Content uploaded by Kathleen Melei
Author content
All content in this area was uploaded by Kathleen Melei on May 13, 2021
Content may be subject to copyright.
Content uploaded by Kathleen Melei
Author content
All content in this area was uploaded by Kathleen Melei on Jul 05, 2020
Content may be subject to copyright.
#;<,-6;7<96)47. ++<8);176)4$0-9)8@#;<,-6;7<96)47. ++<8);176)4$0-9)8@
&74<5- ::<- 9;1+4-
$0-"-4);176:018-;>--64;-96);1=-1-4,>7938897)+0-:)6,$0-"-4);176:018-;>--64;-96);1=-1-4,>7938897)+0-:)6,
#;<,-6;758-;-6+-)6,76B,-6+-.79 ++<8);176)4$0-9)8@16#;<,-6;758-;-6+-)6,76B,-6+-.79 ++<8);176)4$0-9)8@16
-0)=179)4-)4;0-0)=179)4-)4;0
);09@6-+3:;-16
<6;16/;76%61=-9:1;@
*-+3:;-1630<6;16/;76-,<
41A)*-;091;;76
<6;16/;76%61=-9:1;@
*91;;76-0<6;16/;76-,<
7,--74*@
<6;16/;76%61=-9:1;@
+74*@+0<6;16/;76-,<
);04--6-4-1
<6;16/;76%61=-9:1;@
5-4-130<6;16/;76-,<
514@"-05-4
<6;16/;76%61=-9:1;@
9-05-4-0<6;16/;76-,<
#--6-?;8)/-.79),,1;176)4)<;079:
7447>;01:)6,),,1;176)4>793:);0;;8::7)9<:)-,<:27;
!)9;7.;0- ++<8);176)4$0-9)8@75576:
"-+755-6,-,1;);176"-+755-6,-,1;);176
-+3:;-1691;;7674*@-4-1"-05-4-:;#$0-"-4);176:018-;>--6
4;-96);1=-1-4,>7938897)+0-:)6,#;<,-6;758-;-6+-)6,76B,-6+-.79 ++<8);176)4$0-9)8@16
-0)=179)4-)4;0
#;<,-6;7<96)47. ++<8);176)4$0-9)8@
0;;8:,7179/
'(#
$01:9;1+4-1:*97</0;;7@7<.79.9--)6,78-6)++-::*@# "%#;0):*--6)++-8;-,.7916+4<:17616
#;<,-6;7<96)47. ++<8);176)4$0-9)8@*@)6)<;0791A-,-,1;797.# "%#79579-16.795);17684-):-
+76;)+;:7)9<:)-,<-97*16:76<:)-,<
$0-"-4);176:018-;>--64;-96);1=-1-4,>7938897)+0-:)6,#;<,-6;$0-"-4);176:018-;>--64;-96);1=-1-4,>7938897)+0-:)6,#;<,-6;
758-;-6+-)6,76B,-6+-.79 ++<8);176)4$0-9)8@16-0)=179)4-)4;0758-;-6+-)6,76B,-6+-.79 ++<8);176)4$0-9)8@16-0)=179)4-)4;0
<;079:<;079:
);09@6-+3:;-1641A)*-;091;;767,--74*@);04--6-4-1514@"-05-4)6,#)9)-:;
<;079: ",-6;1B-9
);09@6-+3:;-16 0;;8:79+1,79/
41A)*-;091;;76 0;;8:79+1,79/
7,--74*@ 0;;8:79+1,79/
);04--6-4-1 0;;8:79+1,79/
514@"-05-4 0;;8:79+1,79/
#)9)-:; 0;;8:79+1,79/(
$01:)9;1+4-1:)=)14)*4-16#;<,-6;7<96)47. ++<8);176)4$0-9)8@0;;8::7)9<:)-,<:27;=741::
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
The Relationship Between Alternative Fieldwork
Approaches and Student Competence and Confidence for
Occupational Therapy in Behavioral Health
Kathryn Beckstein Elizabeth Britton Codee Colby
Kathleen Melei Emily Rehmel Sara Best
Huntington University
DOI: https://doi.org/10.46409/001.BWXS8816
To cite this article:
Beckstein, K., Britton, E., Colby, C., Melei, K., Rehmel, E., & Best, S. (2021). The relationship between
alternative fieldwork approaches and student preparedness for occupational therapy in behavioral health.
Student Journal of Occupational Therapy, 2(1), 21-52. https://doi.org/10.46409/001.BWXS8816
Author Note: We have no known conflict of interest to disclose. Our work was supervised by Dr. Sara
Best, OTD, CAS and Dr. Kathleen N. Bergman, PhD.
This article is licensed under the Creative Commons Attribution, Non-Commercial license (CC-BY-NC 4.0). You
are free to copy and distribute the work under the following terms: You must give appropriate credit and include a
link to the original work. This cover page or a standard citation including the DOI link will meet this term. You
must also include the link to the CC-BY-NC license. You may not use the material for commercial purposes.
Abstract
Purpose: The purpose of this case-series study was to assess the relationship between three instructional
methods that fall within the parameters of the revised Accreditation Council for Occupational Therapy
Education fieldwork objective C.1.9 and perceived student competence and confidence in providing
therapy services in a behavioral health setting.
Methods: The study included a convenience sample of (n=49) graduate students enrolled in an entry-
level Doctor of Occupational Therapy program and a Doctor of Physical Therapy program in the
Midwest. The participants attended a presentation on bipolar disorder and were randomly assigned to
engage in one of three instructional methods: (a) lived experience academics, (b) problem-based
learning, and (c) standardized patients to further learn about bipolar disorder.
Results: Analyses revealed no significant interaction effects on competence across instructional methods
but did reveal significant main effects of group and time on confidence. Confidence increased across all
instructional methods and exhibited a significant difference between the lived experience academics and
standardized patient.
Significance: The study results demonstrate a need for further research on how to best prepare
occupational therapy students for behavioral health settings.
Keywords: confidence, competence, behavioral health, psychosocial, occupational therapy, student
preparedness, fieldwork, lived experience academics, standardized patient, problem-based learning
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Introduction
While occupational therapy (OT) practitioners
now work in a wide variety of settings with
individuals across the lifespan, the foundation of
the profession embodied mental health as a valued
component of practice (Brown & Stoffel, 2011;
Creek & Lougher, 2008). Psychiatrists and
physicians of institutions allowed participation in
tasks such as gardening and crafts after identifying
individuals experiencing depression and other
mental health ailments displayed fewer symptoms
when engaged in meaningful activities (Creek &
Lougher, 2008). Today, OT interventions target
cognitive impairments; sensory needs; and
difficulties with activities of daily living (ADLs),
instrumental activities of daily living (IADLs), and
social interactions (Swarbrick & Noyes, 2018).
Despite the identified role of OT in mental health,
the American Occupational Therapy Association
(AOTA) (2019) reports that as of 2014, only 2.4%
of OT practitioners work in mental health settings.
A limited pool of OT practitioners may pose as a
barrier in obtaining clinical fieldwork experience
within mental health settings.
To meet the need for more fieldwork experiences
within mental health, the 2020 Accreditation
Council for Occupational Therapy Education
(ACOTE) standards included revisions for C.1.7,
which currently require at least one fieldwork
experience (either Level I or Level II) to address
practice in behavioral health or psychological and
social factors influencing engagement in
occupation (ACOTE, 2018). The council also
revised standard C.1.3 to include a psychosocial
objective to all fieldwork experiences. Lastly, a
revision of fieldwork objective C.1.9 was
included, expanding the current Level I fieldwork
experiences to include additional instructional
methods, such as simulated environments,
standardized patients, and faculty practice (AOTA,
2019).
As mentioned above, the changes to fieldwork
requirements expand OT programs’ ability to
create individualized Level I experiences to best
prepare students to provide OT services in
behavioral health settings. According to Knecht-
Sabres et al. (2013), “[OT] programs prepare
students for practice through didactic course work,
experiential learning opportunities, and fieldwork .
. . OT academic programs have modified the
curricula to better prepare students to address the
current demands of fieldwork and clinical
practice” (p. 1). The current study assessed the
relationship of specific instructional methods that
satisfy the ACOTE Level I requirements and
student preparedness for fieldwork and clinical
practice, specifically the outcomes involving
competence and confidence in understanding the
role of OT practitioners in mental health.
Occupational Therapy and Mental Health
The expansion of fieldwork objectives further
asserts the role of OT in mental health by
differentiating between psychosocial and
behavioral health. Throughout education and
fieldwork, psychosocial is an “interrelation of
behavioral and social factors” (Martikainen et al.,
2002, p. 1091). Whereas, behavioral health, the
historical foundation of OT, “refers to
mental/emotional well-being and/or actions that
affect wellness” (Substance Abuse and Mental
Health Administration, 2014).
According to the National Board for Certification
in Occupational Therapy (NBCOT) (2018)
executive summary of the 2017 practice analysis,
46.8% of OT practitioners who provided
psychosocial services reported addressing anxiety,
36.5% addressed behavioral disorders, and 20.3%
addressed mood disorders. The OT practitioners
who participated in the NBCOT study were in the
field for three years or less (NBCOT, 2018).
Blackwell and Bilics (2017) found that while
programs address the role of OT in schools and
mental health settings, students report limited
experiential learning opportunities. With limited
experiential learning and few OT practitioners
working in mental health settings, programs need
to provide additional instructional methods
regarding behavioral health.
Educational Philosophy for Preparing
Students in Behavioral Health
Limited experience and exposure to OT practice
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
within behavioral health settings inhibit the OT
profession's ability to progress toward an increased
prevalence of practitioners working in behavioral
health settings. Ikiugu and Schultz (2006)
discussed the "identity problems" many OT
practitioners struggle with amidst unclear
expectations and occupation-based goals. Breines
(1987) suggests that OT programs must recognize
that curricula should change and adapt while also
maintaining the profession's foundational beliefs
and principles. OT programs can provide a more
comprehensive definition of OT and professional
identity by maintaining the balance between
curriculum development and the profession’s
foundations. (Breines, 1987). Thus, the recent
opportunity to expand level I fieldwork
requirements poses a unique opportunity to define
OT practitioners' role in mental health.
The philosophy of pragmatism serves as a useful
tool for OT programs to guide students' education
and practice in behavioral health. Breines (1987)
suggested the educational philosophy, values
subjective experiences within one's environment to
apply and test ideas that can lead to social or
personal action. While fieldwork experiences
cultivate a lived, subjective experience, they must
also provide a supportive environment to put ideas
into action and interact with "both human and non-
human" components (Ikiugu & Schultz, 2006, p.
92). OT programs facilitate student preparedness
by using various traditional and alternative
fieldwork experiences based on the
aforementioned educational philosophy.
Fieldwork
Programs must evaluate current fieldwork
experiences before considering additional
instructional methods to maximize students’
clinical skill development. Primary challenge areas
for students included critical thinking and
responding, engaging in hands-on technical skills,
and adjusting to the fast pace and complexity of
clinical practice (Knecht-Sabres et al., 2013). A
study conducted by Crowe and Mackenzie (2002)
evaluated the importance of the OT student
fieldwork experience. The initial research found
that individuals who had a positive fieldwork
experience were more likely to explore careers in
that specific population and setting (Crowe &
Mackenzie, 2002). However, students were less
prone to explore settings in which a negative
fieldwork experience took place. Crowe and
Mackenzie (2002) concluded with fieldwork
playing an integral part in introducing students to
practice areas, and potentially shaping their
practice preference, the contribution of fieldwork
experiences with academic curriculum should be
further researched.
Value of Clinical Experience
Fieldwork plays a critical role in students’ learning
and career paths. Clinical practice is fundamental
to education in providing students with
opportunities to develop cultural awareness,
professional reasoning, and technical skills
(Rodger et al., 2011). However, providing readily
available, standardized, measurable, and high-
quality placements has been found to be difficult
(Rodger et al., 2011; Quail et al., 2016). As a
result, present research typically focuses on new
fieldwork models to prepare students. Some
research suggests placements—whether
traditional, virtual, or simulated—all result in
similar outcomes for students’ communication
skills, knowledge, and confidence (Quail et al.,
2016). Similarly, Roger et al. (2011) suggested the
type of placement did not determine the quality,
but whether the placement met a variety of
criteria. The criteria included optimal and
individualized learning, therapist and student
communication, feedback and support, and a
balance between supervision and autonomy
(Rodger et al., 2011).
Value of Alternative and Additional
Fieldwork Experiences
Despite the value of clinical experience, evidence
supports alternative or additional instructional
methods to prepare students (Schaber et al., 2010;
Rowe et al., 2012; McGee & Sopeth, 2015).
Blended learning is the “systematic integration of
online and in-person support between student,
educator, [and] resources” (Rowe et al., 2012).
Blended learning provides a wide variety of
learning experiences such as small groups, web-
based discussion boards, reading, online classes,
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
practical sessions, and out of class discussions.
Studies have revealed that the use of blended
learning equips students with the necessary
experiences and resources to achieve desired
outcomes (Rowe et al., 2012; McGee & Sopeth,
2015; Schaber et al., 2010). Though many models
exist for clinical education, blended learning
provides opportunities to use and explore a variety
of alternative instructional methods such as: lived
experience academics, problem-based learning,
and standardized patients.
Lived Experience Academics
Lived experience academics (LEA) is one
alternative instructional method that can be
implemented as a model for clinical education.
Ridley et al. (2017), defined LEA as “a form of
expertise that represents a person’s experience of
mental distress, service use, and recovery” (as
cited in Byrne, 2013, p. 372). A study conducted
in Australia analyzed how social work students
perceived mental health problems before and after
the LEA session and how the students could apply
LEA to clinical practice (Ridley et al., 2017).
Students reported the LEA revealed a stronger
understanding of recovery and acceptable
terminology. Most students revealed the LEA
redirected preconceived notions about individuals
with mental health conditions (Ridley et al., 2017).
In Australia, interest is increasing on recovery-
focused services within the mental health field
(Happell et al., 2015). Research analyzed nurses
and lived-experience educators’ perceptions of the
effects of LEA in Australian universities. Results
revealed a primary theme of fear and power with
three subthemes of facing fear, demystifying
mental illness, and issues of power. Although
there is a relation to fear and working with a
mental health population, involving individuals
with lived experience exposes students to the
unique challenges that individuals face with
mental health problems and recovery (Happell et
al., 2015).
Problem-Based Learning
Another alternative instructional model is
problem-based learning (PBL), based on real-life
situations and allows students to gain competence
utilizing resources, reasoning, and problem-
solving skills (Scaffa & Wooster, 2004).
Following a quasi-experimental study by Scaffa
and Wooster (2004), the researchers identified a
statistically significant increase in students’
overall self-perception on clinical reasoning skills
and behaviors as a result of PBL instruction. PBL
requires students to evaluate clients’
environmental contexts and personal components
to encourage integrative learning as opposed to
memorization (Scaffa & Wooster, 2004).
According to Evenson (2011), PBL methods
significantly increased with students’ perceived
confidence in searching and appraising research
evidence in a client case analysis assignment
(Evenson, 2011). Knecht-Sabres et al. (2013)
found the use of standardized patients and
problem/case-based learning activities can
improve the students’ readiness and preparedness
for fieldwork and clinical practice.
Standardized Patient
Combining the approaches of problem-based
learning and lived experience academics, the use
of a standardized patient can be implemented.
Standardized patients are simulated or actual
patients who portray a specific condition or illness
creating an opportunity for students to gain
clinical practice through a simulated case.
(Knecht-Sabres et al., 2013). Simulated
environments allowed students to make mistakes
in a nonthreatening environment and learn from
the experiences (Knecht-Sabres et al., 2013).
Students identified synthesizing information from
clinical coursework and applying it to a medically
complex simulated patient as a helpful method to
prepare for Level II fieldwork and clinical practice
(Giles et al., 2014). Standardized patients may be
used to teach students communication and clinical
skills (Quail et al., 2016). Overall, simulation
using clinical interaction with a trained actor or a
computer-generated virtual patient resulted in
improved outcomes equal to traditional interaction
with a live person (Quail et al., 2016).
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Additional Instructional Methods,
Confidence, and Competence
Ultimately, the goal of the LEA, PBL, and
standardized patient methods are to equip students
with both competence and confidence in clinical
practice. Cohn (2019) referenced Land and Ross
(1998), describing competence as an ability to
complete a task effectively and to provide quality
interventions (Cohn, 2019). The researcher further
defined confidence as a mind-set related to self-
efficacy, wholeheartedness, and action (Cohn,
2019). In her 2019 Eleanor Clarke Slagle Lecture,
Ellen S. Cohn asserted the significance of
competence and confidence for the profession of
occupational therapy. She stated, “to communicate
confidently the grand narrative of our competence,
we need to be role models and mentors for each
other. we must reinforce our belief in the value of
occupation. . . take chances, and try something
new” (Cohn, 2019, p. 9). This statement affirms
the need to advocate for fieldwork experiences
where OT practitioners’ presence is limited,
particularly in behavioral health settings. Cohn
(2019) argued that competence is not what holds
one back, but confidence. While many programs
prepare students for competence, often preparation
for fieldwork experiences do not focus on
confidence development.
Programs that implement new, additional
instructional methods may support the
development of competence and confidence
through providing a variety of individualized and
unique experiences directly related to clinical
practice. Pittman and Lawdis (2017) suggest
online, multifactorial training increased students’
level of confidence and competence with
implementing interventions. Similarly, Dickinson
et al. (2016) stated students who received a high-
fidelity patient simulation in conjunction with a
lecture demonstrated an increase in understanding,
confidence, and competence of the given topics.
With competence and confidence combined,
students are empowered to problem solve,
communicate, and advocate for the profession of
occupational therapy. Further research is needed to
explore the relationship between confidence,
competence, and additional instructional methods
such as the LEA, PBL, and standardized patients
to prepare students for behavioral health settings.
Current Study
The current study aims to evaluate the relationship
of an LEA, PBL, and use of standardized patients
on student competence and perceived confidence
to provide OT services in behavioral health
settings. The literature suggests LEA, PBL, and
the use of standardized patients are effective
methods to benefit students’ clinical reasoning
skills, improved perceptions of performance, and
overall interpersonal skills (Quail et al., 2016;
Ridley et al., 2017; Scaffa & Wooster, 2014).
However, limited research exists in applying
alternative instructional methods within OT
programs’ curricula. The methods utilized within
the study, overall, aim to create additional
Fieldwork I opportunities for a Doctor of
Occupational Therapy (OTD) program in the
Midwest to successfully provide students with
more diverse, accessible, and in-depth experiences
in areas of emerging practice.
Methods
Participants
Following the approval of the institute’s
institutional review board (IRB), participants were
recruited via flyers posted around campus, e-mails,
and classroom presentations. Inclusion criteria
consisted of a convenience sample of OTD and
Doctor of Physical Therapy (DPT) students
enrolled in selected programs in the Midwest who
had not yet begun the Level II fieldwork OTD
requirement or full-time clinical DPT internship.
Exclusion criteria included any student who had
started the Level II fieldwork requirement as an
OTD student or the terminal full-time clinical
internship experience as a DPT student. The
inclusion and exclusion criteria were developed
based on students’ inability to utilize alternative
instructional methods to fulfill the Level II
fieldwork requirement; therefore, the inclusion
criteria were limited to students who are currently
able to benefit from alternative instructional
methods.
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Instruments
Pre-test and post-test questionnaires (see
Appendix B & C) were developed based on
information from multiple sources on OT and
mental health. A pilot study was conducted with a
current OTD student. The pre-test consisted of
demographic data that asked participants their
previous experiences in behavioral health,
undergraduate degree, and fieldwork placements.
Both the pre-test and post-test evaluated
competence and confidence to assess student
preparedness. Initially, the survey was accessed
online, but during data collection, the survey had
to be accessed through paper copies due to a
system malfunction (see limitations). The
participants’ level of competence was measured
using multiple-choice questions created by a
registered OT practitioner. Students responded to
ten Likert scale statements, rating their confidence
along a five-point scale. Statements measured the
level of confidence with various skills such as
therapeutic use of self, developing a plan of care,
and applying interventions.
Procedures
Participants were required to sign a consent form
(see Appendix A) prior to participating in the
research study and were informed that
participation could be voluntarily terminated at
any time. Participants were provided a schedule
which included a timeline of the two-hour session
and were then randomly provided a number that
would evenly distribute them across the three
instructional method groups. Based on participant
volume, participants were randomly split into two
different rooms to receive the lecture. Both lecture
groups received the same lecture, read directly
from PowerPoint notes, and explored OT
practitioners’ role in behavioral health and
evidence-based interventions that addressed a
bipolar disorder diagnosis. Following the
completion of the lecture, participants completed
the pre-test. Participants then attended their
assigned instructional method, which further
addressed the bipolar diagnosis covered in the
lecture material. Participants received one of the
following instructional methods: LEA, PBL, or a
standardized patient. Following the 30-minute
instructional session, the participants completed a
post-test survey (see Appendix C), identical to the
pre-test excluding demographic data.
LEA
An individual with personal experience living with
a bipolar disorder diagnosis spoke to the
participants over a virtual video call about the
effect of the diagnosis on occupational
performance. Participants listened to the
individual’s presentation and engaged in a
question and answer session with the speaker.
PBL
A written case study was provided to the
participants, which contained information about a
hypothetical patient with a bipolar disorder
diagnosis that resembled the LEA presentation.
Participants read and analyzed the case study to
develop a plan of care, including client factors, OT
interventions, and potential therapeutic outcomes
(see Appendix D).
Standardized Patient
A professional who had experience treating
individuals with mental health problems emulated
a hypothetical patient experiencing symptoms of
mania during a simulated therapy session with an
OT. The goal was to provide a simulated, hands-
on, interactive experience for students to receive
participant feedback and correspondence during
the session. Information provided to students
during the simulation reflected that of the LEA.
Participants analyzed the information provided by
the standardized patient and developed a plan of
care, which included client factors, suggestions for
OT interventions, and potential therapeutic
outcomes (see Appendix E).
Results
A total of 49 students participated in the study,
providing a convenience sample of primarily
female (n = 45), OTD students. The majority
of the participants (n = 46) were between the ages
of 22 and 25 years. The top four represented
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Table 1.
Percentage of students per cohort.
2021 Fall
Cohort
2021 Spring
Cohort
2022 Fall
Cohort
2022 Spring
Cohort
DPT Students
Unanswered
28.57%
12.24%
32.65%
18.36%
6.12%
2.04%
Table 2.
In what setting did your Level I psychosocial fieldwork rotation take place?
Inpatient/Outpatient Mental
Health
Community
Not Applicable
10.20%
34.69%
55.10%
Table 3.
Do you have previous work or observation experiences in mental/behavioral health settings?
Yes
No
Not Sure
28.57%
57.14%
14.28%
undergraduate degrees among OTD and DPT
students included exercise science (32.7%),
psychology (24.5%), other related health sciences
(14.3%), and biology (12.2%).
Among the participants who were OTD students,
there were first-year students (n = 24) and second-
year students (n = 21). The sample also included
DPT students (n = 3) and unanswered (n = 1).
Table 1 demonstrates the percentages of students
per cohort. The findings from the demographic
data revealed that 42.9% of OTD participants
had completed a Level I psychosocial fieldwork
rotation in either an inpatient/outpatient mental
health or community setting (see Table 2) and
28.6% reported having previous experience in
behavioral health before fieldwork and the current
study (see Table 3). After receiving the lecture and
completing the pre-test survey, approximately
55% of all participants (regardless of assigned
instructional method) agreed or strongly agreed to
the statement, “I feel confident in my ability to
address a client’s psychosocial factors during the
therapy process in any clinical setting.” Also, 38%
of participants agreed or strongly agreed to the
statement, “I feel confident in my ability to
address a client’s psychosocial factors during the
therapy process in a mental/behavioral health
setting.” On the post-test, 75% and 80%,
respectively, agreed to the above statements,
demonstrating an increase in perceived confidence
in addressing psychosocial factors from pre-test to
post-test. Similarly, confidence increased
approximately from 65% to 86% of participants
agreeing or strongly agreeing to the statement, “I
feel confident in my ability to my ability to work
with a client who has been diagnosed with bipolar
disorder.” On the post-test, 57% of participants
agreed with the statement, “this lesson makes me
feel prepared to work as a therapist in a mental
health setting, even if I do not have a Level II
fieldwork/full-time clinical internship rotation in a
mental health setting.” However, instructional
method was not a predictor of this response (R =
0.196, p = 0.177)
Analysis of Competence and Confidence
Participants were randomly distributed into the
LEA (n = 16), PBL (n = 18), and standardized
patient (n = 15). The participants’ level of
competence was measured using multiple-choice
questions created by a registered OT practitioner.
Students responded to ten Likert scale statements,
rating confidence along a five-point scale (strongly
agree to strongly disagree). Competence and
confidence scores were calculated by summing the
number of correctly chosen multiple choice
answers out of nine possible and the sum of Likert
responses out of 50 possible. One
question (number 21, see Appendices B and
C) was evaluated independently due to a wide
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
variety of correct responses that, if included in
overall competence, would have skewed the data.
Two, two-way repeated measure analyses of
variance (ANOVAs) were conducted to identify
any potential differences between pre-test and
post-test scores on confidence and competence
across instructional methods. Two, two-way
repeated measure ANOVAs were chosen as the
most optimal analyses in order to reduce the
likelihood of Type I error that might occur from
completing several one-way ANOVAs or paired
sample t-tests for each instructional method (3)
and each pre-test/post-test (2).
The first two-way repeated measures ANOVA was
conducted to determine a significant difference
between student competence over time, with a
within-subjects factor of time (pre-test and post-
test scores) and between-subjects factor of
instructional method (LEA, PBL, standardized
patient). An additional two-way repeated measures
ANOVA was conducted to determine a significant
difference in student confidence over time with
a within-subjects factor of time and between-
subjects factor of instructional method. An
additional two-way repeated measures ANOVA
was conducted to determine whether any
differences existed in pre-test and post-test
competence scores across the three instructional
methods.
Competence
There were two outliers, as assessed by a boxplot
(see Figure 1), however, the outliers were not
considered true outliers based on examination of
studentized residuals (see Figures 2 and 3) did not
indicate outliers. For the post-test, the data were
normally distributed, as assessed by the Shapiro-
Wilk test of normality (p > .05). There was
homogeneity of variances (p > .05) and
covariances (p > .001), as assessed by Levene's
test and Box's M test, respectively. However, for
pre-test competence, the data were not normally
distributed, as assessed by the Shapiro-Wilk test of
normality (p < .05). Based on the visual
examination of QQ plots for the pre- and post-test
(see Figure 2 and Figure 3), the data were close to
normal, and the assumptions were met to conduct
an ANOVA.
Results of ANOVA
There was no statistically significant interaction
between the intervention and time on competence,
F(2, 46) = 2.333, p = 0.108 (see Figure 4). There
were no statistically significant main effects time
points, F(2, 46) = 1.826, p = 0.1 (see Figure 5).
Confidence
There was one outlier, as assessed by a boxplot
(see Figure 1). The outlier was retained in the
dataset because examination of studentized
residuals (see Figures 6 and 7) did not indicate
outliers. The data were normally distributed, as
assessed by Shapiro-Wilk’s test of normality (p >
.05). There was a homogeneity of variances (p >
.05) and covariances (p > .001), as assessed by
Levene’s test of homogeneity of variances and
Box’s M test, respectively.
There was no statistically significant interaction
between the intervention and time on
confidence, F(2, 46) = .74, p = .48, partial η2 =
.031 (see Figure 8). The effect size for this
analysis (d = 0.6702) was found to exceed
Cohen’s (1988) convention for a medium effect (d
= 0.5), demonstrating that one instructional
method did not significantly indicate a greater
change in mean confidence from pre-test to post-
test compared to the other instructional
methods (see Figure 9). The main effect of time
showed a statistically significant difference in
mean confidence at the different time points, F(2,
46) = 106.29, p < .001, partial η2=.698. According
to Cohen’s (1988) standards, the effect size (d =
1.5202) exceeds an effect size of large effect (d =
0.8). These results indicate that confidence
significantly increased from pre-test (M = 32.80,
SD = 5.17) to post-test (M = 38.35, SD = 4.151).
Similarly, the main effect showed that there was a
statistically significant difference in mean
confidence between intervention groups, F(2, 46)
= 5.39, p = .008, partial η2 = .19. The effect size
for the analyses across groups over time (d =
0.484) exceeds Cohen’s (1988) convention for a
small effect size (d = 0.2). The standardized.
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Figure 4.
Interaction Effect of Standardized Patient and LEA –
Competence
Figure 5.
Means for Competence Prior and Following
Instructional Method
Figure 6.
QQ Plot for Pre-Test Confidence
Figure 7.
QQ Plot for Post-Test Confidence
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
patient group was associated with a mean
confidence score of 4.47, 95% CI [935, 8.0] higher
than the LEA group, a statistically significant
difference, p < .009.
First- and Second-Year Student Data
Among the OTD students, competence and
confidence scores were analyzed to assess for
differences between first- and second-
year students. The comparison analysis only
included first- and second-year OTD students due
to the limited sample size of DPT students (n = 3).
First-year student’s mean confidence was higher
across the pre-test (M = 34.19) and post-test (M =
39.24) compared to second-year student’s
confidence across pre-test (M = 31.79) and post-
test (M = 37.88). A mixed ANOVA analysis was
conducted and revealed no significant interaction
between instructional method and specific cohort
on post-test competence (F(7, 34) = 0.137, p =
0.372) nor post-test confidence (F(7, 34) = 0.508,
p = 0.822). When participants were grouped into
first- and second-year students, a mixed repeated
measures ANOVA revealed no significant
interactions between time and year of school on
competence (F(2, 45) = 0.437, p = 0.648) and
confidence (F(2, 45) = 1.147, p = 0.327). No main
effects of cohorts were significant for competence
(F(2, 45) = 1.662, p = 0.20) and confidence (F(2,
45) = 1.179, p = 3.17).
Discussion
A case-series study was conducted to explore the
relationship between three instructional methods
and student competence and confidence in
providing occupational therapy services in a
behavioral health setting. The study was
conducted in response to the revision of the
Accreditation Council for Occupational Therapy
Education fieldwork objective C.1.9, including
additional instructional methods to satisfy the
current Level I fieldwork requirement (AOTA,
2019).
Competence
Competence questions required clinical problem
solving; effectively applying definitions that
commonly arise in behavioral health,
differentiating between psychosocial, behavioral
health, and mental health characteristics; and
demonstrating an understanding of best practices.
Individual instructional methods and time did not
significantly interact to affect competence.
Overall, these results suggest that competence did
not significantly change over time between the
administration of the pre-test and post-test,
regardless of the instructional method. However,
the use of alternative instructional methods could
reveal some clinical significance in increasing
student competence over time. With limited
insight into how the instructional methods affect
competence, results indicate the need for more
effective methods to measure competence. The
participants were also only exposed to one
instructional method; therefore, the lack of
significance may indicate a need for more
exposure to one or more instructional methods
before displaying competence.
Confidence
Comparable to the results involving competence,
instructional method and time did not significantly
interact to affect confidence. However,
instructional method and time individually showed
significant effects on confidence. Between the
administration of pre-test and post-test, confidence
significantly increased, regardless of instructional
method. Additionally, participants in the
standardized patient group scored higher on
confidence compared to the participants in the
LEA group, regardless of time.
This result might be interpreted in multiple ways.
Because confidence increased from pre-test to
post-test across groups, it could be interpreted that
the standardized patient group showed a more
considerable change than LEA, and with a larger
sample size and more data points, an interaction
might occur between group and time. However,
this interpretation cannot be given with certainty
because there was no significant interaction with
time. It could also be deduced that the
standardized patient group was inherently different
from LEA, resulting from chance, as the
participants were randomly distributed, and
cohorts were primarily equal across groups. The
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
standardized patient group was also potentially
different because, though the simulation reflected
the case study, the individual presented with manic
symptoms. While the standardized group was
much higher in confidence than the LEA, the LEA
method might have been inherently different to
result in much lower confidence. The LEA group
involved a personal experience of a bipolar
disorder diagnosis, making it less controlled.
Additionally, the LEA group was virtual while the
standardized patient was in person, which could
have decreased its effect on confidence. More
research must be conducted to determine the true
effect of the standardized patient and LEA on
confidence.
Psychosocial vs. Behavioral Health
With the recent changes to the ACOTE Level I
fieldwork standards, the call to ensure OT students
can distinguish between psychosocial factors and
behavioral health becomes more vital prior to
entering Level II fieldwork placements. The new
fieldwork requirements may facilitate curriculum
on OT interventions to address behavioral health
problems. Participants were asked to distinguish
between psychosocial and behavioral/mental
health in the competence question section.
Participants demonstrated a mixed understanding
of the differences, both after receiving the lecture
and the instructional method. For example, Table
4 shows that, while hypomania is considered a
behavioral health factor, more participants
answered incorrectly following the post-test. On
the other hand, determination is a psychosocial
factor, and more participants answered correctly
following the post-test. When examining the
frequency data for distinguishing psychosocial
factors, the wide variability of correct responses
existed not only across factors but over time as
well. The responses suggest that participants did
not have a strong understanding and retention of
the definition of psychosocial, a key concept
within the fieldwork curriculum and in the role of
OT across practice settings.
Over time, Likert scale results revealed perceived
confidence in applying interventions in a
mental/behavioral health setting increased
compared to any clinical setting, contrasting the
results reported in the pre-test. However, due to
the mixed levels of competence in distinguishing
between psychosocial and behavioral health
factors, the reported confidence might not be
beneficial. Overall, understanding the unique
value of psychosocial and behavioral health
factors plays a key role in student preparedness.
Table 4.
Which of the following would be considered psychosocial factors? Select all that apply.
Pre-Test (% correct)
Post-Test (% correct)
Decreased Confidence*
87.8
93.9
Loneliness*
95.9
100.0
Determination*
61.2
73.5
Hallucinations
67.3
67.3
Denial*
71.4
73.5
Hypomania
59.2
42.9
Hopelessness*
87.8
89.8
Depression
69.4
69.4
*correct psychosocial factors
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Limitations
Participants
Limitations should be noted in the review of the
current study. First, the study was completed
based on a small convenience sample, limiting a
representative distribution of the population and
generalizability.
Instruments
Following data analyses, the researchers attempted
a factor analysis on the instruments used to
measure competence and confidence to explore
whether the assessment was reliable. Reliability
analyses revealed low internal reliability for the
ten competency statements (α = 0.329), suggesting
that competence was not effectively measured.
However, reliability analyses for confidence
revealed strong internal reliability for the ten
confidence statements (α = 0.816), suggesting the
instrument was reliable in assessing confidence.
By not being able to measure competence and
confidence effectively, generalizability and the
ability to conduct a thorough analysis of the results
are limited.
Lastly, the study relied on the notion that
preparedness for working in behavioral health is
solely dependent on competence and confidence.
Competence and confidence may not be the proper
variables required for measuring preparedness for
clinical practice.
Procedures
Participants were recruited via fliers that
advertised the study as an exploration of mental
health and OT, which may have inadvertently
attracted participants with a specific interest in
mental health and skewed competence and
confidence scores.
Due to unforeseen technical difficulties with the
virtual data collection assistant, electronic surveys
were not able to be submitted or reviewed;
therefore, pre- and post-test hard copies were
distributed, prompting some participants to
complete the pre-test twice, despite instructions
not to do so. The circumstance could have allowed
participants to change initial responses, skewing
the final data.
The faculty member who led the simulation was a
research team member who had knowledge of the
study objectives. Therefore, potential bias could
have occurred during the standardized patient
instructional method. Although the standardized
patient simulation and the PBL case study were
based on information from the LEA, discrepancies
in presentation and explanation of symptoms may
have varied between the instructional methods,
which could have influenced answer selections
during the post-test. Additionally, A “practice
effect” may have occurred from participants
answering the same competence and confidence
questions in both the pre-test and the post-test,
potentially resulting in decreased validity of the
data.
The outliers identified through the box plot were
not identified as true outliers following the
studentized residual. Thus, the data met the
assumptions of the ANOVA. Due to this finding,
non-parametric testing was not conducted,
resulting in a possible limitation.
Generalizability of this study is limited by the fact
that the instructional methods were based on one
diagnosis – bipolar disorder – restricting the
participants’ experience compared with the variety
and complexity of diagnoses and situations an OT
would address in a mental health setting. Further
research is warranted to broaden the study and
explore the relationship with additional diagnoses.
Conclusion
This study's limitations support the need for
further research regarding the role of OT in mental
health and how best to prepare students for clinical
fieldwork experiences. The current study
evaluated the relationship of an LEA, PBL, and
use of standardized patients on perceived student
competence and confidence to provide OT
services in behavioral health settings. Analyses
revealed no significant effect of the instructional
method and no significant interactions on
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
competence. However, the data did reveal
significant main effects of group and time on
confidence. Confidence increased across all
instructional methods and exhibited a significant
difference between the LEA and standardized
patient. This study is an provides important data
regarding instructional methods used in response
to recent ACOTE changes to best educate and
prepare students. It addresses different
instructional methods and poses a new avenue to
improve curriculum within OT programs
concerning mental health.
Additionally, this study is unique in attempting to
measure preparedness through competence and
confidence, which may lead to further research.
By developing a reliable measurement of
competence and confidence, OT programs will
have an objective measure of curriculum
effectiveness. Similarly, longitudinal research is
recommended to determine which instructional
methods have a significant effect on student
preparedness. With more research related to the
current study, OT programs can better prepare
students to be confident and competent entry-level
OT practitioners within mental and behavioral
health.
References
Accreditation Council for Occupational Therapy
Education. (2018). 2018 Accreditation council
for occupational therapy education standards
and interpretive guide. American Journal of
Occupational Therapy, 72(Suppl. 2), 1-83.
https://doi.org/10.5014/ajot.2018.72S217
American Occupational Therapy Association.
(2019). 2018 Accreditation Council for
Occupational Therapy Education (ACOTE®)
Standards and Interpretive Guide.
https://acoteonline.org/wp-
content/uploads/2020/10/2018-ACOTE-
Standards.pdf
Blackwell, C. & Bilics, A. (2017). Preparing
occupational therapy students to address
mental health promotion, prevention, and
intervention in school-based practice. Journal
of Occupational Therapy, Schools, & Early
Intervention, 11, 1-10.
https://doi.org/10.1080/19411243.2017.13866
05
Breines, E. (1987). Pragmatism as a foundation for
occupational therapy curricula. American
Journal of Occupational Therapy, 41(8), 522–
525. https://doi.org/10.5014/ajot.41.8.522
Brown, C. & Stoffel, V. C. (2011). Occupational
therapy in mental health: A vision for
participation. F.A. Davis Company.
Byrne, L. (2013). A grounded theory study of lived
experience mental health practitioners within
the wider workforce (Doctoral dissertation).
https://acquire.cqu.edu.au/articles/thesis/A_gr
ounded_theory_study_of_lived_experience_m
ental_health_practitioners_within_the_wider_
workforce/13387079
Cohn, E. S. (2019). Asserting our competence and
affirming the value of occupation with
confidence. American Journal of
Occupational Therapy, 73(6).
https://doi.org/10.5014/ajot.2019.736002
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Cohen, J. (1988), Statistical Power Analysis for
the Behavioral Sciences, 2nd Edition.
Hillsdale, N.J.: Lawrence Erlbaum.
Creek, J. & Lougher, L. (2008). Occupational
therapy and mental health (4th ed.). Elsevier.
Crowe, M., & Mackenzie, L. (2002). The
influence of fieldwork on the preferred future
practice areas of final year occupational
therapy students. Australian Occupational
Therapy Journal, 49, 25-36.
https://doi.org/10.1046/j.0045-
0766.2001.00276.x
Dickinson, T., Hopton, J., & Pilling, M. (2016).
An evaluation of nursing students' perceptions
on the efficacy of high-fidelity clinical
simulation to enhance their confidence,
understanding and competence in managing
psychiatric emergencies. Journal of Clinical
Nursing, 25(9-10), 1476-1478.
https://doi.org/10.1111/jocn.13211
Evenson, M. (2011). Preparing for fieldwork:
Students' perceptions of their readiness to
provide evidence-based practice. IOS press,
44, 297-306. https://doi.org/10.3233/WOR-
121506
Giles, A. K., Carson, N. E., Breland, H. L., Coker-
Bolt, P., & Bowman, P. J. (2014). Use of
simulated patients and reflective video
analysis to assess occupational therapy
students’ preparedness for fieldwork.
American Journal of Occupational Therapy,
68(S2), S57-66.
https://doi.org/10.5014/ajot.2014.685S03
Happell, B., Bennetts, W., Harris, S., Platania-
Phung, C., Tohotoa, J., Byrne, L., &
Wynaden, D. (2015). Lived experience in
teaching mental health nursing: Issues of fear
and power. International Journal of Mental
Health Nursing, 24, 19-27.
https://doi.org/10.1111/inm.12091
Ikiugu, M. N., & Schultz, S. (2006). An argument
for pragmatism as a foundational philosophy
of occupational therapy. Canadian Journal of
Occupational Therapy, 73(2), 86–97.
https://doi.org/10.2182/cjot.05.0009
Knecht-Sabres, L. J., Kovic, M., Wallingford, M.,
& St. Amand, L. E. (2013). Preparing
occupational therapy students for the
complexities of clinical practice. Open
Journal of Occupational Therapy, 1(3).
https://doi.org/10.15453/2168-6408.1047
Martikainen, P., Bartley, M., & Lahelma, E.
(2002). Psychosocial determinants of health in
social epidemiology. International Journal of
Epidemiology, 31, 1091–1093.
https://doi.org/10.1093/ije/31.6.1091
McGee, C., & Sopeth, L. (2015). Occupational
therapy student learning in acute care
contexts: Blending online, classroom,
simulation, and fieldwork education.
American Journal of Occupational Therapy,
69, 879–882.
https://doi.org/10.5014/ajot.2015.69S1-RP401
National Board for Certification in Occupational
Therapy. (2018). Practice analysis of the
occupational therapist registered- Execute
summary [PDF file]. NBCOT.
https://www.nbcot.org/-
/media/NBCOT/PDFs/2017-Practice-
Analysis-Executive-
OTR.ashx?la=en&hash=42CC69FEB1F23F48
0B90A733E031DAEB5D5AD1FD
Omari Pittman, C., & Lawdis, K. (2017). Does the
use of multifactorial training methods increase
practitioners' competence? Journal of
Educators Online, 14(2).
http://doi.org/10.9743/jeo.2017.14.2.2
Quail, M., Brundage, S., Spitalnick, J., Allen P.,
Beilby, J. (2016). Student self-reported
communication skills, knowledge and
confidence across standardised patient, virtual
and traditional clinical learning environments.
BMC Medical Education, 16(73).
https://doi.org/10.1186/s12909-016-0577-5
Ridley, S., Martin, R., & Mahboub, L. (2017).
Learning from mental health lived experience
and the influence on students’ practice.
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Australian Social Work, 70(3), 372–380.
https://doi.org/10.1080/0312407X.2016.12357
18
Rodger, S., Fitzgerald, C., Davila, W., Millar, F.,
& Allison, H. (2011). What makes a quality
occupational therapy practice placement?
Students’ and practice educators’ perspectives.
Australian Occupational Therapy Journal, 58,
195-202. https://doi.org/10.1111/j.1440-
1630.2010.00903.x
Rowe, M. Frantz, J., & Bozalek, V. (2012) The
role of blended learning in the clinical
education of healthcare students: A systematic
review. Medical Teacher, 34(4).
https://doi.org/10.3109/0142159X.2012.64283
1
Scaffa, M. & Wooster, D. (2004). Effects of
problem-based learning on clinical reasoning
in occupational therapy. The American
Journal of Occupational Therapy, 58(3), 333-
336. https://doi.org/10.5014/ajot.58.3.333
Schaber, P., Wilcox, K., Whiteside, A. L., Marsh,
L., & Brooks, C. D. (2010). Designing
learning environments to foster affective
learning: Comparison of classroom to blended
learning. International Journal for the
Scholarship of Teaching and Learning, 4(2).
https://doi.org/10.20429/ijsotl.2010.040212
Swarbrick, M., & Noyes, S. (2018). Effectiveness
of occupational therapy services in mental
health practice. The American Journal of
Occupational Therapy, 72.
https://doi.org/10.5014/ajot.2018.725001
Substance Abuse and Mental Health
Administration. (2014). National Framework
for Quality Improvement in Behavioral Health
Care [PDF File].
https://www.nasmhpd.org/sites/default/files/S
AMHSA%20Quality%20Improvement%20Ini
tiative.pdf
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Appendix A: Consent Form
Statement of Informed Consent
DISCLOSER STATEMENT: The following study involves topics surrounding mental/behavioral
health and may be emotionally distressing to some participants. All participation is voluntary, and
participants can withdraw from the study at any time.
I have been asked to participate as a subject in a research project entitled:
OTD Student Preparedness for Applying Interventions in Behavioral Health Settings
This project is under the direction of Dr. Sara Best, faculty at Huntington University, as a component of
the Doctorate of Occupational Therapy Program’s research course, OTD 732: Research IV: Design. The
supervising professor can be contacted at the following number: 260-702-9625 The Huntington
University Institutional Review Board Chair, Dr. Mike Rowley, can be contacted at 260-359-4277 for any
questions pertaining to the research.
• I understand that I will be asked to participate in an online survey after a lecture and I may elect
to participate in a instructional method at a later date.
• I understand that there are minimal associated risks with participating in this project. These risks
may include emotional distress due to the nature of the lecture topic, the instructional method to
which I am assigned, and/or questions in the test and survey.
• I understand that at any point in time I may withdrawal myself from the study, and that any data I
have provided will be excluded from the data analysis.
• I understand that information gathered from me during this project will not be reported to nor
shared with anyone outside the project team in any manner which might allow someone to identify
me. A confidential number will be assigned to each individual participating in the survey and
instructional method to protect individual identities.
• I understand that report of combined and generalized results involving multiple participants will
be prepared and may be presented for educational purposes only. I understand that results of this
study may be submitted for professional publication and/or presentation.
• I understand that some information shared today is based off of real individuals and must
remain confidential. I understand that I cannot share any information about the
discussions today.
My signature indicates that I understand and voluntarily agree to the conditions of participation described
above and that I may withdraw from the study at any time.
______________________________ ________________
Printed Name Date
_______________________________
Signature
________________________________ ________________
Parent/Guardian Signature (if under 18 years old) Date
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Appendix B: Pretest Survey
Pre-and Post-Test
Demographic Information
Questions
Answers
What is your ID number?
Age
Gender Identity
Background Information
Questions
Answers
Undergraduate Degree
Psychology
Exercise Science
Kinesiology
Recreational Therapy
Nursing
Art/Music
Social Work/Human & Family Services
Early Childhood Development/ Education
Biology
Biochemistry/Chemistry
Other health sciences/medical/therapy not listed
Other liberal arts not listed
Are you currently enrolled in the institution’s Doctorate
of Occupational Therapy Program?
Yes
No
Of which cohort do you belong?
Fall cohort, class of 2021
Spring cohort, class of 2021
Fall cohort, class of 2022
Spring cohort, class of 2022
DPT Student
Did you participate in the “Mental Health in OT”
survey or focus group during the institute’s qualitative
course (Summer 2019)
Yes
No
Have you completed the institute’s psychosocial
fieldwork rotation?
Yes
No
In what setting did your psychosocial rotation take
place?
Inpatient/Outpatient Mental Health
Community Setting
Not Applicable
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
In which settings do you hope to complete your Level
II fieldwork? (check all that apply)
Acute Care
Behavioral Health
Community-Based
Corrections/Juvenile Detention
Home Health
Inpatient Rehab Facility
Other
Outpatient/Hand Therapy
Pediatrics/ School
Skilled Nursing Facility
Do you have previous work or observation experiences
in mental/behavioral health settings?
Yes
No
Not sure
Assessment of Perceived Confidence and Competency
Questions
Answers
After the lesson on occupational therapy in Mental
Health and Bipolar Disorders, I feel confident in…
… understanding how to use therapeutic use of self with
clients in a therapeutic relationship.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… addressing a client’s psychosocial factors during the
therapy process in any clinical setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… addressing a client’s psychosocial factors during the
therapy process in a mental/behavioral health setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… helping clients to accept new functional deficits when
they experience depression, anxiety, anger, and other
maladaptive emotional responses following illness or
injury.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to assess the impact of bipolar disorder on
a client’s occupations.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
… my ability to work with a client who has been
diagnosed with bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to develop long- and short-term goals for a
client with bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to develop and implement evidence-based
interventions for a client who has bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
This lesson makes me feel prepared to work as a
therapist in a mental health setting, even if I do not have
a Level II fieldwork/full-time clinical internship rotation
in a mental health setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
This lesson, along with my Level I fieldwork/CARE
experience, makes me feel prepared to work as a
therapist in a mental health setting. (If you have not yet
completed the psychosocial Level I fieldwork
experience, select “Neutral”)
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Knowledge Assessment
Questions
Answers
Which of the following would be considered
psychosocial factors? Select all that apply.
Decreased confidence
Loneliness
Determination
Hallucinations
Denial
Hypomania
Hopelessness
Depression
You are about to evaluate a new patient, who has
recently undergone right lower extremity, below-knee
amputation. The patient refuses therapy, stating, “I can’t
even walk anymore, what’s the point?” Which of the
following is the most appropriate example of using
therapeutic use of self in this situation?
“I’m sorry you feel that way, but you really can do more
than you think you can.”
“This is a lot to deal with. Besides mobility, what other
things are you concerned about not being able to do
now?”
“The doctor wrote an order for therapy, so we have to at
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
least try!”
“Are you feeling suicidal? I can have someone come in
and talk to you.”
“A lot of people have this type of amputation.
Let’s look at some options for wheelchairs to get you
moving around independently again.”
Therapeutic use of self is
the way in which the OT uses their own verbal and non-
verbal communication skills, empathy, and clinical
reasoning to develop a collaborative relationship with
clients.
the way in which the OT uses components of cognitive-
behavioral therapy and interpersonal psychotherapy to
help a client accept their new level of function.
a specific therapeutic technique which requires special
training in order to use with clients diagnosed with a
bipolar disorder.
only appropriate to use with clients with mental health
disorders.
A client who has had surgery to repair rotator cuff
damage in his right shoulder has just been told that he
will not be able to play baseball this season. Though the
client has not been officially diagnosed with a mental
illness, he is exhibiting symptoms of depression
and asks, “what am I supposed to do all summer?”
The client is experiencing problems with:
mental health
behavioral health
psychosocial factors
both mental health and behavioral health
both mental health and psychosocial factors
both behavioral health and psychosocial factors
A client with bipolar disorder is worried about losing her
job due to several days missed during depressive
episodes. The therapist can help the client
Develop strategies for increasing motivation to get out of
bed and go to work during depressive episodes
Come up with ways to tell her boss that she has
bipolar disorder, so he understands why she calls out of
work
Look for a job that offers more sick time
Ask her boss for less responsibility at work so there is
less impact on the company when she isn’t there
A client with bipolar disorder is having difficulty
focusing on a schedule-making task during occupational
therapy. She is easily distracted, jumps from topic to
topic in conversation, and is having a difficult time
sitting still. The occupational therapist (OT) determines
that the client is experiencing a manic episode. The OT
Giving the client constant verbal reminders to redirect
back to the task
Offer to let the client choose a more preferred activity if
they can successfully finish the schedule-making task
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
could address this by
Point out that the client appears distracted, ask how this
decreased attention is affecting the client, and have the
client identify strategies for staying on task
End the therapy session and suggest that the client
reschedule when manic symptoms have decreased
A new client with bipolar disorder has just moved to this
city and started a new job. It is his first time living
outside of his hometown, and he is worried about being
able to manage his manic and depressive episodes
without his friends and family nearby. A first step that
the therapist might take would be to
Have the client identify dates when he can visit his
hometown
Help the client make a list of local activities to help
motivate him during depressive episodes
Research local support groups and activities in which the
client is interested, and have the client make a goal to
participate in one before next week’s OT session
Have the client make a goal to introduce himself to three
of his neighbors before the next OT session
An OT is evaluating a new client who is diagnosed with
a bipolar disorder. The client is having difficulty
identifying goals for leisure activities, stating “when I’m
depressed, I don’t want to do anything, let alone anything
fun.” How might the OT proceed?
Have the client identify other areas of occupation which
are affected by depressive and manic episodes
Rephrase the question using the client’s own words, and
ask which activities he considers “fun”
Explain to the client the importance of leisure activities
in maintaining mental health
Suggest that the client make a list of activities that
someone else might consider “fun”, then have the client
choose one from the list to develop a goal for
participation
A client with bipolar disorder is experiencing a manic
episode, and states that she wants to quit her job and
travel the country, writing a travel blog to earn money.
When the OT asks how much a travel blogger makes and
would it be enough to cover expenses, the client states
that she would “figure it out” as she goes. The OT knows
that the client is already having financial difficulties, and
that this idea is impulsive and would probably be more
detrimental than helpful. The OT should
Have the client research a profession other than travel-
blog writing which would be more financially lucrative
Have the client list all of the reasons that this may not be
a good idea
Have the client list her current expenses and research the
costs and expenses of traveling to see if it is a viable
goal
Remind the client of her current financial state by
showing her the treatment note for the session in which
the client admitted to having financial problems
A client with bipolar disorder admits that he feels like his
friends and family cannot relate to him because of his
mental illness, and that he often feels isolated and alone.
This client is describing issues with
mental health
behavioral health
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Appendix C: Posttest Survey
ID NUMBER:
Assessment of Perceived Confidence and Competency
Questions
Answers
After the lesson on occupational therapy in Mental Health
and Bipolar Disorders, I feel confident in…
… understanding how to use therapeutic use of self with
clients in a therapeutic relationship.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… addressing a client’s psychosocial factors during the
therapy process in any clinical setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… addressing a client’s psychosocial factors during the
therapy process in a mental/behavioral health setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… helping clients to accept new functional deficits when
they experience depression, anxiety, anger, and other
maladaptive emotional responses following illness or
injury.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to assess the impact of bipolar disorder on a
client’s occupations.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to work with a client who has been
diagnosed with bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
… my ability to develop long- and short-term goals for a
client with bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
… my ability to develop and implement evidence-based
interventions for a client who has bipolar disorder.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
This lesson makes me feel prepared to work as a therapist
in a mental health setting, even if I do not have a Level II
fieldwork/full-time clinical internship rotation in a mental
health setting.
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
This lesson, along with my Level I fieldwork/CARE
experience, makes me feel prepared to work as a therapist
in a mental health setting. (If you have not yet completed
the psychosocial Level I fieldwork experience, select
“Neutral”)
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Knowledge Assessment
Questions
Answers
Which of the following would be considered
psychosocial factors? Select all that apply.
Decreased confidence
Loneliness
Determination
Hallucinations
Denial
Hypomania
Hopelessness
Depression
You are about to evaluate a new patient, who has
recently undergone right lower extremity, below-knee
amputation. The patient refuses therapy, stating, “I can’t
even walk anymore, what’s the point?” Which of the
following is the most appropriate example of using
therapeutic use of self in this situation?
“I’m sorry you feel that way, but you really can do more
than you think you can.”
“This is a lot to deal with. Besides mobility, what other
things are you concerned about not being able to do
now?”
“The doctor wrote an order for therapy, so we have to at
least try!”
“Are you feeling suicidal? I can have someone come in
and talk to you.”
“A lot of people have this type of amputation.
Let’s look at some options for wheelchairs to get you
moving around independently again.”
Therapeutic use of self is
the way in which the OT uses their own verbal and non-
verbal communication skills, empathy, and clinical
reasoning to develop a collaborative relationship with
clients.
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
the way in which the OT uses components of cognitive-
behavioral therapy and interpersonal psychotherapy to
help a client accept their new level of function.
a specific therapeutic technique which requires special
training in order to use with clients diagnosed with a
bipolar disorder.
only appropriate to use with clients with mental health
disorders.
A client who has had surgery to repair rotator cuff
damage in his right shoulder has just been told that he
will not be able to play baseball this season. Though the
client has not been officially diagnosed with a mental
illness, he is exhibiting symptoms of depression
and asks, “what am I supposed to do all summer?” The
client is experiencing problems with
mental health
behavioral health
psychosocial factors
both mental health and behavioral health
both mental health and psychosocial factors
both behavioral health and psychosocial factors
A client with bipolar disorder is worried about losing her
job due to several days missed during depressive
episodes. The therapist can help the client
Develop strategies for increasing motivation to get out of
bed and go to work during depressive episodes
Come up with ways to tell her boss that she has
bipolar disorder, so he understands why she calls out of
work
Look for a job that offers more sick time
Ask her boss for less responsibility at work so there is
less impact on the company when she isn’t there
A client with bipolar disorder is having difficulty
focusing on a schedule-making task during occupational
therapy. She is easily distracted, jumps from topic to
topic in conversation, and is having a difficult time
sitting still. The OT determines that the client is
experiencing a manic episode. The OT could address this
by
Giving the client constant verbal reminders to redirect
back to the task
Offer to let the client choose a more preferred activity if
they can successfully finish the schedule-making task
Point out that the client appears distracted, ask how this
decreased attention is affecting the client, and have the
client identify strategies for staying on task
End the therapy session and suggest that the client
reschedule when manic symptoms have decreased
A new client with bipolar disorder has just moved to this
city and started a new job. It is his first time living
outside of his hometown, and he is worried about being
Have the client identify dates when he can visit his
hometown
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
able to manage his manic and depressive episodes
without his friends and family nearby. A first step that
the therapist might take would be to
Help the client make a list of local activities to help
motivate him during depressive episodes
Research local support groups and activities in which the
client is interested, and have the client make a goal to
participate in one before next week’s OT session
Have the client make a goal to introduce himself to three
of his neighbors before the next OT session
An OT is evaluating a new client who is diagnosed with
a bipolar disorder. The client is having difficulty
identifying goals for leisure activities, stating “when I’m
depressed, I don’t want to do anything, let alone anything
fun.” How might the OT proceed?
Have the client identify other areas of occupation which
are affected by depressive and manic episodes
Rephrase the question using the client’s own words, and
ask which activities he considers “fun”
Explain to the client the importance of leisure activities
in maintaining mental health
Suggest that the client make a list of activities that
someone else might consider “fun”, then have the client
choose one from the list to develop a goal for
participation
A client with bipolar disorder is experiencing a manic
episode, and states that she wants to quit her job and
travel the country, writing a travel blog to earn money.
When the OT asks how much a travel blogger makes and
would it be enough to cover expenses, the client states
that she would “figure it out” as she goes. The OT knows
that the client is already having financial difficulties, and
that this idea is impulsive and would probably be more
detrimental than helpful. The OT should
Have the client research a profession other than travel-
blog writing which would be more financially lucrative
Have the client list all of the reasons that this may not be
a good idea
Have the client list her current expenses and research the
costs and expenses of traveling to see if it is a viable
goal
Remind the client of her current financial state by
showing her the treatment note for the session in which
the client admitted to having financial problems
A client with bipolar disorder admits that he feels like his
friends and family cannot relate to him because of his
mental illness, and that he often feels isolated and alone.
This client is describing issues with
mental health
behavioral health
psychosocial factors
both mental health and behavioral health
both mental health and psychosocial factors
both behavioral health and psychosocial factors
Any Additional Comments
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Appendix D: PBL Handout
Case Study
Client is a 38-year-old female, and mother of two sons, diagnosed with Bipolar Type II Disorder seven
years ago. Initially, symptoms were overlooked by medical professionals until she sought help from a
counselor, following her divorce, who officially diagnosed her with Bipolar Type II Disorder. Her
symptoms include a deep state of depression, rapid speech, avoidance of sleep, and never getting tired
with four to seven days of no sleep. She has a tendency to become highly irritable, easily upset, and cries
often. During her depressive state, she withdrawals from family, friends, responsibilities, and has trouble
with simple tasks such as taking her dog out, showering, and cleaning. Her current coping strategies
include medication management, cognitive strategies, social support, and, recognizing the present
symptoms. Client utilizes stress management as her primary coping skill. She chooses to take more time
to complete tasks and is conscious of the potential impact that symptoms can have on her daily routine.
The client also uses social support as a coping strategy, in which her family went to counseling sessions
with her to be educated on her diagnosis. Her loved ones also hold her accountable when she exhibits
intense emotions. Medication management is critical to regulate symptoms and minimize the side effects
during the adjustment period. Client reported having to take off work for two weeks while adjusting to
new medication or after receiving a change in dosage. When the client is experiencing severe states, she
sees her counselor once a week. When her symptoms are stable, she checks in with her counselor every
few months or during stressful times.
What other information do you need from this patient?
What common symptoms does the client experience?
If the client said her coping strategies were not working, what would you recommend?
What occupations are impacted by the client’s diagnosis?
What assessments would you utilize to evaluate the client during their first visit?
What interventions would you recommend using to improve the client’s ability to engage in meaningful
occupations?
Student Journal of Occupational Therapy, 2(1), 21-51
https://doi.org/10.46409/001.BWXS8816 Spring 2021
ISSN: 2689-1662
Appendix E: Standardized Patient Handout
Standardized Patient Discussion
What other questions do you have for the patient?
What common symptoms does the client experience?
What coping strategies does the client utilize?
What occupations are impacted by the client’s diagnosis?
What assessments would you utilize to evaluate the client during their first visit?
What interventions would you recommend using to improve the client’s ability to engage in meaningful
occupations?
