Apprehension and interest Therapist and student views of the role emerging placement model in the Republic of Ireland

Purpose – Role-emerging placements have been used internationally within occupational therapy education but are relatively new to Ireland. At times, there has been a debate in the profession regarding the use of this placement model. This paper aims to generate views from both occupational therapists and occupational therapy students on the use of role-emerging placements in the Republic of Ireland. Design/methodology/approach – Electronic surveys were administered to occupational therapy students and occupational therapists in Ireland. Quantitative data were analysed using the SPSS Statistics software package and the content of the open question responses were analysed into themes. Findings – Occupational therapists (n = 60) and occupational therapy students (n = 45) indicated that there were inconsistent views surrounding role-emerging placements. It is deemed as an effective method for student learning, but apprehension exists around inclusion within occupational therapy programmes in the Republic of Ireland. Preference was indicated towards inclusion of role-emerging placements on a part-time basis within formal occupational therapy education. Originality/value – Both respondent groups viewed that role-emerging placements can positively influence new areas of occupational therapy practice and concern over the use of the placement model requires further exploration and debate. This study is from an Irish context, although there are similarities with other countries’ use of the placement model. There is a need for research through an in-depth exploration of the learning experience of undertaking role-emerging placements from the students’ perspective and identification of supports required to promote an optimal learning experience.


Introduction
Role-emerging placements are described as taking place in a non-traditional setting where there is no occupational therapist currently employed.Students receive on-site supervision from an employee of the host organisation and are supported through distant supervision from an occupational therapist (Wood, 2005).
As documented in the literature, the use of role-emerging placements is not a new phenomenon internationally.Such placements have been discussed and incorporated into occupational therapy professional qualification for decades (Friedland et al., 2001) with encouragement for the revival of the placement model since the 1990s (Alsop and Donald, 1996).In relation to the Irish context, service learning with community organisations is well established in some university programmes, with the University of Limerick commencing their first full-time role-emerging placement as part of the graduate entry master's programme in 2009 (Warren et al., 2010(Warren et al., /2011)).Currently, there are restrictions on the timing (only to occur in the second half of professional programmes) and a limit of hours allocated to this placement model on programmes in Ireland (maximum of 300 of the 1,000 placement hours) [Association of Occupational Therapists of Ireland (AOTI), 2010].

Literature review
A review of the literature highlighted the use of this placement model in North America (Bossers et al., 1997), the United Kingdom (Alsop and Donald, 1996;Clark et al., 2014a;Thew et al., 2008;Wood, 2005), Australasia (Rodger et al., 2009;Thomas et al., 2005) and Ireland (Warren et al., 2010(Warren et al., /2011)).Craik and Turner (2005) propose that new ideas for practice education provision are necessary within occupational therapy.Students require preparation for diverse and challenging working environments (Huddleston, 1999).The World Federation of Occupational Therapists (WFOT) developed practice education standards to include settings that do not have an on-site occupational therapist (Hocking and Ness, 2002) and globally role-emerging placements are being incorporated into occupational therapy professional programmes.It is important to note that there are different models of role-emerging placements in terms of how the supervision is structured and delivered (Thew et al., 2011).
Several reasons for the development of such placements have been highlighted (Clarke et al, 2014a).An increase in the amount of occupational therapy students resulting in a greater demand for placements (Thomas et al., 2005).Also, the shift from traditional hospital based positions to community settings (Cooper and Raine, 2009;Friedland et al., 2001;Quick et al., 2010;Strong et al., 2003;Thomas et al., 2005) has reduced the availability of practice education sites for students (Casares et al., 2003).
Role-emerging placements have both positive as well as challenging aspects.Research, mainly qualitative in nature, into the experiences of students who have completed roleemerging placements highlight areas of growth including greater independence, understanding the complexity of collaborative working (Dancza et al., 2013), beneficial preparation for future practice (Bossers et al., 1997), increased confidence in abilities (Thew et al., 2008), the opportunity to be creative (Mulholland and Derdall, 2005) and linking theory to practice (Fieldhouse and Fedden, 2009).More personal reflective, descriptive accounts revealed that students through doing a role-emerging placement further developed their own professional identity while also developing the skills to work independently (Alecock, 2010;Kinghorn et al., 2006).Students viewed their experiences as an opportunity to grow in confidence (Alecock, 2010;Marson, 2007), develop core clinical skills (Anderson et al., 2010;Hook and Kenny, 2007;Kinghorn et al., 2006), deepen their understanding of the profession (Doherty and Stevenson, 2009;Jamieson, 2009) and develop communication skills (Chandler, 2010).
Challenging aspects with this placement model include a lack of appreciation for nontraditional skill development (Friedland et al., 2001), feelings of isolation (Cooper and Raine, 2009;Wood, 2005), the settings' lack of understanding of the profession (Hook and Kenny, 2007) and the lack of structure to supervision (Mullholland and Derdall, 2005).Other noted issues were role blurring (Chandler, 2010), the lack of an existing occupational therapy Role emerging placement model process (Anderson et al., 2010), the emotional reactions of students (Dancza et al., 2013) and unrealistic expectations of the students (Thew et al., 2008).Healy (2006) expressed that a main aim of having student placements in role-emerging setting is to create links between services and the profession.Overton et al. (2009), from a critique of the literature, also stated that these placements provide students with a chance to take the profession to new areas and are consequently laying out the future for occupational therapy practice.Occupational therapy practice education experiences influence the job preference of graduates (Lee and Mackenzie, 2003;Simhoni and Andersen, 2002;Thomas et al., 2007) and likewise role-emerging placements have resulted in the development of occupational therapist positions (Kearsley, 2012;Overton et al., 2009;Thew et al., 2008).Therefore, it is important to investigate new, emerging areas of occupational therapy practice through the use of innovative placement models.
Overall, there is a scarcity of research and published information surrounding the perspectives of the use of occupational therapy role-emerging placements in Ireland.This study aimed to investigate occupational therapists' and occupational therapy students' perceptions of the strengths and challenges of role-emerging placements and whether a roleemerging placement should be part of occupational therapy programmes in Ireland.

Design
Descriptive research is valuable for highlighting explanations and areas for further research (De Vaus, 2014).The method of a self-completion survey was used in this particular study as data were required from a large group of respondents from a wide geographical area (David and Sutton, 2011).A national survey was chosen, as role-emerging placements were relatively new to Ireland at the time of the survey; therefore, a wider scope of respondents was required.

Surveys
The survey had mainly quantitative elements with some open-ended questions to provide an opportunity for both research groups to expand on their responses in text boxes.This method was used, as much of the current literature surrounding the topic of role-emerging placements is mainly qualitative and this research aimed to generate views from a larger sample of occupational therapists and occupational therapy students.The surveys were developed with key themes from the literature and from one of the author's experience of developing and supervising with role-emerging placements.To eliminate bias surrounding interpretation of a "role emerging placement", a definition was provided within the survey.
Both surveys began by accruing basic demographic information for example gender, background of qualification of occupational therapists and for the occupational therapy students, number of placements completed.Closed questions focused on the experience and opinions of role-emerging placements followed by open ended questions allowing respondents to elaborate and add any additional comments at the end of the survey.Two separate surveys, one for occupational therapists and one for occupational therapy students, were used and distributed electronically through the use of an internet-based survey tool: Survey Monkey (Survey Monkey, 2010).The same questions were used in both surveys to aid in the comparison of results with any differences relating specifically to qualified occupational therapist roles.As experience in completion of a role-emerging placement within Ireland is limited, an exclusion criterion for participation within the study was omitted as the research aimed to gain an overall view of opinions.

IJOT 45,1
Quantitative data were analysed through coding using the SPSS statistics package version 16.0 (Pallant, 2007).Closed question responses included both categorical and ordinal forms.These were then coded and comparisons were made where appropriate between both research groups.In relation to the open-ended questions, the responses were collated and analysed to highlight similarities and differences in the key themes emerging from the data (Silverman, 2010).

Reliability and validity
A survey was specifically designed for the purpose of this study, as there was no existing survey which addressed the study aims.The surveys were piloted with two occupational therapists and two occupational therapy students, to evaluate the data collection tool and to increase its internal validity (De Vaus, 2014).From the pilot testing, there were no suggestions made to address any ambiguity and so the original survey was used in this study.Reliability was increased through using non-ambiguous terms within the survey and the inclusion of a definition of a role-emerging placement to avoid interpretation bias.

Respondents
The occupational therapists were accessed via the system established by the Association of Occupational Therapists of Ireland (AOTI, 2014) to access members for the purpose of research.A description of the research and a cover letter containing the survey link was emailed by AOTI to all of the occupational therapists on their database who had agreed to take part in research (n = 150).In relation to the student respondents, an email providing information about the study and containing a link to the online survey was emailed to the practice education co-ordinator within each of the four universities in the Republic of Ireland who deliver occupational therapy programmes.A total population of 420 occupational therapy students were sent this survey.In an attempt to enhance the response rate, a reminder email was sent to both research groups approximately two weeks after the initial email.

Ethical considerations
Ethical approval was obtained from the Clinical Therapies Research Ethics Committee, University of Limerick.In relation to consent, both occupational therapists and occupational therapy students were informed through the introductory email that by completing the electronic survey, this provided evidence of their consent and the data collated was anonymous.

Results
The following section displays the results derived from the completed questionnaires of both the occupational therapists and occupational therapy students who took part in the study.The results include the views of role-emerging placements as well as some demographic information on the respondents.

Demographic information
A total number of 60 therapists: 51 female/8 male (1 unaccounted for) and 45 students and 44 female/1 male completed the online surveys.The occupational therapists qualified from a number of countries including Ireland, England, Australia, the Philippines, India, South Africa, Zimbabwe and the USA.Their length of time from graduation ranged from those newly graduated to those qualified over 20 years.Eleven of a possible 60 occupational Role emerging placement model therapists had completed a role-emerging placement.Just under half of the occupational therapists (n = 26) had been employed to establish a new occupational therapy service, although the majority were in traditional occupational therapy settings.
The student research respondents had completed from one to four placements.In total, 25 of 45 students were interested in completing a role-emerging placement.Two occupational therapy students had already completed a role-emerging placement in Ireland.Following from this, the students and therapists were questioned on their views of the effectiveness of roleemerging placements on the development of occupational therapy students and whether such a placement should be part of the occupational therapy professional qualification.Figures 1  and 2 display the responses.Figure 1 indicates the broad and varied views of the perceived effectiveness of roleemerging placements from both occupational therapists and occupational therapy students.In Figure 2, both groups of respondents were asked whether the role-emerging placement should be a part of the occupational therapy professional qualification in Ireland with the majority responding negatively to this suggestion.
Following on from this question, respondents were asked whether they thought such a placement should be full time or part time.There was a poor response rate to this question, but both occupational therapists (n = 24) and students (n = 11) indicated a preference for part-time role-emerging placements (Figure 3).
The majority of respondents viewed role-emerging placements as positively influencing the development of the profession into emerging areas of practice.Occupational therapy students were interested in completing role-emerging placements with a range of populations including the homeless, refugees, teenager mothers and within mental health settings.
Analysis of the open-ended questions led to benefits and concerns relating to role-emerging placements.

Benefits
Commonly viewed benefits of involvement with role-emerging placements expressed by both occupational therapists (n = 37) and occupational therapy students (n = 41) fell under the subcategories of gains for students, the profession and the wider community.
The majority of occupational therapists and occupational therapy students expressed gains for students including putting new theory into practice, the opportunity to be more creative, to develop evidence-based practice, increased independence, diversity of experience, the development of skills and developing their understanding of the occupational therapy role:

Role emerging placement model
It would be a great opportunity for an OT student to hone skills which will be utilised when they begin work as a basic grade (Student 28).
Some occupational therapists and occupational therapy students expressed gains for the profession through promotion leading to the development of new areas of practice and new occupational therapy post: Emerging areas of practice tend to be practiced before they are officially recognised.This is the nature of the evolution of the service.It is essential to its' development (Therapist 3).
Several occupational therapist and occupational therapy students iterated gains for the wider community through meeting the needs of clients, highlighting the needs of the community and in some cases providing health promotion interventions.

Concerns
Concerns expressed by occupational therapists (n = 47) and occupational therapy students (n = 41) related to supervision, role challenges and the setting generally.
The majority of occupational therapists and students had concerns related to supervision including the lack of a role model onsite and observation of a qualified occupational therapist."Imagine a doctor being supervised by a radiographer or the hospital administrator" (Therapist 39).
The difficulty in grading students was raised and the lack of clear goals established for the placement.Learning style suitability and that the student may not be practicing in the correct way was also expressed as a challenge.The role-emerging placement is viewed as one which should not be undertaken in the early years of a programme.Concerns were raised that students may be missing out on developing basic occupational therapy skills and the solitary nature of the placement was highlighted to be testing: One of the biggest challenges of the role-emerging placement was the lack of direction on the ground (Student 10).
The majority of occupational therapists and occupational therapy students expressed concern that students experience difficulty finding the appropriate role within the setting.Some occupational therapists and students highlighted issues including role conflict and that the non-occupational therapist supervisor may lack the ability to reflect on occupational therapy expertise.Concern was raised that the setting may not fully understand the role of occupational therapy and may have false expectations of the student.Some occupational therapists and occupational therapy students expressed concerns relating to the placement setting including communication difficulties between all the parties involved, the lack of structure to the placement, limited client contact and the quality of the role-emerging setting overall.

Discussion
While almost two-thirds of respondents to the survey held strong views that role-emerging placements should not be completed as part of occupational therapy programmes in Ireland, the majority acknowledged that there are benefits to the use of the placement model.This was mainly evident in the open-ended questions which highlighted value in students linking theory into practice, being creative and independent that could positively influence their development and supports findings from previous research (Clarke et al., 2014b).Interestingly, a sizable proportion of the occupational therapy students (25/45) surveyed expressed that they would be interested in completing a role-emerging placement if the possibility arose.This survey also highlighted a preference for part-time role-emerging IJOT 45,1 placements which is already used in occupational therapy programmes in the UK and Canada (Thew et al., 2011).
A benefit of the role-emerging placement as highlighted through this study is diversity of experience.This is a requirement for placement experience as outlined by the WFOT in the standards for practice (Hocking and Ness, 2002).There is discussion within the literature supporting flexibility in the types of practice education experiences provided for students (Bossers et al., 1997;Doherty et al., 2009;Huddleston, 1999), thus equipping students with the skills necessary for future practice (Rodger et al., 2007;Thomas et al., 2005).Occupational therapy education needs to focus towards preparation for modern practice challenges and students that experience alternative placement models may expand their vision for career opportunities (Knightbridge, 2014).
Respondents indicated a reluctance to incorporate role-emerging placements into professional education which was also noted by Huddleston (1999) in the United Kingdom.An area of concern raised by therapists' and students' groups within this study included the possibility that the student through completing a role-emerging placement may be missing out on the development of core occupational therapy skills due to a lack of direction and limited client contact.Similar concerns were raised by Friedland et al. (2001) where students who had completed a role-emerging placement viewed skills acquired in the community setting to be of lesser value to skills acquired in more traditional settings.
The lack of an on-site occupational therapist was also expressed by the research respondents due to the lack of a role model or access to supervision.This was also evident in research by Cooper and Raine (2009) and Mullholland and Derdall (2005).This implies that other professionals or staff in the organisations are not viewed as potential role models for occupational therapy students which contrasts with the values of interprofessional education of learning through cross-disciplinary opportunities.In line with statements from regulators of the profession, it is essential that occupational therapy students have access to occupational therapists for professional supervision, but their competency development can be supported by others including service users.Research into the use of role-emerging placements has demonstrated that students develop as critical, reflective thinkers who can problem solve (Dancza et al., 2013;Thew et al., 2008) which is essential for working as a professional in the twenty-first century (Doncaster and Lester, 2002).Through being too apprehensive about using the placement model, it could stifle the competency and capability development of occupational therapists and lead to the profession overlooking-emerging areas of practice.
The issue of misinterpretation of the role of the student and of occupational therapy by the placement setting was found to be a concern by these respondents.This view was supported by Hook and Kenney (2007) where students commented on the role-emerging settings lack of understanding of the occupational therapy role which can be resolved through discussion of expectations when preparing sites for placements and the implementation of relevant guidelines (COT, 2006;Warren, 2011).Although there is apprehension over the use of role-emerging placements, a growing body of research has highlighted the strengths of the placement model (Clarke et al., 2014a).Where there is concern that students may not have a clear understanding of the occupational therapy role, it may be useful to only have role-emerging placements when students have already completed placements.This is the case in the Republic of Ireland where students can only experience a role-emerging placement in the second half of the programme (AOTI, 2010).Although it could be suggested that this may reduce the student's creativity in applying their interpretation of occupational therapy theory in new contexts if already influenced by previous placement experiences.

Study limitations
The findings from this survey cannot be regarded as representative, as sampling bias must be acknowledged in this research, as the occupational therapists and students who completed the survey may have strong views on the use of role-emerging placements.Also, there was a low response rate by students (45/420) which may have improved with a more extensive pilot of the survey to add clarity, as it was not a requirement to have completed a role-emerging placement to participate in the survey.This research identified some benefits to be harnessed if using role-emerging placements, but it is important to note that these comments are based on minimal exposure or experience of the placement model due to only 11 occupational therapists and two students actually experiencing the placement model during their professional programme.The therapist and student views were also included to gain insights into views on this placement model to move beyond anecdotal discussion.This study is only from within an Irish context, although there are similarities with other countries use of the placement model.A further limitation of the survey tool led to the inability to differentiate between those respondents who had completed a role-emerging placement and those who had not leading all data being consolidated into either a student or therapist response.
Although a definition of role-emerging placement was provided within the study, ambiguity around the use of terms within the survey such as "effective", "strengths" and "challenges" may have led to interpretation bias.

Implications for education research and practice
Through this study occupational therapy students in Ireland have expressed interest in undertaking a role-emerging placement which should be supported by educational institutions to provide a range of placement experiences which has the potential to influence career choice and the expansion of the profession.
Further research into the in-depth experience of undertaking a role-emerging placement from the students' perspective would be valuable.Such research may highlight areas in which students could be supported to promote an optimal learning experience.A survey to establish current and emerging areas of occupational therapy practice in Ireland would also be of benefit for both student learning and the development of the profession to reach a wider community.
Role-emerging placements fit well with current trends in higher education in Ireland that focuses on community engagement, promoting creativity and innovation (Hunt, 2011).These aims of higher education are universal and often begin with service learning which has been incorporated into many occupational therapy programmes.Role-emerging placements can be another educational method to connect with the focus of community engagement and promoting entrepreneurial approaches by graduates.In order that the placement model is successful, all stakeholders need to be prepared, supported and involved in regular reviews of placements.Following relevant guidelines on the introduction of roleemerging placements can reduce the replication of mistakes and assist in setting out clear expectations and learning outcomes (COT, 2006;Warren, 2011).As with any placement, the structure and quality requires regular review.

Conclusion
This research highlighted that occupational therapists and occupational therapy students' views encompass both gains and apprehensions regarding role-emerging placements.There are undoubtedly concerns surrounding the topic and it is important that these views are raised and addressed in a professional forum to facilitate more IJOT 45,1 understanding surrounding the topic.Change is occurring within health care and such change requires a focus on preparing occupational therapy students for diverse practice to reach a wider community.
Occupational therapy has the opportunity to emerge into new areas of practice and create new posts in diverse settings with the use of this placement model.If roleemerging placements continue to be underused in Ireland and other countries then, opportunities to expand and develop the profession in new areas will have been missed and student learning opportunities lost.
Figure 1.Perceived effectiveness of roleemerging placements Figure 3. Role-emerging placement influence on emerging areas of practice