Resilience, professionalism, and reflective thinking: The three-legged stool of health professional and teacher education students’ fieldwork practice / Resilienz, Professionalität und reflektierendes Denken: die drei Säulen für das Praktikum von Studierenden der Gesundheitsberufe und der Lehrerbildung

The study was conducted between March and August 2019 at a metropolitan university in Victoria, Australia. The courses had varying requirements for fieldwork duration, context, and stage of course (see Table 1).

A purposive sample of participants (N = 78) was recruited from the OT, pharmacy, SW, and education disciplines at a large Australian university. OT students were in their third or fourth year of undergraduate studies or second-year master's program. Pharmacy students were in their third year of undergraduate studies. SW students were in their first- or second-year master's, and education students were in their second or third year of undergraduate studies or first-year master's degree.

University Human Research Ethics Committee approval was obtained in January 2019 (Project ID: 15205), and recruitment notices, including an explanatory statement, were posted on course learning management system fora. In some discipline areas, a blind copy recruitment email was also sent to potential student participants. Students indicated their interest in participating in the focus group via return email. Students meeting the inclusion criteria were provided with the focus group schedule details.

Participants took part in one of ten 1.5 hour focus groups, each with a maximum of 10 students from a single discipline. One researcher facilitated the focus group, while the second one recorded fieldnotes. The focus group proceedings were audio-recorded and transcribed verbatim. To minimize the impact of power relationships, the two investigators were not involved in providing any direct teaching or learning activities to the participants.

Prior to commencing the focus group, participants were given a brief outline of the aims of the study, a plain language participant information sheet, and a consent form. The focus groups were conducted in a university classroom with questions posed relating to professionalism, reflective thinking, resilience, and fieldwork (see Box 1). Each participant received an AU$25 voucher as a token of thanks.

Focus group recordings were transcribed into Microsoft Word™ documents. The transcriptions were cross-checked with audio files prior to analysis and then imported into the web-based qualitative platform Dedoose^™ for organization and analysis.

Participants were coded to denote their study discipline and year level (e.g., fourth-year SW, SW4; third-year pharmacy, PH3, etc.). Data were analyzed for themes iteratively by two of the authors (CC, AH). Audio recordings were first listened to, and then transcripts were read and reread while taking notes. Initial open coding was used, followed by focused line-by-line coding to refine existing codes and create categories. Forming themes and sub-themes involved collating the codes and categories and searching for commonality of ideas and constructs in the data. Themes and sub-theme descriptions were reviewed and refined through joint discussions and eventually assigned meaningful names with summaries and illustrative participant quotations (Braun & Clarke, 2006).

The 78 participants spanned four disciplines: OT (n = 18, 23.1%, two focus groups); pharmacy (n = 6, 7.7%, one focus group); education (n = 16, 20.5%, three focus groups); and SW (n = 38, 48.7%, four focus groups) (see Table 2).

Just over three-quarters (n = 60, 76.9%) of the participants identified as female. The remaining participants identified as male (n = 15, 19.2%) or preferred not to say (n = 3, 3.8%) (see Table 3). The mean age of the participants was 25.0 years (SD = 4.9, range = 23 years) (see Table 4). All but one participant were enrolled in their course on a full-time basis (n = 77, 98.7%). Majority (n = 51, 65.4%) of the participants were international students and 34.6% (n = 27) were domestic students. Nearly half had entered their course with a school leaving certificate (n = 38, 48.7%), while less than a third entered their course with a bachelor's degree (n = 26, 30.8%). The remaining participants, all of whom were Master of Social Work students, entered their course having completed a previous master's degree (n = 14, 20.5%).

Six overall themes relating to participants’ fieldwork performance and perceptions of professionalism, resilience, and reflective thinking were identified in the data. These six themes were an aggregate representation of 27 sub-themes, as depicted in Figure 1.

Figure 1

Unsurprisingly, many of the participants spoke extensively about the opportunities which fieldwork afforded them in exposing them to the lived experience of their profession of choice. They noted convergence and disparities between the theory of university courses and the “hands-on” reality of fieldwork, where eight sub-themes were identified relating to bridging the university/workplace divide (bridging the gap). Further, four sub-themes were identified regarding becoming situated among other professionals and the keys to becoming a colleague (growing as a professional). Two additional sub-themes around the skills needed to cope with a sudden transition from student to proto-professional (grit and perseverance) were identified. Each of these six themes is explored below.

This theme describes the interplay between university preparation for, and the realities of, fieldwork. It was coded into eight sub-themes (Figure 1). Fieldwork is seen by participants as a dynamic learning environment where skills and theories learned in the classroom began to make sense in a practical real-world way. For example, comparing university learning activities to fieldwork, an education student commented:

“It's really helpful for classroom management to say you can talk about how you’re going to handle a student who's playing up, but it's very different to actually going out and doing it.”

Participants also found that fieldwork provided a level of practicality and a sense of consequence (e.g., client outcomes) that cannot be replicated in the classroom. This helped build future competence in less-tangible concepts such as forming therapeutic relationships or clinical reasoning skills. One pharmacy student revealed:

“It makes sense now, it's like tangible and you actually feel that like it's an actual patient rather than just having words on a screen.”

Similarly, an OT student noted the stark contrast between the classroom and fieldwork:

“We did some mock interview in class, you can ask your partner to pretend being a client with a stroke, but it's really different from a real person with stroke with slow speech and so on. So that's a really important experience.”

Participants indicated that fieldwork increased their ability to understand and apply non-technical skills to their practice, thus bridging the gap between controlled classroom environments and nuanced and unpredictable real-world experiences. Reflecting on the personal impact of placement, a pharmacy student stated:

“Without the context of having it in a real-world scenario with the real-world consequences as a result. Placements will be a good way to bridge that gap… it's a bit more personally impactful.”

Participants noted an inconsistency between the concepts and practice recommendations learned at university and those experienced during fieldwork placements. As one SW student indicated: “I think a placement is our opportunity to learn how to deal with the conflicts between that ideal social work and the real social work” (SW1). Participants view these inconsistencies as pragmatic and functional choices based upon their supervisors’ workload and resource availability in the field. Concerns were also noted regarding perceived inconsistent supervision, and sometimes contradictory advice. These experiences may result in mixed messages for students relating to best practice and the impact on assessments of their fieldwork competence. As one SW student reported:

“[They said] ‘Yes, this is what you learn from your uni but in a practice, we don’t do that.’ And they just try to get me to accept that and to follow the requirements of the organisation rather than the theories.”

Variability in the quantity and quality of supervisor guidance, feedback, and support was also perceived to impact participants’ confidence in their decision-making during fieldwork. For example, an OT student linked developing confidence to having opportunities to act with independence:

“I think knowing that you can actually do something, depending on how much, what is the word, independence you were given in your setting can also influence whether that confidence grew or whether it actually went backwards.”

Participants described a range of personal costs (e.g., loneliness, increased stress, and loss of income from part-time work) related to the practicalities of balancing university demands (e.g. assessments), fieldwork, and personal commitments. For instance, an education student commented: “…it's just hard to balance your academic commitments, as well as your placement commitments” (ED2), while an SW student stated: “it's just not fair to have a uni assignment while on placement as well as trying to have a life” (SW1).

Participants also noted the negative impact of late notification, changes to placement, and in some cases, the tyranny of distance from home to fieldwork venues. These could all compound financial hardship and loneliness. For instance, an OT student recalled:

“I got an email halfway through last week saying it's been cancelled. And you’ve been moved to Wodonga, which is four hours away. So I think that for me, I was like, ‘All right, cool. What do I do now?’”

A second-year SW student also recounted:

“I’ve never been there [remote rural setting] before, so I think it's going to be a lifestyle and that's a part of the culture, and well it's very different from my own lifestyle so I think it's going to be a process… to just settle down.”

There was a sense from participants that the difficulties they face during fieldwork play a significant role in developing the resilience needed to “bounce back.” Fieldwork provided an opportunity to experience the complex balance of professionalism, resilience, honest reflective thinking, and the “passion” that their chosen profession demands. For instance, an education student commented:

“Yeah, it's kind of like a three-legged stool, and you’re sitting on it, and you’re in placement. If you’re not professional, you’re going to fall over. Or if you’re not reflecting [on] all you’ve been doing, your class is going to fail, and you’re going to fall over. If you’re not resilient, first day, you’re going to fall over. You can try and balance on two legs for a little bit, but really, particularly, you need all three to be really strong. Because otherwise, you’ll fall over, and you won’t be able to do it.”

Participants also identified passion for their chosen profession as an important element for building resilience, with another education student stating:

“…one key factor is passion. If you don’t have that passion for teaching, you’re just going to collapse really quickly. No matter. That would not be any resilience. Then everything else is going to collapse.”

Participants viewed fieldwork as a valuable exercise in enabling them to grow their own professional profiles, acquire knowledge of workplace culture and norms, and develop their interpersonal skills. They saw it as an opportunity to foster professional relationships, demonstrate competence, and to create “…a good first impression” (OT3; p. 6, l. 22). Participants felt a need to prove their professional selves, as one third-year pharmacy student reflected:

“You realise that they are watching you in detail and they are noting how you conduct yourself around their workplace, not grooming you for a job….”

Many reported this was the first time they had encountered such scrutiny of their professional growth regarding interpersonal communication, building rapport, and developing their own practice styles and opinions. A second-year SW student described applying such skills in the clinical setting:

“…I had the ability to be a bit more informal because it was more about building a relationship with the child but also the parents. So, you would have to change the communication style depending on who you were talking to.”

A third-year OT student reported that fieldwork was where they developed their identity as an OT, stating: “It's [fieldwork] where you develop your professional identity. That's where you get that experience. Obviously, everyone's probably worked in other areas, but it's developing a professional identity within occupational therapy. That's where you do it.” (OT3; p. 22, l. 8–10) Participants identified pre-fieldwork preparation as an area needing improvement. They felt relaying more anecdotes, tips, and common pitfalls would help them to visualize what to expect on fieldwork. While some felt “even just reading what others go through on their placement might help you better understand what you’re in for” (OT3; p. 27, l. 21–23) or these types of insights “…would give you insight into pitfalls” (OT3; p. 27, l. 33), others realized that it may not be of much practical value:

“They can tell you these are the things that you are going to expect… you’ll see that this might happen but then honestly, actual experience, you don’t know how you are going to react. I think every placement is very different.”

International students, in particular, flagged the benefits of workplace cultural acclimatization:

“If before we go to the field practice, we have some workshop and then we understand the difference of background of different organisations and what kind of service they are doing or even some social worker working there and share their experience in working at that organisation. About the culture, about the service, and their value. The thing that we can have broader understanding how social work in Australian contexts.”

Participants tended to view resilience in largely conventional terms as bouncing back from a difficult situation and continuing with their placement optimistically. Grit and perseverance were seen as a means to manage anxiety and distressing situations. As one education student commented:

“It's like when you get back in the car [at the end of the day], you sit there for a bit. Then you cry. Then you drive home, you go to bed. You get up the next morning, and then you go to work with a smile on your face. You just keep going.”

Students also observed that perseverance had a self-protective quality, as one pharmacy student explained:

“You need to be resilient too, not let that affect you as much. I know like you have to show empathy, you have to care for them. But then if you let that affect you, then I don’t know, how would you be able to handle that every single day? That's so much emotional pressure on you and it's like that will affect your life every day and then you can’t get back from that.”

Reflection on practice also arose spontaneously and played a crucial and cyclical role as participants developed an understanding of what to expect from their experiences. As one OT student stated, “so I reflect like a lot. I did it every day in the shower – Shower thinking” (OT3; p. 31, l. 16). While some participants viewed reflection as an “…ongoing process for you to improve yourself” (SW2; p. 5, l. 27), other participants questioned more deeply where their insights into “what to expect” came from and how to include these reflections in their future practice.

By bridging the gap between theory and practice, by exposing students to the realities of what it is like to be a professional in their career of choice, and by requiring the development of grit and perseverance, fieldwork acts as a window that gives students a preview of professional life. These practice-focused themes were complimented by others relating to the nature of fieldwork as a type of learning. We turn to these now.

As a pedagogical method, fieldwork brings a unique set of challenges for students to deal with. Being in “live” workplaces and clinics introduces expectations and demands of students that are simply not present in a classroom. Fieldwork exposes students to local practices that are dictated by the host organization or mentor, typically with a strong focus on catering for the needs of clients. This often places students in difficult situations where they need to embrace a new world that is sometimes at odds with the world of the classroom (grouped under the theme: the principle of the matter). Similarly, they need to adapt to the diverse backgrounds of new colleagues and clients as they learn the ropes of the profession, while simultaneously bracketing their personal beliefs and views and discovering their professional identity and voice (theme: diversity and adaptation). As they start to identify with the profession, they become increasingly aware of having to represent the profession, and to use the criticism of others as a means of improving as a professional and adopting the practices of a professional in seeking their own resources, supports, and learning (theme: maintaining the standards). These three themes are explored in more detail below.

Participants were concerned about, but not surprised by, a perception of an uneven balance of power that they sometimes felt with supervisors or teachers. Participants accepted this imbalance with tolerant resignation and as an inconsequential relinquishment of their own principles for the sake of completing the placement. As one education student stated:

“But what I felt was, even though we’re not happy about it [unconventional practice], because the power imbalance between supervisor and we don’t like any trouble, so we just do what we have to do to pass the placement.”

Participants were also mindful of their position of power over a patient, client, or child during fieldwork and felt the need to exert this power respectfully and carefully to the benefit of their client. An OT student commented, “you are in a position of power, so you use that power, if that's the right word. Just very respectfully. And carefully” (OT3; p. 3, l. 3–4).

Conversely, participants also identified, and were often surprised by, the power that clients could bring to bear on fieldwork students. Participants reported professional growth arising from these encounters such as when interacting with a client who did not want to be treated by a student:

“It's a huge challenge of placement. But then at the same time, it is a benefit of placement because you learn how to manage clients like that, you learn how to manage that kind of interaction and how you’re going to come back and develop your resilience around it and things like that.”

Participants reported that professionalism was poorly defined and inconsistently role modeled by university faculty and fieldwork placement supervisors. One education student felt that the definition of professionalism is “very subjective, because they always say it's a professional manner, and you’re like, ‘What is that?’” (ED2; p. 3, l. 23–24), capturing a tension between students’ own principles (e.g., providing patient-centered care over key performance indicators) and their understanding of what constitutes authentic professionalism (e.g., the core values of the profession).

Participants spoke of experiencing and adapting to a diverse set of cultures during fieldwork. These experiences were described as important and challenging elements, which sometimes entailed embracing difference, or required them to be simply accepted as different. Exposure to diverse communities, values, and cultures required students to adapt their own beliefs, principles, and behaviors. For example, one OT student commented:

“Sometimes you find that the things that you have to do in placement, the expectations and the professionalism of this profession is different from what your core beliefs are.”

Adjustments ranged from superficial tweaking of behaviors to align with an agency's requirements (e.g. dress code), to intricate and weighty challenges to the participant's own beliefs and principles:

“With the acute hospital, they just want people in and out, and that can be a real challenge when you’ve got these different beliefs… but part of your professionalism is following that organisation's procedures and their vision on what their healthcare model is.”

However, these tensions also promoted a view of resilience as an important and powerful part of participants’ professional identity:

“Resilience is, I guess acknowledging that there are differences and kind of just, not tolerating it, you just have to stand back up and make your professional identity known and disagree with, in a respectful and collaborative way, because otherwise you don’t move forward, and you are just stuck in the same rut. And that is not resilience. That is just passiveness.”

The tasks of adjusting, resisting, or balancing professional and personal beliefs were seen as a means of strengthening professional resilience. That is, a workplace culture could either encourage through supporting growth or, in an unsupportive and culturally unhealthy work environment, merely require students to develop their resilience as the means to cope. An SW student shared an example of the former:

“Something that comes to mind for me is the workplace culture, and if that can help foster individual resilience. So, having positive and supportive team and supervisors and a workplace that understands you as an individual in addition to the work that you do for the organisation, can help with resilience.”

While an example of an unsupportive environment was given by an OT student:

“…it can be a power imbalance between management and staff, which says ‘staff just have to become more resilient, go in a resilience course.’ I have seen that happen too often and when in actual fact it is the culture of the workplace itself, whatever that workplace is, that can be toxic. And it is not up to staff to be resilient.”

Fieldwork required students to adapt to diversity and made them aware of their role as advocates of cultural safety. They saw their own sensitivity to the cultural needs of their clients and colleagues as a key element of their professionalism:

“I think maybe you have kind of personal view about religion or maybe LGBTs or something like that. But a social worker, we really need to be very open minded and then basically see everyone as equal human beings.”

However, some of the participants reported a lack of culturally sensitive reciprocity for their own cultural differences. For example, one first-year SW student described a situation where he was told he was “being not Asian enough, just because we decide to speak up for ourselves” (SW1; p. 15, l. 40). Navigating these complexities of diversity and adaptation was seen as a central component of the fieldwork experience.

There was a strong perception that following workplace guidelines and behaving in an ethically responsible way is a desirable professional trait, despite the potential for misalignment with one's own preferences or beliefs. For example, an OT student suggested that maintaining professionalism during fieldwork is recognized by patients and others in:

“How you dress, and how you… present yourself to the people who are around you, whether they be clients or within the multidisciplinary clinical team, it's how you dress, how you have your badge, how you have your hair, all those considerations all fall under that umbrella.”

Participants also indicated that treating client data as confidential was an important element in ensuring the trustworthiness of individual students and their professional discipline. While some participants perceived this as following guidelines, others described ethical professional behavior as a value that transcended organizational requirements. One pharmacy student observed:

“…I think a big part of professionalism in our profession at least, is privacy. And pharmacists are one of the most trusted professionals. And when people come in, we need to show that we respect them, we hear them, but also that their business is staying their business. There's a lot of stuff that we come in contact to that, if it got out there, it would really upset people. They would lose trust in that particular pharmacy. I feel like, when we’re going on placements, we have to make sure that we’re upholding those privacy rules and laws and guidelines.”

This suggests that participants consider professionalism as being expressed in terms of presentation through dress, communication, and ethical, respectful practice. This complimented views around reputation – both theirs and the profession's – which often manifested in reflections on negative aspects of their performance (i.e., what went wrong). This was evident by the inward-looking critique of a third-year pharmacy student who shared that “I’m someone that's pretty critical of myself, so there's always something I feel like I need to improve on” (PH3; p. 5, l 2–3). However, such reflective practices could also be outward seeking, for instance, being open to the views of others, as expressed by a third-year OT student:

“Sometimes we’re hard on ourselves and we focus on the things we did wrong and not the things we did right. So that's part of reflective thinking as well. And getting feedback from other people as well, because sometimes the things that you see from your perspective wasn’t how other people saw what went on too. So that's important.”

Participants desired practical tools such as fieldwork handbooks and learning management system modifications to use, not only during fieldwork, but also as an aide-mémoire as they transitioned to the workforce. As a second-year education student said:

“…a handbook that you can use, it's like a bible for what you should do in placement and that kind of stuff, and how to manage possibly would really help. Something you can use throughout the university life, and then potentially even continue when you become a teacher.”

Participants also sought easy access to expert and targeted feedback from on-site supervisors, which they perceived as rare, or as one student stated, “They’re like unicorns” (ED2). A level of assertiveness was required of students to gain feedback:

“Sometimes if I want to get help, get direction for where I’m going to improve, I had to actually seek out one of my tutors and it would be nice if it was just forthcoming”

Supportive individuals and services, other than the supervisor, were also mentioned as resources for learning. For example, participants were eager for mentoring and insights from near peers:

“Maybe you can talk to the person who did a similar placement as you last year or last semester. Should they, he or she, share much experience with you, that would be very helpful.”

Greater pastoral care from universities was further seen to be an area of support that participants believed could improve the standard of their preparation for, and performance during, fieldwork:

“It would be good if [university supervisors] checked in with you before you started placement, as well. Rather than just in the middle of placement or at the end of placement. Sometimes just the anxiety of going on placement can be really, really tough. Especially that first day.”