation discussed by Kiely (2004). Personal transformation includes when students who have engaged in ISL “actively develop more individually and socially conscious lifestyle, relationships, career and educational choices (Kiely, 2004, p. 11). This theme of social consciousness was recurrent throughout the student reflections. Evidence of this theme includes:
I learned about the importance of simplicity: in my life and in my profession.
I am better able to recognize the simplicity and beauty that is life.
I've become much more conscious of my own way of life and have embraced the importance of living in the present. While I always wanted and believed that I would do something that would actually make a difference in the world, I now know I will.
The themes of stepping outside my comfort zone, growth, cultural sensitivity, and simplicity and being present yielded from the study demonstrate the value of international service learning experiences to deepen occupational therapy students’ understanding of social justice and to promote OT providers who practice with a consciousness about social justice for all. The themes identified here demonstrate the power of international service learning experiences to promote the development of occupational therapy practitioners with a strong sense of social justice prepared to meet the needs of diverse and marginalized patients.
The results of this study support previous research in the field of occupational therapy regarding the impact of international service learning on OT students. In a previous study conducted by Humbert, Burket, Deveney and Kennedy (2012), OT students reported similar experiences to this study of gains in cultural awareness and connectedness which are similar to the themes extracted in this study. Through these written reflections students demonstrate comprehension on how they can exist as change agents within their own profession and beyond. Similar findings were noted in studies by both Hansen (2013) and Clingerman (2011), where participants began to understand social injustices and the importance of advocacy through their ISL experiences. The students’ reflections in this study echo these findings and demonstrate increased awareness of cultural differences, health disparities, and self-reflection allowing for contemplation of the role these students will play as occupational therapists in enhancing health care services for all individuals.
Participants are also seeking ways to continue to embrace the experience even once they have left by taking small life lessons and applying them in their own lives. Increasing simplicity in daily life and appreciating the beauty around them are small but powerful ways that students can be impacted through these experiences. In these same reflections students connected with a deeper understanding of their ability to make changes in the world around them and expand beyond what they ever thought possible. It is these potent and expansive changes in participant thinking that continues to point towards the transformative and essential need to continue to educate health care students within the global community.
International service-learning experiences clearly have an impact on burgeoning occupational therapy professionals in transforming world views, impacting clinical perspectives and developing critical consciousness. Educators have a responsibility to facilitate such experiences for students to encourage students to move beyond learning entry-level skills to be prepared to engage with the diverse population. Understanding the impact of such experiences also ensures that such experiences are designed by educators with thoughtfulness and correct intent. Ultimately, the true teachers become the people with whom the students interact in these international settings who show the beauties of human nature despite cultural differences and varying health beliefs. In international service-learning experiences, community members receive needed services but these individuals are also catalysts for forming professionals who will go on to be advocates for injustices and provide health care grounded in the principles of social justice.
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