‘i'm allowed to experiment’: the role of people with psychiatric disorders in facilitating...

‘I’m allowed to experiment’:The role of people with psychiatricdisorders in facilitating students’learning

MICHAEL LYONS, Faculty of Medicine and Health Sciences, The Universityof Newcastle, Australia

JENNY ZIVIANI, The University of Queensland, Australia

Abstract: Fieldwork education brings students into close contact with the people whouse occupational therapy services and is an important avenue for socializing studentsinto professionally accepted views of, and behaviours towards, these people. Draw-ing on narrative data from a naturalistic study of nine Australian occupational ther-apy students’ fieldwork experiences in psychiatric hospital settings, this paperexplores the role of people with psychiatric disorders in facilitating students’ learning.Two terms are used by the authors to represent students’ understanding of these people for educational purposes, namely, as learning resources and as demonstrationmodels. From students’ narratives, examples of the attributes they sought to acquireand demonstrate through involvement with people with psychiatric disorders are dis-cussed. There are indications from these data that students’ educational needs mayfoster a view of people with psychiatric disorders as objects in the service of students’learning.

Key words: fieldwork education, socialization, mental health, psychosocialoccupational therapy.

Introduction

Fieldwork has been described as ‘the crucible of the [occupational therapy]profession’ (Tompson and Ryan, 1996, p. 65) – in the sense that, during field-work, students’ theoretical knowledge is coupled with practical experiencewith patients or clients to forge a sense of professional identity and ability(Cohn, 1989; Shepherd, 1991). Educators expect students to learn a great dealabout many things during fieldwork – for example, about healthcare servicesand occupational therapy practice on the one hand, and about human experi-ence and personal value systems on the other. Among all the valuable learn-

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ing outcomes that educators anticipate for students, there are likely to besome unplanned (and even unintended) consequences: part of what has beentermed the ‘hidden curriculum’ (Atkinson, 1983, p. 229).

Our purpose in this paper is to explore a small but important manifestationof the hidden effects of fieldwork education practices on students’ learningabout people with psychiatric disorders. The data being discussed arose from astudy by the first author (ML) of some undergraduate occupational therapystudents’ fieldwork experiences in psychiatric settings. The choice of psychi-atric settings as the study context was prompted by the first author’s interestin students’ perceptions of people with disabilities, particularly disabilitiesthat are commonly regarded as highly stigmatizing, as is the case with psychi-atric disabilities (Wolfensberger and Tullman, 1991). What is more, bothauthors are occupational therapy educators who possess a strong interest instudents’ socialization into occupational therapy through the medium of field-work education.

Socialization into occupational therapy

‘At the centre of the process of becoming [an occupational therapist] isacquiring the identity and outlook of a particular type of health professional’(Jongbloed and Crichton, 1990, p. 36). The term ‘socialization’ has been usedto describe this process of ‘social development and the acquisition of attitudes,values, and behavioural orientations’ (Mechanic, 1990, p. 96) central to theprofession.

A good deal of students’ professional socialization in fieldwork settings issaid to be implicit and has been likened to ‘a process of osmosis’ (Tompsonand Ryan, 1996, p. 69). At the same time, students are not simply passivelearners, merely absorbing what is presented to them; they also seek andrespond to learning experiences in accordance with their own goals andexpectations (Stroot and Williamson, 1993). What is more, their fieldworklearning runs the gauntlet of an array of demands ranging from supervisors’performance expectations, through patients’ or clients’ needs and require-ments, to the demands of students’ personal lives beyond the fieldwork setting(Tompson and Ryan, 1996). It is apparent that the socialization process is‘complex, with multiple dimensions impacting upon each individual attempt-ing to find his or her place in the world of [the profession]’ (Stroot andWilliamson, 1993, p. 343).

Socialization and professional values

The principal focus of the literature regarding socialization into the healthprofessions has been on medical education. Medical educators, being key play-ers in the socialization of medical students, regard the development of profes-sional values and ethics as important educational objectives (Mitchell et al.,

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1992). However, as Shapiro (1989) has noted, there is a considerable litera-ture that indicates that medical students become more cynical and lesshumanitarian as they progress through medical school. This has been attrib-uted to conflicting messages, within the curriculum and from faculty, aboutmatters of professional orientation (for example, regarding the importance of adeep-seated concern for fellow human beings). Doubts have been expressedabout the capacity of medical students who are not taught in a humanisticlearning environment to bring such qualities to bear in their future relation-ships with patients (Wolf et al., 1991).

Within some sectors of the occupational therapy profession, considerableemphasis has been placed on students’ being open to learning from patients’or clients’ views about the nature of quality professional service (Sabari,1985; Neistadt, 1987). This position is espoused for its regard for people asactive, responsible participants in the rehabilitation process (a fundamentalvalue of client-centred practice) (Larson and Fanchiang, 1996). Beyondsuch ideals, students must also cope with the complexities of the clinicalworld, including demands for high productivity and rapid patient turnover, agrowing emphasis on financial accountability for therapists’ use of theirtime, and the likelihood of interprofessional conflict within the healthcareteam (Wittman, 1990). What is more, students on fieldwork also face thepressure of being observed and evaluated by fieldwork educators (Swinehartand Meyers, 1993).

A priority for students on fieldwork is to satisfy fieldwork educators’requirements for skilled and professional performance. Such performanceappraisal encourages students to engage in impression management (that is,calculated actions designed to promote a positive image of themselves or atleast to prevent negative impressions being formed) (Ashford and Northcraft,1992). This combination of factors may create considerable anxiety for students, which may have a substantial impact on their attention topatient/client service in the face of potentially competing educationaldemands.

Serving students’ educational needs

Within the fieldwork learning context, patients or clients have an importantrole to play (Mitchell and Kampfe, 1990; Shepherd, 1991). They serve aslearning resources (that is, a source of learning and skill acquisition for stu-dents), and as demonstration models (that is, a means whereby studentsdemonstrate their competencies to supervisors for the purposes of evaluation).

In interpreting data from this study, the representation of people with psy-chiatric disorders as learning resources and as demonstration models appearedto be useful in conveying certain aspects of the study informants’ understand-ing of the patients/clients whom they encountered. These conceptualizationsare by no means presented as indicative of all students’ fieldwork experiences,

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embedded as they are in particular temporal and spatial contexts. Indeed, theyshould not even be taken as representing the totality of the study informants’understanding of the people with psychiatric disorders whom they encoun-tered during fieldwork. The study informants’ perceptions were influenced bymany factors, giving rise to a greater complexity of understanding than we canconvey in this paper. Within these limitations, these data do provide anopportunity for reflection on aspects of the professional socialization of occupational therapy students – including some possibly unforeseen aspectsthat occupational therapists may wish to address in the light of espoused values of service to patients/clients.

Method

These data were drawn from a naturalistic investigation of the fieldwork expe-riences of a group of junior and senior undergraduates at an Australian occu-pational therapy school. An abbreviated account of procedures in the conductof the research study is presented here. Further details were given in Lyonsand Ziviani (1995).

Informants

These data were gathered from nine female occupational therapy students in alarge city on the eastern seaboard of Australia. All of the informants wereundertaking fieldwork in psychiatric hospital settings, both short-stay andlong-stay facilities.

Data collection

The primary technique used for collecting data on informants’ experienceswas unstructured (and later semi-structured) interviewing (Bogdan andBiklen, 1992). Typically, informants were interviewed by the first author onfour or five occasions, each lasting about an hour. With informants’ permis-sion, the interviews were audiotaped to provide for increased accuracy in cap-turing their words: the essence of what Maxwell (1992) has termed thedescriptive validity of their accounts.

To strengthen what Maxwell (1992) has termed interpretive validity (orthe accuracy of interpretation of informants’ perceptions), participantobservation was incorporated as a means of triangulating data gathering.Most of the participant observations were conducted around therapy groupsin which informants were playing a major role, for example, discussiongroups, exercise and relaxation groups, and cooking groups. Typically, thefirst author undertook one participant observation session with each infor-mant, lasting from 30 minutes to 3 hours, from which detailed field noteswere then prepared.


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Data analysis

The narrative data from interviews and observations were analysed inductive-ly. Analysis began while data collection was still under way, that is, data werebeing subjected to preliminary inspection and comparative analysis (Henwoodand Pidgeon, 1992). Furthermore, to maximize the trustworthiness of ourinterpretation, member checking was routinely used (Krefting, 1991), so thatinformants were questioned concerning our evolving interpretations of theirfieldwork experiences. When data collection was complete, the data were sub-jected to a detailed coding using concepts arising from the data – both indige-nous concepts (that is, those used by informants such as ‘the occupationaltherapy role’ and ‘being professional’) and sensitizing concepts (that is, thosedeveloped by the researchers such as ‘values’ and ‘student role behaviour’)(Patton, 1990). Issues emerging from this coding process were then groupedinto themes, some of which have been discussed elsewhere (Lyons, 1996).

Results

People as learning resources

Students on fieldwork are keen to acquire the skills of occupational therapypractice (Kautzmann, 1987). Thus, one of the meanings that students mayattribute to patients or clients is that of being learning material – like a livingtextbook, a means (of learning) to an end (of greater competence). For example:

I’m more concerned about what’s going to happen because of the lack of referrals, Ithink. Maybe when they come, I’m just going to be getting anyone that is referred,rather than a good case or something that I would really learn from. (Jo)

I’d like the opportunity to try the treatments that I’m interested in, like running arttherapy groups and using some ideas that I’ve read about. Just having the opportunity todo what I think I like and see if I do like it or if I can handle it. (Hannah)

People may have been viewed by students as an opportunity to pursue cer-tain interests in learning or to practise particular skills. This was most pro-nounced in informants’ comments made early in their affiliation, perhapsbecause additional priorities emerged as students progressed through the affili-ation. At the same time, even if students’ learning imperatives were diluted asother realities of the fieldwork setting were manifest, they were apparent tothe end. For example, one student complained at the end of her affiliationthat its shortness (7 weeks) had frustrated her zest for learning from patients.

What was it that students sought to learn (and/or valued once they hadlearned) from their dealings with patients/clients? Several examples of skills orattributes that students placed value on acquiring are discussed: confidence withindividuals, mastery with groups, and powers of observation and judgement.


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A sense of confidence in one’s dealings with people one to one

Accompanying students’ quest for professional competence is a striving forconfidence in dealing with patients or clients. Feeling confident makes assum-ing a position of authority much easier. In cases where students were not per-forming to an expected level of competence, predictably their sense ofconfidence suffered. Informants reported differing experiences with supervisorsregarding their failures, presumably a function not only of supervisory style butalso of many other factors including the extent of and importance attributed tothe perceived incompetence. For example, one informant, Hannah, found herconfidence gravely undermined by her supervisor’s responses to her perfor-mance with groups of patients. On the other hand, Sophie’s difficulties in oneaspect of her work prompted a more supportive response, namely:

I had a bit of trouble in the beginning with initial interviews. Other places I’ve been to,I’ve just skipped over them; but they’ve given me extra practice with different peopleand it’s been good. I think I’ve improved a lot in that, which will be good anywhere Iwork. (Sophie)

Supervisors may arrange for students to have patients on whom to practisein order to meet students’ needs for learning about assessment. In a similarvein, patients may be assigned to students as a means of their learning aboutproblem solving in accordance with the occupational therapy process. Forexample:

[These patients are] just a bit difficult I guess and we haven’t sat in on any individualtreatments with any of the other therapists. So we don’t have any idea of what’s accept-able for individual treatment or not. They sort of told us that anything goes, whateverwe think is needed, but it’s sort of hard to know where to start. I know I’ve got one ladywho’s very suicidal and just has no motivation to get better and I don’t know where tostart with her. (Rosie)

Rosie’s experience suggests that some patients are presented to students inthe manner of a complex exercise to be puzzled over – with a view that notmuch harm can be done. Clearly students have to learn to problem-solve and toact independently of supervision. What they learn of the value of service users’time and, more importantly, their welfare in the course of these activities is notclear from these data. If students perceived a possible conflict with patients’needs or priorities in such circumstances, this was not apparent in their com-ments to the researcher. Perhaps they assumed that their supervisors would beattentive to any such issues in arranging these learning opportunities.

A sense of mastery in dealing with groups of people

The process of occupational therapy practice involves working with peoplenot only individually but also within groups. Psychiatric practice, more so


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than other practice arenas, emphasizes the group context and the skills of‘group work’ (Willson, 1988). Some students spoke enthusiastically of thegroup work learning opportunities available in certain settings. For example:

I think we will get really good experience. Like, you go to a big hospital, you’re lucky toget people in a group. You might plan a whole group and only one person will turn up.Here, you can be assured of a full room every time. They kind of have to come; it’s partof the rules. I think we’ll get a lot more experience, especially with groups. (Karen)

For other students, the realities of working with groups of patients weremore than they had bargained for. They struggled to master ‘adaptive’ strate-gies for coping with unexpected or undesired responses from patients:

If the patients are falling asleep or not looking at me, that makes me think ‘Oh, they’renot interested in what I’m saying’ and I just lose confidence. I was talking to [the OTsupervisor] and she said ‘That’s something that you build up with practice. You becomemore confident and you believe in what you’re saying and don’t worry as much abouthow the patients react to what you’re saying.’ (Hannah)

Although they were presumably not the only group work skills to be mas-tered, there was none the less a prevailing sense of the importance of certainskills by which students maintained control over group members. Informantsplaced a great deal of emphasis on learning to exert their professional authori-ty, in the interests of achieving certain pre-established goals. Part of the learn-ing process with patients, identified by some students, included becomingsufficiently confident to disregard individuals (at least some of the time) whenthey did not react in acceptable or expected ways.

Powers of observation of, and judgement about, the human condition

Informants perceived that part of the therapist’s skill that they must acquire is tobe able to observe people’s behaviour through professional eyes. For example:

We went into the city and had a cup of coffee and a bit of a stroll around the shops witha few of the ladies in the group. . . . It was good practice of observation because I had tokeep an eye on how they appeared to be feeling. (Rosie)

Such observation is regarded as a form of patient assessment of such mat-ters as the level of their pathology, their responsiveness to intervention, ortheir readiness for discharge. The student observer has to learn to ascertainthe significance of people’s actions, from a professional perspective. How dostudents achieve this perspective? They do so by modelling from their super-visors. For example:

If I observe something, then I’ll comment about it [in a report]. But I depend on [thesupervisor’s] experience with them to say ‘Oh, that’s really good’ or ‘Did he really?’ I’mfinding I’m able to pick up more information that’s really pertinent to that person. I


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mean that might be influenced by what [the supervisor] sees as important; but I meanthat’s all I can rely on. I haven’t got my own experience to rely on. (Chia)

Under this model of the novice learning from the expert, students learnthe parameters that define what is or is not important about people’s behav-iour. Students learn to see people as patients through the eyes of an occupa-tional therapy professional, and to express what they see using professionaljargon. Important elements of this professional gaze discussed by informantsincluded various typologies to describe patients, including their psychiatricdiagnoses, the duration and severity of their disorder (for example, acute,chronic), and their perceived level of motivation to engage in treatmentactivities. Although these professional typological understandings of peoplewere obviously very important to acquire and use in fieldwork settings, someinformants expressed the belief that they had also become more attuned tothe individuality of people as a result of fieldwork contact. This seemed mostapparent in association with nonclinical contact with people with psychiatricdisorders (for example, through social activities such as outings and camps).

It can be seen that, in keeping with the educational mission of the field-work settings where students were placed, a notable feature of the presenta-tion of patients was as a means of satisfying students’ own learning needs:

I’ve enjoyed the relaxation groups because I haven’t been supervised, basically, and I’mallowed to do what I want. I’m allowed to experiment without fear of being jumpeddown on afterwards. (Hannah)

Although students may provide useful service to patients in the course oftheir fieldwork education, it appears that sometimes student education maytake precedence over the patient/client service goals of mental health agen-cies. One informant, Nancy, recounted with some dismay an example of thisduring her fieldwork in a hospital psychiatric ward. She reported takingpatients on several outings from the ward, not for these people’s sake but sothat they would be out of the way while psychiatrists-in-training undertooktheir professional exams with a few, selected ward patients. The same studentexpressed other concerns about a mismatch between student education andquality patient service:

It’s like when you come into practice striving to get to know everybody, and when youget to know everybody, it’s time to leave. So you don’t get to know what it’s like tohave people comfortable with you and you with them; and then do therapy or activitiesor talk to them. (Nancy)

For the informants in this study, their fieldwork was structured in short,intense affiliations of 7 weeks’ duration. The educational rationale for this isto allow students to obtain a breadth of experience in a variety of practice set-tings. In Nancy’s view, however, the shortness of the affiliation precluded herfrom developing effective relationships with people using the service. Infor-mants talked a good deal about the development of rapport with patients as


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crucial to the effectiveness of their intervention. These data raise some ques-tions, therefore, about the effects of the use of people as learning resources onstudents’ perceptions of patients and ultimately on patients’ welfare, whichwill be discussed later in this paper.

People as demonstration models

Within the context of student learning, people with psychiatric disorders mayfunction not only as resources for learning by doing but also as living modelsfor the purposes of demonstration. People may be selected by supervisors asillustrative of particular human attributes or circumstances. During their field-work affiliation, students will in turn be expected to demonstrate their profi-ciency in responding to these attributes or circumstances (when studentsundergo the process of assessment).

[Our supervisors] are looking for patients who aren’t too hard for a student to handle;they haven’t got too many complex problems; one that is good for OT treatment, likeall the areas that an OT would be interested in, that they’re having problems with; andthe patients have to agree to be handled by a student. They can’t be too chronic; theywant the students to be able to see some change. So [there are] a number of criteria andthey’re finding it hard to find people who fit all of these. (Hannah)

Hannah here spoke of patients being handpicked by her supervisorsbecause they demonstrated certain ‘problems’ of interest to an occupationaltherapist, at a level that students can handle and that will be responsive tochange within the short space of a 7-week placement. This is understandableeducational practice in aiming to promote students’ skill acquisition anddevelopment of confidence.

Examples of ways in which people were used for purposes of demonstration,within the realms of students’ fieldwork experience, include exhibiting perfor-mance capacity, and meeting academic requirements.

Exhibiting one’s capacity to meet minimum requirements

When students undertake fieldwork, supervisors often set certain goals forthem to reach within specified periods over the course of the 7 weeks. Forexample:

Well, in the guidelines they said like ‘You’ll end up taking control of a minimum of twopatients or something like that; ‘At least write two good reports’ or something. (Sophie)

Whereas standards of performance quality are hard to define, quantitystandards may be more easily specified. Thus, patient numbers managed by astudent become a demonstrable measure of performance outcome. As withother aspects of expected fieldwork behaviour, students may struggle to learnthe rules of this numbers game. For example:


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Karen and I thought we had to spend an hour or at least half an hour with our individ-ual patients a day. At the moment, we’ve only got three so we were only just able to dothat. But [the supervisors] were talking about giving us more and we didn’t know whatto do, where we would fit them all in. They just said ‘No, you’re looking at it in thewrong way’ and cleared it up. They said we really have to spend only five minutesmaybe, following up how they’re going every day. (Rosie)

The use of numbers as a performance criterion for students may well be areflection of the system operating for staff in the service, where statistics arekept on the number of patient contacts as a primary means of service evalua-tion. How informants perceived the issue of the quality of outcomes was notapparent from their comments.

Meeting academic assessment requirements

While on fieldwork, students may be required to meet several academicrequirements. One such requirement for these informants was that they com-plete what is called a ‘case study’ on one of the people with whom they wereinvolved. This required that students record considerable detail about thisperson’s life (particularly regarding his or her deficits and problems) and aplan for occupational therapy intervention, in accordance with universityguidelines. The intention of the case study was clearly an academic one forthe purposes of grading students. Any benefits that accrued to the person whowas the subject of the case study were outside the realms of consideration ofthis academic exercise.

It appears, then, from informants’ comments that most of the use of peopleas demonstration models related to satisfying assessment requirements.Although it is presumed that supervisors would be sufficiently attentive toprevent students from acting in a harmful manner, at the same time the prin-ciple of allowing students to engage people in therapy without the primaryintent of enhancing their wellbeing should be questioned. For example:

Well, I’m still running that group. I’ve got my last day on tomorrow. And the feedbackthat I’m getting now is that I’m not very good at it but I’m not bad enough to take meaway. I’m not hurting the patients any but I’m not helping them by running the group. . . . Yeah, I think that I have done better than my supervisors thought I would do run-ning the groups; they really thought I was going to bomb out terribly with them. But Ihaven’t done that and I’ve stuck in and kept doing it. I feel pretty proud of myself thatI’ve stuck to it. (Hannah)

In Hannah’s opinion, her supervisor was allowing her to be kept occupied.The prevailing view seemed to be that, worthwhile service or not, as long asHannah was not causing any harm she could continue to work with thesepatients. Thus, the conceptualization of patients as demonstration models didnot appear to account for the time, energy and wellbeing of the patients ashuman beings. Some ramifications of students’ dealings with people as learn-ing tools and demonstration models will now be considered.


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Discussion

These data raise concerns about some presumably unintended, though poten-tially serious, consequences of fieldwork education practices on students’ per-ceptions of people with psychiatric disorders. From informants’ comments,there is a sense in which people may become objectified (Lieberman, 1989) aslearning and demonstration material. This may occur for such purposes asdeveloping interview skills, refining powers of observation, applying problem-solving strategies, mastering specific intervention techniques, managinggroups of people, and generally enhancing students’ sense of confidence intheir abilities.

This was most apparent in one informant’s account of being encouraged tooverlook patients’ unfavourable reactions to her group programme. Ratherthan question the effectiveness of her approach with people, this student feltdisposed to interpret the situation uncritically in terms of these patients’ recal-citrance. This disposition towards self-affirmation, in the face of unfavourablepatient reaction, suggests a professional stance of unquestioned superiority(that is, whereby professionals are assumed to know what is best for serviceusers) (Fulcher, 1989).

There were many instances when people seemed to be offered to studentsas if they were complex puzzles to problem-solve; students were expected tonegotiate their own way through the puzzle, with minimal assistance. Innocu-ous as the experience may be for these patients, the image conveyed to stu-dents is one of students’ rather than patients’ needs as the primary factorbehind the exercise. Even if the supervisor saw great benefit for the patient,this did not seem to emerge as an issue to be considered in some of the scenar-ios conveyed by informants.

On occasions, such as when students’ efforts with patients were not beinghighly regarded by supervisors, the time, energy and wellbeing of the patientsdid not seem to be highly regarded either. Students might be allowed toremain occupied as long as they were considered not to be doing any harm.Even in cases where supervisors are monitoring students’ progress, the ques-tion remains: would we place someone of importance to us (for example, aloved one or a famous, powerful person) in the hands of a young student andtell him or her to ‘go and work it out’?

Regarding the evaluation of their performance, informants identified theimportance of target numbers of patients being ‘seen’ by them as a primaryperformance criterion used by supervisors. From informants’ accounts, a simi-lar degree of attention to the quality of time spent with patients was not iden-tifiable. There was here a sense of the patients as a commodity and thenumbers of them serviced as a student’s output. Yerxa et al. (1990) decried the‘assembly line mentality’ of healthcare systems where occupational therapistsbecome like ‘treatment machines’ and patients are ‘products’ to be ‘displayedon a balance sheet’ (p. 2).


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Even the structure of short fieldwork placements was regarded by someinformants as working to the detriment of building rapport and effectiveworking relationships with people with psychiatric disorders. The experienceof having to leave the fieldwork setting just when a student has got comfort-able with a patient, however, is one that echoes the broader context of thechanging healthcare systems in many Western countries with an acute careemphasis. Betz and O’Connell (1983) noted the general tendency for long-term, personalized relationships between health professionals and patients tobe replaced by short-term, less personal interactions.

Indeed, given students’ and their supervisors’ understandable preoccupa-tion with students’ learning experiences, informants had surprisingly little tosay about learning from patients’ own narratives. With the attention currentlybeing paid to patients’ narratives within the occupational therapy literatureon clinical reasoning (for example, Kautzmann, 1993; Peloquin, 1993; Frank,1996), it would seem reasonable to expect students to be more attuned to theview of patients as knowledgeable about their lives and having much to teachstudents about their world.

Conclusion

This paper has explored the issue of how fieldwork education processes mayhave an impact on occupational therapy students’ perceptions of people withpsychiatric disorders using their services. It is important to acknowledge thelimitations of the data from which this paper is derived. The few informants(nine) from one occupational therapy school were all placed in hospital set-tings. Data gathered at the same time from students in community mentalhealth settings might have suggested a somewhat different picture in the faceof a more client-oriented culture. This could prove an enlightening researchdirection to follow for what it may reveal about the interaction of fieldworkcontext with students’ perceptions of people with psychiatric disorders.

A major influence on students’ interactions with people with psychiatricdisorders is a set of educational goals established for each student. The wholefieldwork scheme in the context of this study was a practical learning exercisefor students during their last two years of undergraduate education. Many ofthe tasks assigned to them, particularly those related to dealing with servicerecipients, are intended to provide a learning experience. Furthermore, super-visors may create artificial learning situations with people (that is, beyondthose occurring naturally or routinely) whereby students can practise specificskills or demonstrate their competence for the purposes of assessment.

To return to the metaphor of patients as living textbooks: within the limi-tations of this representation, there is still something to be gleaned about theissue under discussion. Patients, like books, carry the fruits of a wealth ofhuman experience and wisdom. We and our students can learn much that isimportant and useful from the people we serve, as from the books we read. As


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occupational therapists, we talk about the science of practice coupled with theart. At the forefront of our art is the therapeutic relationship; and our experi-ence of life tells us that the relationships that work best are founded on mutu-al respect. Further research into the nature of students’ contact with and theformation of their beliefs about the people they serve is warranted.

These data have raised questions about the propensity for a primary focuson students’ fieldwork learning needs such that only secondary attention maybe paid to the interests of those people using the services of the fieldworkagency. It is most important that occupational therapy educators do not fostera mindset where, to paraphrase Marshall McLuhan (1964), the medium ofoccupational therapy fieldwork education is the message to students that ser-vice recipients’ needs do not come first after all.

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Address correspondence to Michael Lyons, Associate Professor and Head, Discipline of Occu-pational Therapy, Faculty of Medicine and Health Sciences, The University of Newcastle,Callaghan NSW 2308, Australia. Email: mlyons@medicine. newcastle.edu.au


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