Students in entry-to-practice occupational therapy programs throughout the world apply the knowledge gained from academic theory and practice courses while performing a minimum of 1,000 hours of supervised fieldwork (World Federation of Occupational Therapists, 2016). With instruction and mentorship from practicing occupational therapists, students receive essential training, feedback, and socialization within the professional environment to foster the development of professional competency. The provision of sufficient and varied fieldwork experiences for students has been a long-standing issue for many occupational therapy programs (Doubt, Paterson, & O'Riordan, 2004). This problem results from organizational shifts in occupational therapy employment, greater demands for productivity by occupational therapists, and increased enrollment in occupational therapy programs in Canada and other parts of the world (Casares, Bradley, Jaffe, & Lee, 2003; Thomas et al., 2007; Tiberius & Gaiptman, 1985).
In Canada, the practice of occupational therapy and other health care professions continues to be shaped by budgetary and structural reforms within the private and publicly funded health care systems. Canada has a publicly funded health care system with universal health coverage called Medicare that provides free access to physician and multidisciplinary hospital health services. Most Canadian occupational therapists work within the public/government sector, although the number of occupational therapists working in private practice has increased (Canadian Institute for Health Information, 2014). Currently, 24% of practicing occupational therapists in Canada work outside of the public/government sector (Canadian Institute for Health Information, 2014), providing services that are not covered by Medicare. However, few fieldwork placements are available in private practice, creating a gap in the opportunity for students to develop competency specific to private practice. Because the fundamental principle of fieldwork is to prepare students for practice entry, fieldwork opportunities must reflect both current and projected needs.
Private practice fieldwork placements within Canada have been scarce for many years (Sloggett, Kim, & Cameron, 2003), despite decades-old identification of the issue and some proponents extolling the benefits of these placements (Maloney, Stagnitti, & Schoo, 2013; Potts, Babcock, & McKee, 1998). To address this need, it is important to understand the factors related to the shortage of fieldwork opportunities in the private sector.
A survey of occupational therapists working in private practice in one Canadian province (Ontario) identified the following barriers to offering fieldwork education: fluctuations in caseload and time; lack of space and other resources; concerns that students are not sufficiently prepared; direct costs and loss of revenue associated with student supervision; legal considerations and liability issues; uncertainty about expectations for clinical teaching and supervision; and concerns about the quality of care and client satisfaction associated with student involvement. These barriers were similar to those identified in previous studies (Hunt & Kennedy-Jones, 2010; Kobbero, Lynch, Boniface, & Forwell, 2018; Maloney et al., 2013; Sloggett et al., 2003). In previous studies, key factors enabling fieldwork education included student skills, practitioner clinical skills and experience, and previous experience with supervising students (Maloney et al., 2013; Sloggett et al., 2003). Possible solutions to the identified challenges to fieldwork education within private practice in Ontario included: (a) offering a joint placement where students spend a negotiated amount of time with an occupational therapist in private practice and the rest of the time with another preceptor or a university mentor; (b) preparing students before placement with more in-depth education about issues specific to private practice; and (c) allowing occupational therapists in private practice to be more involved in the student selection process (Barker et al., 2014).
The current study sought to replicate the Ontario 2012 study (Barker et al., 2014) at the national level to allow for provincial comparisons and engage a larger number of private practitioners in proposing viable strategies for clinical education opportunities, perhaps reflective of geographically unique issues. The study research questions were:
What do Canadian occupational therapists working in private practice consider challenging about the provision of fieldwork placements for occupational therapy students?
What strategies would optimize the capacity of Canadian occupational therapists working in private practice to provide fieldwork placements?
Using a cross-sectional study design, Canadian occupational therapists working in private practice completed an online multiple-choice survey to clarify the challenges associated with providing fieldwork education in private practice settings and to examine their receptiveness to strategies to increase their capacity to provide placements. Private practice was defined as organizations or individual occupational therapists providing services outside of publicly funded health care, education, or social service systems. Therapists who contract their services to a third-party agency that provides services funded by publicly funded service providers were considered private practitioners. Private practitioners also provide services to third-party payers, such as Workplace Safety and Insurance Boards/Workers Compensation Boards, auto insurers, casualty insurers, providers of extended health benefits, lawyers, and employers, or they may be paid directly out-of-pocket by recipients of services.
No identifiable risks or benefits were associated with study participation, and no incentives were offered. The university research ethics boards at two Canadian universities approved all phases of the study.
The survey tool was developed based on the survey used for the 2012 Ontario study of fieldwork in private practice (Barker et al., 2014). That questionnaire was grounded in the literature and expert opinion and piloted with 17 private practitioners, with subsequent revisions before its dissemination. For the current study, the survey was revised to reflect a Canada-wide audience and was subsequently reviewed by five expert occupational therapists in private practice who were identified by occupational therapy educational programs as leaders from various regions across Canada. The experts were asked to provide input on language, terminology, and relevance to each province, and minor revisions were made based on this feedback.
The survey was anonymous, but demographic questions about years of practice, previous involvement in fieldwork education, funding sources, clientele, province, urban versus rural setting, and involvement of the private practitioner with an occupational therapy university program were included to facilitate further analysis and understanding of the survey results. Multiple-choice survey questions asked respondents to identify which potential barriers to fieldwork education were applicable to their practice setting/personal experience. These barriers included fluctuations in caseload and time available to supervise students; limited physical space and/or resources for students; concern about student capability to succeed/lack of involvement in student selection; costs associated with student supervision; legal (e.g., reluctance to include students in client care because of the high risk of situations leading to court involvement) or liability issues (e.g., third party payees' concerns about the quality of care of student-delivered therapy services); uncertainty about effective clinical teaching; and concerns about client satisfaction and quality of care with student involvement.
Respondents who identified a barrier that reflected their practice reality were asked to choose among possible solutions. The solutions included preceptor incentives, such as honoraria and status/adjunct appointments; curriculum augmentation and increased preparation for student placement; varied timing of placements; joint placement with other clinical instructors; use of student peer-assisted learning; involvement in student selection; increased student project work or involvement in other aspects of the practice, such as advertising; and provision of a preceptor handbook.
For all questions, the survey included open text boxes to allow participants to qualify their responses. An “other” response option was also provided for all questions.
In all Canadian provinces, practicing occupational therapists must be registered with their provincial regulatory college. The Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO) is the national organization of the 10 occupational therapy regulators in Canada, and ACOTRO agreed to support this research project by assisting with participant recruitment. Eight provincial regulatory colleges (British Columbia, Manitoba, Ontario, Quebec, Nova Scotia, New Brunswick, Newfoundland and Labrador, and Prince Edward Island) sent e-mail invitations to participate to registrants working in private practice or to all registrants (depending on the ability of the regulatory college to distinguish between the practice of members). The Canadian Territories do not have regulatory colleges; however, occupational therapists practicing in the Territories often register with neighboring provincial regulatory bodies. One regulatory college (Alberta) could not assist with recruitment because of its by-laws, and so in this province, participant recruitment occurred through an e-mail blast from the provincial professional association (Society of Alberta Occupational Therapists) to its members. Another provincial regulatory college (Saskatchewan) advised the primary investigator to e-mail occupational therapists listed in the publicly available Private Registry of Occupational Therapists to recruit participants. Given the diversity of recruitment methods across provinces, the exact number of potential participants was difficult to determine; however, the Canadian Institute for Health Information reported that the total number of occupational therapists working in “private sector or individual client(s),” “public/private mix,” and “other” (i.e., funding source not otherwise described) in 2014 (the most recent data available) was 2,592.
The e-mail invitations, including an information letter and a link to the online survey, were sent out in spring 2016. The survey was available to participants in both English and French, Canada's two official languages. Participants were given 4 weeks to complete the survey, and they received one reminder e-mail to encourage participation.
Quantitative survey data were analyzed descriptively through the survey tool. Frequencies, percentages, and cross-tabulations were analyzed with Stata, version 11.0 (StataCorp, 2009).
Of the 352 respondents who completed the survey, most were located in Ontario (42.3%), Quebec (22.2%), and British Columbia (19.9%) (Table 1). Most respondents worked at more than one practice site (53.4%). More respondents were independent practitioners (50.6%) than were practitioners within an organization/institution (28.2%). The remainder of respondents were in a combination of the previous categories (11.1%). Response rates by province are shown in Table 2.
Characteristics of Participants in Private Practice
Response Rate by Province
Respondent Involvement in Clinical Education
Table 3 shows that, nationally, most respondents had not been actively providing student fieldwork placement in the past 5 years. Of independent practitioners, 83% had not taken a student placement in the past 5 years, whereas 1.7% reported accepting more than five students in the same period. Nearly 60% of employees of an organization had not accepted any students in the past 5 years, whereas 6.1% had accepted more than five students in the past 5 years. The remainder had accepted one student (10.2%).
Number of Students Accepted by Respondents Over the Past 5 Years
Most respondents agreed with all suggested challenges to varying degrees, including fluctuations in caseload and time (93.5%), costs associated with student supervision (89.9%), concern about student capability to succeed (85.3%), lack of involvement in student selection (79.9%), liability issues (79.6%), concern about quality of care (79.3%), limited physical space or resources for students (78.9%), uncertainty about the preceptor role (78.9%), concern about client satisfaction (78.9%), and legal considerations (76.4%).
Table 4 lists responses to proposed solutions to identified challenges to the provision of fieldwork placements. Respondents in five regions across Canada (Ontario, Quebec, British Columbia, the Prairie provinces [Alberta, Saskatchewan, and Manitoba], and the Atlantic provinces [Prince Edward Island, New Brunswick, Nova Scotia, Newfoundland, and Labrador]) ranked joint placement as their top solution to address fluctuations in caseload and inadequate time to supervise students (chosen by an average of 51.6% of respondents across Canada). Joint placement was also the top-ranked solution to address concerns about limited physical space and/or resources to supervise students (chosen by an average of 31.3% of respondents). Similarly, joint placement was the top solution to challenges to supervising students identified by respondents who were independent practitioners, those funded by the government, and those funded by auto insurance. The provision of a preceptor handbook to clarify uncertainties about the preceptor role was the only top-ranked solution selected by respondents in all geographic regions, employment settings, and funding types.
Challenges and Solutions to Fieldwork Placements
Consistent with the findings of previous Canadian provincial research, most of the respondents had not provided a fieldwork placement (Barker et al., 2014; Kobbero et al., 2018). The finding that 75% of respondents had never provided a fieldwork placement suggests that a large number of Canadian occupational therapists potentially could provide placements if challenges within the private practice setting were addressed.
Challenges appear to remain consistent because the current respondents confirmed barriers that had been reported in previous studies (Barker et al., 2014; Hunt & Kennedy-Jones, 2010; Kobbero et al., 2018; Maloney et al., 2013; Sloggett et al., 2003). Hunt and Kennedy-Jones (2010) identified a lack of experience and the need to “get supervision right” as key issues among novice therapists. Similarly, respondents in this study expressed uncertainty about the preceptor role. Maloney et al. (2013) identified limited time and concerns about client satisfaction, and these findings were mirrored by respondents in this survey. In the United States, fieldwork educators were less inclined to accept students without foundational communication, problem-solving, and clinical skills into their practice (Hanson, 2011), and these findings are similar to the current findings regarding concerns about student capability to succeed. Previous studies also noted fluctuations in caseload, limited physical space, costs associated with student supervision, liability issues, and legal considerations (Barker et al., 2014; Kobbero et al., 2018; Sloggett et al., 2003). To increase fieldwork opportunities within the occupational therapy private practice sector, university fieldwork faculty must acknowledge these challenges and work with private practitioners to implement solutions.
This survey of the top-ranked solutions to the challenges associated with supervising students in fieldwork placements suggests that these barriers continue to be significant, despite decades of awareness of these issues. This study did not strongly support previously identified solutions, such as financial compensation, preceptor education, and involvement in student selection (Barker et al., 2014; Sloggett et al., 2003). Responses to this survey suggest that, overall, private practitioners have little confidence that augmenting the academic curriculum, engaging private practitioners in selecting students, or providing an honorarium would make a significant difference. Our findings are in congruence with other studies suggesting that there have been few guides to help university programs to design creative solutions to address the growing demand for fieldwork education (Hamilton et al., 2015; Maloney et al., 2013; Sobiechowska & Maisch, 2006). Our findings suggest that joint fieldwork placements (where students' time is shared between two therapists or between a therapist and a faculty member) could meet the needs of both the private practitioner and the university. Based on the results of the Ontario study (Barker et al., 2014), the Department of Occupational Science and Occupational Therapy at the University of Toronto developed a series of student online modules, labs, and online discussions of occupational private practice that run concurrently with a private practice placement. An online module for the preceptor on the clinical teaching role is also available. This variation of a joint placement, with the university responsible for some of the clinical teaching, especially during the first half of placement, has been used for 2 years, with students and preceptors reporting high rates of satisfaction. The findings of this study support the implementation of this fieldwork model throughout Canada.
Although joint placement was the overall top-ranked solution to identified challenges to fieldwork placements in private practice and was identified as the best solution to address fluctuations in caseload and limitations of space and other resources, this solution may not address all of the concerns that private practitioners have about supervising students. More specific analysis of the top-ranked solutions by years in private practice, funding source, and employment setting within geographic regions may identify niche strategies (such as a student-run summer day camp for children with autism in a province with little funding for this service) that could overcome specific barriers to fieldwork supervision experienced by private practitioners. Such an approach may be appropriate for future studies.
University fieldwork faculty in entry-to-practice occupational therapy programs may want to consider engaging willing private practitioners in demonstration projects to employ and test solutions on a case-by-case basis. Novel initiatives, such as having students volunteer with private practitioners before they begin a fieldwork placement (Singh, Gaya, Martin, & Barker, 2017) or having students trained to provide ergonomic assessments to fulfill a contracted service for a private practice company, can help to increase comfort and familiarity with students and the university program and highlight additional benefits of fieldwork education (Singh et al., 2017). Learning collaboratively through strategic trials may inform both practitioners and fieldwork faculty of successful variations to top-ranked solutions, effective combinations of known solutions, and potentially novel solutions learned through experience.
Occupational therapists in Canada are regulated provincially, so recruitment of private practitioners for this survey was done through those colleges. However, in one province, the private practitioners were recruited through the newsletter of the provincial professional association, resulting in poor recruitment. Because of the challenges associated with recruitment, we could not determine accurate response rates. Also, because of the anonymous study format, duplicate responses may have occurred. Finally, individual practitioners and those practicing within organizations were both categorized as private practitioners, and within-group differences were not examined.
The development of a representative proportion of fieldwork placements in private practice is a high priority if students are to gain competencies in this practice sector. However, the availability of private practice fieldwork placements in Canada remains disproportionately low. Canadian private practitioners' ranking of possible solutions to overcome challenges experienced when supervising fieldwork placements identified no solutions but favored the implementation of joint placements to overcome many of the identified barriers.
In a subsequent study, we will examine the facilitators and barriers to accepting students in occupational therapy private practice with regression analysis, which may identify opportunities to tailor supervision parameters to types of private practitioners or perhaps identify alternate supervision models. Because fieldwork experiences may shape graduates' future employment decisions (Crowe & Mackenzie, 2002; Rodger et al., 2007) and as the number of occupational therapists in private practice increases (Canadian Institute for Health Information, 2014; Kobbero et al., 2018), it is crucial that fieldwork faculty and private practitioners collaborate to increase available private practice fieldwork placements. Future trials of possible solutions to overcome barriers to private practice fieldwork placements are needed, and the authors welcome commentary and possible collaborations on strategies to increase fieldwork opportunities in private occupational therapy practice.
- Barker, D., Stack, R., Miller, C., MacEwen, H. & Rappolt, S. (2014). Enhancing fieldwork opportunities within private practice settings. Occupational Therapy Now, 16(6), 20–22.
- Canadian Institute for Health Information. (2012). Occupational therapist workforce, 2012. Retrieved from https://secure.cihi.ca/estore/productSeries.htm?pc=PCC375
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- Casares, G. S., Bradley, K. P., Jaffe, L. E. & Lee, G. P. (2003). Impact of the changing health care environment on fieldwork education: Perceptions of occupational therapy educators. Journal of Allied Health, 32(4), 246–251.
- Crowe, M. J. & Mackenzie, L. (2002). The influence of fieldwork on the preferred future practice areas of final year occupational therapy students. Australian Occupational Therapy Journal, 49(1), 25–36. doi:10.1046/j.0045-0766.2001.00276.x [CrossRef]
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- Kobbero, T. K., Lynch, C. H., Boniface, G. & Forwell, S. J. (2018). Occupational therapy private practice workforce: Issues in the 21st century. Canadian Journal of Occupational Therapy, 85(1), 58–65. doi:10.1177/0008417417719724 [CrossRef]
- Maloney, P., Stagnitti, K. & Schoo, A. (2013). Barriers and enablers to clinical fieldwork education in rural public and private allied health practice. Higher Education Research & Development, 32(3), 420–435. doi:10.1080/07294360.2012.682255 [CrossRef]
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Characteristics of Participants in Private Practice
|Location of practice (n = 352)|
| British Columbia||70||19.9|
| Nova Scotia||19||5.4|
|Setting (n = 350)|
| Combination of rural and urban||144||41.2|
|Years of occupational therapy experience (n = 350)|
| > 20||114||32.6|
|Work arrangement (n = 348)|
| Independent practitioner||176||50.6|
| Employee of an organization||98||28.2|
| Sole proprietor||35||10.1|
|Employment status (n = 348)|
|Years of work experience in private practice (n = 351)|
| > 20||37||10.5|
|Client population (n = 661)|
| Older adults||166||25.1|
| School age||140||21.2|
Response Rate by Province
|Province||n||Estimated number of private practitioners by jurisdictiona||Response rate|
|Quebec||78||Not applicable||Not applicable|
Number of Students Accepted by Respondents Over the Past 5 Years
|Variable||n||Number of students accepted|
|0 (%)||1 (%)||2–5 (%)||> 5 (%)|
|Geographic region of practice|
| British Columbia||68||75.0||10.3||11.8||2.9|
| Atlantic Canadab||23||95.6||0||4.4||0|
| Independent practitioner||174||83.3||8.6||6.3||1.8|
| Employee of an organization||98||59.2||10.2||24.5||6.1|
| Sole proprietor||35||84.8||6.1||6.1||3.0|
| Private insuranced||12||70.6||17.7||8.8||2.9|
| Auto insuranced||93||79.6||5.4||11.8||3.2|
Challenges and Solutions to Fieldwork Placements
|Variable||Fluctuations in caseload and time||Lack of physical space and/or resources||Concern about student capability to succeed||Costs associated with student supervision||Liability issues||Uncertainty about preceptor role||Concerns about client satisfaction||Concerns about quality of care||Legal considerations|
|Geographic region of practice|
| Ontario||Joint placement (51.6)||Joint placement (31.3)||Augmenting curriculum (31.1)||Joint placement (27.6)||Preceptor handbook (38.0)||Preceptor handbook (39.8)||Joint placement (45.5)||Increased student preparation (29.7)||Joint placement (28.7)|
| Quebec||Joint placement (54.4)||Joint placement (27.4)||Augmenting curriculum (32.6)||Joint placement (23.9)||Joint placement (23.6)||Preceptor handbook (54.3)||Increased student preparation (26.7)||Increased student preparation (33.7)||Increased student preparation (31.9)|
| British Columbia||Joint placement (50.4)||Joint placement (29.0)||Involved in the student selection process (26.0)||Provide honorarium (27.4)||Joint placement (31.7)||Preceptor handbook (41.6)||Joint placement (35.8)||Joint placement (42.2)||Joint placement (33.7)|
| Prairies||Joint placement (52.3)||Joint placement (37.8)||Increased student preparation (29.3)||Joint placement (30.9)||Involved in the student selection process (30.4)||Preceptor handbook (36.7)||Involved in the student selection process (26.8)||Increased student preparation (26.7)||Increased student preparation (23.3)|
| Atlantic Canada||Joint placement (47.8)||Joint placement (26.8)||Increased student preparation (24.4)||Joint placement (26.4)||Involved in the student selection process (25.0)||Preceptor handbook (39.1)||Joint placement (46.9)||Joint placement (44.1)||Joint placement (32.0)|
| Self-employed||Joint placement (51.1)||Joint placement (29.3)||Augmenting curriculum (23.8)||Joint placement (26.8)||Joint placement (27.7)||Preceptor handbook (39.0)||Joint placement (34.5)||Joint placement (36.2)||Joint placement (29.9)|
| Employee of organization||Joint placement (54.1)||Joint placement (31.9)||Augmenting curriculum (27.6)||Joint placement (29.8)||Joint placement (29.7)||Preceptor handbook (42.0)||Joint placement (43.4)||Joint placement (27.7)||Increased student preparation (35.3)|
| Other||Flexibility with placement timing (45.2)||Outlining student requirements (38.1)||Structured placement (50.0)||Student involvement with business development (48.3)||Increased student preparation (34.8)||Fieldwork orientation workshop (63.2)||Joint placement (45.0)||Joint placement (54.6)||Completion of project (37.5)|
| Sole proprietor||Flexibility with placement timing (34.5)||Outlining student requirements (62.5)||Structured placement (46.7)||Student involvement with business development (55.2)||Structured placement (44.4)||Fieldwork orientation workshop (52.4)||Offer discounted services (42.3)||Offer discounted services (47.8)||Completion of project (48.0)|
|Funding by sector|
| Public/government||Joint placement (47.9)||Joint placement (35.7)||Involved in the student selection process (30.4)||Joint placement (32.5)||Joint placement (34.1)||Preceptor handbook (43.8)||Joint placement (26.2)||Joint placement (25.7)||Joint placement (31.3)|
| Private insurance||Joint placement (54.2)||Joint placement (36.8)||Augmenting curriculum (33.3)||Joint placement (31.0)||Increased student preparation (28.6)||Preceptor handbook (50.0)||Increased student preparation (36.8)||Joint placement (43.8)||Increased student preparation (50.0)|
| Auto insurance||Joint placement (56.5)||Joint placement (31.4)||Augmenting curriculum (26.3)||Joint placement (26.2)||Joint placement (33.6)||Preceptor handbook (42.5)||Joint placement (38.7)||Joint placement (40.3)||Joint placement (33.3)|