Exploring Students' Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development Ndaa, P. O., Wimpenny, K., Khanna, R., Goodman, S. & Bello, A. I Published PDF deposited in Coventry University’s Repository Original citation: Ndaa, PO, Wimpenny, K, Khanna, R, Goodman, S & Bello, AI 2022, 'Exploring Students' Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development', Qualitative Report, vol. 27, no. 1, 3, pp. 64-78. https://doi.org/10.46743/2160-3715/2022.5162 DOI 10.46743/2160-3715/2022.5162 ISSN 1052-0147 ESSN 2160-3715 Publisher: Nova Southeastern University This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 International License. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.. https://doi.org/10.46743/2160-3715/2022.5162 The Qualitative Report The Qualitative Report Volume 27 Number 1 Article 3 1-3-2022 Exploring Students’ Experiences in Occupational Therapy Exploring Students’ Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Education: A Phenomenological Study of Professional Identity Development Development Peter O. Ndaa University of Ghana, pndaa@chs.edu.gh Katherine Wimpenny Coventry University Rebecca Khanna Sheffield Hallam University Simon Goodman De Montfort University Ajediran I. Bello University of Ghana Follow this and additional works at: https://nsuworks.nova.edu/tqr Part of the Curriculum and Instruction Commons, Curriculum and Social Inquiry Commons, Educational Assessment, Evaluation, and Research Commons, Educational Methods Commons, Higher Education and Teaching Commons, and the Quantitative, Qualitative, Comparative, and Historical Methodologies Commons Recommended APA Citation Recommended APA Citation Ndaa, P. O., Wimpenny, K., Khanna, R., Goodman, S., & Bello, A. I. (2022). Exploring Students’ Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development. The Qualitative Report, 27(1), 44-63. https://doi.org/10.46743/2160-3715/2022.5162 This Article is brought to you for free and open access by the The Qualitative Report at NSUWorks. It has been accepted for inclusion in The Qualitative Report by an authorized administrator of NSUWorks. 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However, in most countries with less resourced occupational therapists like Ghana, education in occupational therapy is fraught with inadequate number of same professionals to mentor undergraduate occupational therapy students. The students are thus faced with serious dilemma regarding their professional identity which tends to elicit a bleak perception of their chosen career. The present study was therefore envisaged to interpret and analyse the students’ lived experiences, with the view to capture the process of constructing and developing professional identity. The study focused on purposively sampled group of nine undergraduate occupational therapy students during their practice placement education, and their learning styles on didactic lectures. A hermeneutic phenomenological approach was adopted for the study. The students were followed up throughout their four-year study program for data collection, using one-to-one semi-structured interviews each year. With reference to the threshold concepts, transcribed interview data were analyzed using interpretative phenomenological procedures. The study established a transformational development of professional identity from the novice stage into graduate professionals, amidst complex interaction of co-constructed themes which included: personal knowing, professional knowing and experiential knowing. Keywords Keywords professional identity, learning environment, learning experience, threshold concepts, occupational therapy, professional socialization, phenomenology Creative Commons License Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-Share Alike 4.0 International License. Acknowledgements Acknowledgements We acknowledge the maiden cohort of BSc occupational therapy students in Ghana who willingly agreed to participate in the project. Other appreciations go to Dr. Louis Connolly who helped to formulate the research idea. This article is available in The Qualitative Report: https://nsuworks.nova.edu/tqr/vol27/iss1/3 https://goo.gl/u1Hmes https://goo.gl/u1Hmes https://creativecommons.org/licenses/by-nc-sa/4.0/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://creativecommons.org/licenses/by-nc-sa/4.0/ https://nsuworks.nova.edu/tqr/vol27/iss1/3 The Qualitative Report 2021 Volume 27, Number 1, 44-63 https://doi.org/10.46743/2160-3715/2022.5162 Exploring Students’ Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development Peter O. Ndaa Department of Occupational Therapy, University of Ghana, Korle Bu, Ghana Katherine Wimpenny Intercultural Engagement and Global Education, Coventry University, UK Rebecca Khanna Sheffield Hallam University, South Yorkshire, UK Simon Goodman De Montfort University, Leicester, UK Ajediran I. Bello Department of Physiotherapy, University of Ghana, Korle Bu. Ghana The existing literature on professional identity enactment and development, subscribes to students’ socializing in a learning environment, where they regularly encounter practicing professionals throughout their education period. However, in most countries with less resourced occupational therapists like Ghana, education in occupational therapy is fraught with inadequate number of same professionals to mentor undergraduate occupational therapy students. The students are thus faced with serious dilemma regarding their professional identity which tends to elicit a bleak perception of their chosen career. The present study was therefore envisaged to interpret and analyse the students’ lived experiences, with the view to capture the process of constructing and developing professional identity. The study focused on purposively sampled group of nine undergraduate occupational therapy students during their practice placement education, and their learning styles on didactic lectures. A hermeneutic phenomenological approach was adopted for the study. The students were followed up throughout their four-year study program for data collection, using one-to-one semi-structured interviews each year. With reference to the threshold concepts, transcribed interview data were analyzed using interpretative phenomenological procedures. The study established a transformational development of professional identity from the novice stage into graduate professionals, amidst complex interaction of co-constructed themes which included: personal knowing, professional knowing and experiential knowing. Keywords: professional identity, learning environment, learning experience, threshold concepts, occupational therapy, professional socialization, phenomenology Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 45 Introduction Study Context Watson and Swartz (2005) defined occupational therapy (OT) as “a service that is offered by professionals who aim to collaborate with individuals, groups, organizations and communities to achieve particular health-related purposes.” The definition encompasses all activities that are associated with everyday occupational behaviours. World Federation of Occupational Therapists has mandated occupational therapy (OT) education to comprise class- based and a minimum 1000hours practice-based learning (WFOT, 2002). Practice-based education enables the development of core OT skills and techniques, and the personal skills that are foundational for professional behavior. However, there are very limited occupational therapists in developing countries like Ghana, either at education institution or in practice. For example, the Bachelor of Science (BSc) OT program at the University of Ghana remains the first and only training institution in the country to date (Ndaa, 2014). The few available occupational therapists in private and public practice serve as the main faculty in the training institution thus having very limited time on the field to serve as mentors to the students. Due to the extreme limited resources, including human and infrastructure, the number of intakes onto the programme is low. However, the situation hopes to improve as graduate professionals get absorbed into practice market and begin to support in building the profession locally. Under such prevailing circumstances, OT students spend less time with practicing occupational therapists, and more time with other healthcare professionals such as nurses, physiotherapists and medical doctors, during their placements. This scenario potentially provides avenue for mutable interest on the students’ chosen program and a potential gap for concept of professionalism. Within the context of such peculiar environment therefore, the present research team sought to explore the evolving nature of students’ professional identity development (PID), with the view to bring the profession into limelight among the future prospective students in less resourced OT communities. Theoretical Framework The current study is influenced by Meyer and Land’s (2003) threshold concepts theory which considers students’ limited opportunity to spending time with, and taking part in, activities with qualified professional colleagues to enable them to define their specific role (Meyer & Land, 2003). Threshold Concepts Meyer and Land’s study on threshold concepts highlighted that knowledge and learning are examples of concepts that can have a range of interpretations, from novice to complex understanding (Meyer & Land, 2003). Earlier studies by Saljo (1979) and Perry (1988), similarly identified particular stages in the development of the threshold concepts that have a transformative effect on the person traversing through stages from naivety to professional. Meyer and Land (2003) developed on Perry and Saljo’s work and referred to the above- stated concept of learning as “threshold concept,” whose acquisition is of a transformative nature, and it underpins the contextual framework for this study. The authors defined threshold concepts in relation to the following characteristics: 46 The Qualitative Report 2021 1. Transformative: which implies that a significant shift occurs in person’s view of subject, once it is understood. This could sometimes lead to personal identity change. 2. Irreversible: which connotes that when a change happens it is unlikely to be forgotten and would require considerable effort to unlearn it. 3. Integrative: which implies that threshold opens up previously hidden interrelations and creates new understanding relative to the subject. 4. Bounded: which stipulates that there is always a new threshold to master once the concepts have been understood. 5. Troublesome: which suggests that some knowledge may not be well grasped, and that can lead to troublesome knowledge. (Meyer & Land, 2003) While Meyer and Land (2003) suggested five characteristic natures of their concepts, they hardly stated the number of criteria from these characteristic concepts needed for a threshold concept. There are variations in the literature concerning how many criteria are required for a threshold concept. More recently, Meyer (2010, p. 205) declared that “Threshold concepts cannot be described as an essentialist nor definitive list of characteristics.” However, Cowart (2010) argued that a concept must meet all the above five criteria, if they must conform to the tenet of threshold concepts. Meanwhile, Park and Light (2010) were of the view that, there are two essential characteristics (integrative and transformative), and three other associative concepts. Some researchers including O’Donnel (2010), however queried all the criteria for a threshold concept due to lack of definitiveness in the definition of the criteria. This argument was in agreement with the earlier submission by Rowbottom (2007), that the definitions of all five criteria makes it impossible, even in principle, to empirically isolate them thus appearing too vague. The present study however upholds the conviction that the characteristics of the threshold concepts could serve as a metaphor for what goes on when students attempt to understand their professional identity development in a learning environment. Research Questions 1. How do OT students in less OT resourced countries like Ghana understand the development of their professional identity? 2. How would PID of OT students in less OT resourced countries like Ghana be influenced by professional socialization among other healthcare professionals? Positioning Self in the Study An important paradigmatic issue about my diverse roles as the primary researcher, supervising clinician, and consultant occupational therapist need to be considered to clarify the context for this study. Maree (2009) argued on the importance to acknowledge the multiple roles existing in conjunction with research and intervention. Within these multiple roles, I engaged in the research that further encouraged students to learn mainly via reflexivity, diary keeping and hands-on therapy. These roles are consolidated mainly to promote the professional development of the undergraduate occupational therapy students while on placement at various settings throughout their years of training. Knowledge of my personal experience was relevant in this study as this Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 47 has influenced the need to carry out this project as well as assisting readers to appreciate what unfolds in the inquiry. I am an occupational therapist trained in the United Kingdom (UK) from 2000 to 2003 and practiced in the UK until 2010 when I decided to work with the University of Ghana as a lecturer and, to coordinate a new occupational therapy program. As I recollected my past experiences as a student occupational therapist, questions were raised like: where is the occupational therapy service? Where is the occupational therapy staff? Where are the placement educators? Who will students associate with as their mentors? How will the training place students confidently in the world market as qualified occupational therapists? In the attempt to answer these questions, there was a realization that I could explore this experience through exploring students’ perception about themselves as they develop and become occupational therapists. This starting point prompted the research question and informed the method of inquiry. The aim of the study was to dwell on lived experiences to explore PID amongst occupational therapy students in less OT resourced countries like Ghana. Method Design and Processes This is an in-depth qualitative longitudinal study, using hermeneutic phenomenology. The study involved working with a purposive sampled group of undergraduate OT students who are followed up through four years of their program. Study Site and Recruitment A sample group of 9 participants consisting of four males and five females were purposively recruited from the first cohort of eighteen OT students in Ghana, at the School of Allied Health Sciences (now known as School of Biomedical and Allied Health Sciences), University of Ghana. Participants were de-identified by associating them with real Ghanaian names but not their actual names. Purposive sampling was used as it was important that the participants involved would be able to address the aims of the inquiry (Carter & Henderson, 2005; Teddlie & Yu, 2007). Further, the sample size needed not to be more than 15 in accordance with earlier work by Reid, Flowers, and Larkin (2005). Participants’ profiles have been outlined to showcase the real people who engaged with the team of researchers in this research project. Table 1.1 introduces participants and biographies. Table 1.1 Participants’ Profile Participant Sex Biography Kwesi M I gained admission to the University of Ghana at 19 years to study occupational therapy. My aspiration was to be a pharmacist. Joining occupational therapy never crossed my mind as I initially knew nothing about the course. Kwame M I am 20 years old, and because I am the first person in my family who has made it to the University, my parents are interested in my choices. Before joining the first cohort of occupational therapy students, I had the aspiration of becoming a medical doctor, a Neurologist to be precise. 48 The Qualitative Report 2021 Akosua F I am 19, the only daughter of my family. I have been inspired to remain on the study program because of my willingness to contribute my quota to the health sector. It was my mother’s choice that I became a medical doctor though. Ama F I am a 19 years old lady, who originally wanted to enrol on Physiotherapy or Medical Laboratory Science programs. Kojo M I got admitted to the university at 21 years. I initially wanted to offer Medicine. I was perplexed when I was given occupational therapy since I had no idea of what the course entailed. Efua F I am 18 years on admission to the university. When I was given occupational therapy my first reaction was “I’ve never heard of occupational therapy before.” However, my dad urged me on. Kwabena M I am 20 years old. I had the opportunity to study Radiotherapy or occupational therapy. I however chose occupational therapy when I was briefed by the departmental head of occupational therapy. Adwoa F I am 18 years and the only child of my deceased parents. The first time I heard about occupational therapy was when I went for my admission interview. I actually thought I was going into medical laboratory Sciences. Yaa F I am 21 years. I did not choose occupational therapy when I was applying to the University because I had no knowledge about it. I could not get admission to pursue pharmacy, the program I wanted. I however chose occupational therapy over dietetics. Interpretative Phenomenological Analysis (IPA) Research Approach Interpretative Phenomenological Analysis approach was adopted in this study. According to Smith, Flowers, and Larkin (2013), IPA is committed to the examination of how people make sense of their major life experiences. Denzin and Lincoln (2012) had earlier argued that understanding the concept of PID could be best achieved through analysis of interpretations, and actions of the participants which form the core value of qualitative approach. Based on these arguments, Polger and Thomas (2013), inferred that IPA is an organized means of examining the personal meanings of individuals’ experiences and actions in the context of their social environments. The preference for such qualitative research in a natural environment, serves as the justification for the present study design by choosing the participants’ social environment. Procedures Ethical Considerations The researchers needed to ensure that there was no explicit or implicit pressure on students as they took part in the activities or interviews for the sake of this inquiry. Carefully worded information sheets and consent forms helped participants to be clear about the procedure. Coventry University Ethics Board granted the study’s ethics approval (Reference: P15580). The University of Ghana Gatekeeper’s Approval letter was granted based on the assurance that participants are not put under undue situations that could affect their academic activities. To ensure confidentiality, fictitious names are used throughout the study. All the data Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 49 collected were kept under lock and key during and after the research. They were however made accessible to the statistician and researchers. Data Collection Methods Four groups of data were collected, that is, data was collected every year within participants four-year training period. These included one-to-one interviews that were digitally recorded with consent. Interviews time ranged from 50 to 75 minutes per interview. After each interview, the recording was transcribed with meticulous accuracy. Reflective diaries were used as another means to capture students’ voices in this research. Participants’ diaries clarified their experiences, opinions, thoughts, and feelings (Janesick, 1999; Ortlipp, 2008). Additional information was gathered from students’ reflective diaries at the end of every year with concurrent data analyses at every stage. Data Analysis Analysis strategies for IPA in this enquiry were emergent, “bottom up” where codes were generated from the transcribed data rather than using a pre-existing theory or framework to identify codes. These codes were then catalogued into themes. Data were therefore gathered from one-to-one interviews and from participants’ logbooks (diaries) and they were analysed in stages as postulated by Smith, Flowers, and Larkin, (2013). Stage One During stage one, transcriptions from individual interviews including data from participants’ diaries continued to revolve round the close reading and re-reading of the text. At this first stage each audio-recorded interview was listened before reading through the transcribed script. This helped to imagine the voice of each participant as their transcripts were subsequently read through. During this rigorous reading, notes were made of any thoughts, observations and reflections occurring while reading the transcript. Stage Two At the second stage it was important to re-read the text in a more exploratory manner to identify themes that best captured the essential qualities of that interview. This stage saw the need to maintain an open mind and to note anything of interest within the transcript. The process encouraged more familiarity with the transcript to identify specific ways by which participants talked, understood and thought about their experiences. Stage Three At the third stage a provision of an overall structure to the analysis was made by identifying emergent themes. At this stage the task of managing the data changed as there was simultaneous attempt to reduce the volume of the transcript and the initial notes. This was done with cognizance to the complexity in terms of mapping the interrelationships, similarities and patterns between exploratory notes. There was a shift from working with the original transcripts to the initial notes at this stage. 50 The Qualitative Report 2021 Stage Four At this stage, a set of themes had been established within the transcript and arranged in the order they came up. The stage saw the development of a master list of themes located in an orderly manner. The master list of themes was moved around to form clusters of related themes. Some themes acted as magnets pulling other themes towards them. The cluster of themes formed the super-ordinate themes. This involved putting like to like and developing a new sense. Stage Five This next stage involved moving to the next participant’s transcript and repeating the processes from stages 1 to 4. It was important the next participant’s transcript was treated on its own independent terms of merit. In order to achieve this as far as possible, it was ensured to bracket off the ideas of the previous analysis as work was done on the next. This decision was in keeping with IPA’s idiographic commitment. Stage Six This last stage involved looking for patterns across cases. This was about putting themes of different participants together and identifying how a theme from one case helped illuminate the other or which theme was found more potent. This led to configuration and re- labelling of themes that saw the analysis moving into a more theoretical level because some super-ordinate themes in some cases also represented instances of higher order concepts shared by other cases. The final result of these processes was produced in a table format with evidence from the interview using quotations. Table 1.2 is an example of the sub-themes that constituted the first master-theme in this study. Table 1.2 Master Theme with Constituent Sub Themes MASTER THEME SUB THEMES Knowing self, course program and aligning with profession Adjusting to training as an occupational therapy when this wasn‘t the chosen career Understanding occupational therapy by regular explanation of the discipline to others Coping with experiential learning with limited clinical supervision Acknowledging potential prospects within occupational therapy with pride Findings Findings were analysed under the 3 master-themes identified, including their corresponding subthemes. The first master theme: “Knowing self, study program and aligning with profession,” is based on early experience accounts of all nine participants. The master- theme and sub-themes were analysed as follows: Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 51 Master-Theme 1: Knowing Self, Study Program and Aligning with Profession It was noticed in the narratives obtained that the participants were unhappy with the University’s decision to place them on the OT program because they had planned to study other specific programs. The university-determined course of study is a means of introducing prospective students to newly introduced programmes like occupational therapy. The students, though made the grades to enter the university, could not get the opportunity to read their chosen programmes due to factors including extreme competitiveness and limited resources for some programmes. This master theme illustrated participants’ personal self-reflection, developing a knowledge base about OT, and how this had progressed from their earlier understanding of the discipline. Each sub-theme is now presented. Sub-theme 1.1: Adjusting to Training as a Prospective Occupational Therapist When This Wasn’t the Chosen Career Participants expressed their disgruntled feelings about being offered a study program they had not chosen to study. Almost all participants appeared ignorant about the newly introduced OT program. Kwabena expressed his feeling as follows: “I am not the type who jumps into something I have no idea about; my parents even did not know of this profession and I am not comfortable” (Kwabena). Kojo’s experiences were similar. He was equally skeptical about this program and was concerned with how to encounter qualified occupational therapists in the Ghanaian healthcare system to assist them. He narrated his feeling as: I have checked from friends and some staff I met since we started the program… this is new and they haven’t heard of occupational therapists practicing in Korle Bu. It is a worrying experience when I think of who will be working with us. (Kojo) Sub-theme 1.2: Understanding OT through Regular Explanation of the Discipline to Others The participants had something to say about the influence of the environment in relation to both the study program and OT as a profession in general. For example, Kwesi shared the following: For me, the major problem experienced is where I find myself, that is, people have less knowledge about OT. For instance, you tell someone you are an undergrad OT, you now should explain what OT means, what they do and so on…this was enough to make me no longer feel like an OT. (Kwesi) The attitude to create awareness was taken up by the wider occupational therapy students’ group. As mentioned by Adwoa: … initially, I used to wonder how people will see us at the hospital but I am fine because I realized that when they get to understand our services and how important our roles are… then we will feel very relieved. (Adwoa) 52 The Qualitative Report 2021 Sub-theme 1.3: Coping with Experiential Learning with Limited Clinical Supervision Most participants hoped that if the course outline was improved with more fieldwork, it could be a source of more knowledge for them. This was Kwesi’s view: I am confident that if we had more opportunity on the field to acknowledge OT in practice it would have tuned us quickly into the program… I believe having no practitioners is also a factor so we needed to work out with other professionals. (Kwesi) Kwabena, however, related his learning in the field with more direct contact with the client. He thought OT could be better understood through direct contact with clients: “… to me I believe that seeing the client face-to-face and interacting with the client was very different because it made understanding quite simpler. But it looks as if we are not going to get it that much” (Kwabena). Sub-theme 1.4: Acknowledging Potential Prospects within OT with Pride Kwesi was self-motivated to be identified as a student occupational therapist especially when he knew there were diverse job opportunities ahead for him. This was narrated in his statement: I feel I certainly have diverse opportunities, which is one thing that makes me happy…, because I am needed almost everywhere. I read from one of the journals in the library and it said that OTs could work almost everywhere. (Kwesi) Another interesting dimension identified under this sub-theme was Efua’s statement on professional identification. In her anticipation, she associated the experience of wearing a uniform to being identified with the profession. She said: “Their dress codes…Yes, some of them they have dresses that distinguish them from other professionals, and we are still contemplating on what to wear but…” (Efua). Master-theme 2: Transitioning into Identifying Professional Self through Learning at Work This master-theme illustrates that there were interacting forces that complemented each other in directing the students’ program of their learning experiences. Participants indicated in their lived experience how they took advantage of the seemingly polarized feeling of, “here are the jobs but where is the experience?” Participants’ ambivalent feelings were displayed in the two opposing sub-themes. Sub-theme 2.1: Feelings of Uncertainty with Team Members’ Attitude and Being Overwhelmed with Caseload In their narrations, participants referred to a gap between the sheltered nature of discussions in the class and the unanticipated challenges encountered during practical placement. For example, Kwabena shared: Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 53 I think we have limited professional foresight to be left on our own. We do not properly anticipate or understand the challenges until we become enveloped in them . . . this makes me feel exposed but will grow out of them with time. (Kwabena) On a different note, Kwaku felt intimidated and unwelcomed by other staff at his placement setting. He stated that this made him feel disorientated and disconnected from the clinical setting. He narrated: “the unwelcome attitude of my on-site supervisor’s colleagues make me feel like not going to work...they just don’t understand and they do not consider my contributions… it is bizarre if those expected to support you treat you this way” (Kweku). Sub-theme 2.2: Feeling Respected and Valued by Clients and Team Members Over OT Values This sub-theme encompasses the feelings of being respected and value that came with responsibility. Whilst hostility and negativity had been experienced, most students could indicate that, they had also felt respected and valued as professionals by other team members, and also by their clients. For example, Efua made a comment as follows: …the team members listen to you very eagerly and it’s like they are expecting some special input to help the client and the team in general. The client was also like very hopeful in my expected contribution as he looked into my face as I was being introduced as one of the first upcoming Ots in the country. (Efua) Ama similarly acknowledged that she felt her expertise was appreciated as evidenced by the increasing respect accorded her: “…there’s more respect when they see that you can do something for a reason. This will be the expected outcome. This is my plan. This is our goal. This is why I do it” (Ama). Master-theme 3: Re-identifying the OT Profession and “Self” This explains experiences that enhanced students’ PID as they matured to understand the profession and the re-conceptualization to see themselves as professionals as well as recognizing their growth as individuals. The three sub-themes are described next. Sub-theme 3.1: Improved Knowledge on OT Profession to Enhance Quality Therapeutic Relationship with Clients In the third year of study, the participants sensed a shift in their ability to assess, plan and deliver effective occupation-focussed interventions with their clients. The shift in ability was based on understanding a person beyond knowledge of the person’s condition or diagnosis. The sub-theme describes participants’ increase in respect, empathy and compassion for their clients. With her improved combined knowledge now drawing from diagnostic or procedural reasoning and narrative reasoning, Ama appreciated her therapy role, and was more confident in discussing her plan of action: … I will get closer to find out even if there was this little thing that I could do to improve their quality of life. I demonstrated this professional relationship to 54 The Qualitative Report 2021 the benefits of my clients’ improvement… my actions impressed other team members at the stroke unit. (Ama) Kwabena also appreciated the unique role of OT within the wider and more established Ghanaian healthcare delivery system. …for example, Medical Doctors, Nurses and Physiotherapists are known to clients and among the healthcare professionals in my learning environment, but Occupational Therapists are not known, so I need to do something different to demonstrate the unique professional roles of the occupational therapist as equally important. (Kwabena) At this stage, participants appeared comfortable and confident to express and demonstrate who they were and what they stood for. Participants linked their understanding of the profession to their ability to create a better therapeutic relationship as people who cared about their clients’ wellbeing. Sub-theme 3.2: Experiencing Change in Clinical Practice Environments with Appreciation of OT Role within Multidisciplinary Teamwork In this second sub-theme, participants expressed the changes they brought into the healthcare delivery system in general. Their reports included positive comments made by other multidisciplinary team members. Kwame, for example, narrated his experience at the “Burns Unit” as follows: I realized the need for occupational therapy services at my placement setting because almost every patient at the burns unit received physiotherapy and other rehabilitation services yet most of them could not perform simple “activities of daily living” (ADL) tasks like teeth brushing, washing and grooming. (Kwame) Kweku appreciated the importance of having contributed his professional perspectives to the team, based on his understanding of occupational performance deficits as experienced by his clients. I felt a valuable team member when another member said my involvement as the occupational therapist has made a client’s functional recovery in dressing look simple and quick. (Kweku) Narrating his experience from a special school with children with LD, Kwesi made a remarkable statement that: “a successful approach by the occupational therapist might look simple but you need to have the creative thoughts on functional ability to unearth the simple approach.” This was his impression of the OT profession that revolutionized care management at the setting. Sub-theme 3.3: Consolidating Personal Experience to Help Make Decisions on Future Plans This third sub-theme discusses participants’ sense of skills development from their personal experiences with development of their self-concept and self-esteem. They now take pride in their accomplishments and wanting to do more to engage in OT in various aspects of health care in the Ghanaian community. Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 55 Kwame, for example, continued to reflect on his early experiences of limited knowledge on OT, the little support he had from other non-occupational therapy staff and the difficulty he had to demonstrate the roles of the discipline. Kwame expressed this as: “Reflecting on how other non-occupational therapy lecturers skewed their teaching, for example, towards physiotherapy… the experience has however made me know what occupational therapy is, and what is not. The experiential knowledge gained is helping in my decision making as a multidisciplinary team member” (Kwame). Efua also commented on her improved confidence in promoting the profession because the group of graduate occupational therapists had remained on a networking group to professionally support one another. …using the profession’s WhatsApp group page setting, has helped me to dwell on our existing knowledge including individual researches to improve my professional development. Additionally, I have gained more confidence when discussing the OT discipline because I have regular supporting information from visiting the website of Occupational Therapy Africa Regional Group (OTARG) that is linked with WFOT website. (Efua) Generally, participants commented on the need to improve their knowledge through more learning after school. They believed their presence in the health sector was the beginning of the establishment of an occupational therapy profession in Ghana, and the sub-region at large. Discussion This discussion is presented with reference to the aim of the study, that is, to explore PID amongst occupational therapy students in less OT resourced countries like Ghana from their lived experiences in relations to the findings – personal knowing, professional knowing and experiential knowing. Personal Knowing as a Threshold Concept Students’ narratives at the early stages of the study indicated that they focused much on their ideal self. According to Ruvolo and Markus (1992, p. 98) this self-concept is continually active and it is a shifting array of assessing knowledge. Possible self was therefore seen as the students’ guide into the future, reflecting a dynamic, forward moving conception that explains students’ movement from the present towards the future. Personal knowing involved students own innate and personal factors that influenced their professional identity construction. Personal knowing was essential to the development of knowledge central to the students’ professional practice. It was about a discovery of self that the students experienced through reflection and synthesis of their perceptions and connecting with their new forms of learning. Thus, integratively, the students were not only changing in their ways of knowing, but also in their ways of being, because different disjointed aspects of the profession/course program started having meaning to them. The impact of a course program’s effect on students’ sense of self was earlier considered by Markus and Nurius (1986) in their work on possible self, documented by Valerie Mannix (2008). According to Markus and Nurius, possible selves consisted of future self-state rather than a current one that represents the idea students have regarding to what they could become (hope for self), what they would like to become (ideal self) and what they are afraid of becoming (feared self). 56 The Qualitative Report 2021 These are transformative potentials inherent in students and their capacity to bring reflexive insight used in professional development to address relevant threshold concepts. Also, of note were the students’ dispositions and qualities that offered the propensities for their actions. For instance, Valerie Mannix (2008) advocated how learners’ disposition and qualities contribute not only to a collaborative teaching/learning process but also facilitate the reconstruction of how they perceive knowledge and of their own identities. For example, the students demonstrated being more creative and metacognitive through their motivation for independently directed research as a result of their curiosity and self-developed learning pursuits. Though it was evident that students took responsibility for aspects of their self- regulated learning, they also had assistance from faculty in the Department of Occupational Therapy. This aspect of the faculty’s assistance towards students and their experience to change, was earlier supported by Dall’Alba and Barnacle (2005; 2007) and later Barnett (2010), who discussed the benefits of learning to involve the demonstration of acquired knowledge in practice. This was apparent with students who did not only focus on their epistemology but as integrative action; they had to consider this in relation to their ontological perspectives. Persisting through this reflexive process, through their own will and determination, taking on board the external influences of the faculty, their perceptions on professional identity began to shift. Students’ encounter with just a few occupational therapy faculty and other limited resources was troublesome enough to spark anxiety. This had been studied by Auxier et al. (2003) and Brott and Myers (1999). These researchers highlighted from their studies that the PID process comprises of both intrapersonal and interpersonal factors. Students thought they were mostly self-dependent, which is related to just one aspect of intrapersonal factors for PID regarding cycle of the individuation process described by Auxier et al. (2003) and Brott and Myers’ (1999). Students felt they least experienced the interpersonal aspect of the cycle where they needed to rely on practicing mentors for their skills acquisition in the field. This missing element of the cycle is what the researchers argued as the important professional community that shapes the new professionals (Auxier et al., 2003; Brott & Myers 1999). The urgency to be knowledgeable in the OT discipline delineated a particular conceptual space that made students’ perception constitute a bounded demarcation from other disciplines. The students’ bounded perception of their “new” program affected their “self,” their being, and what they would become, who to associate with, and how they should act as argued by Dall’Alba (2009). Students demonstrated these attitudes in their narratives where they mostly focused on their studied discipline and how to move it forward. Professional Knowing as Threshold Concept Students’ limited experience in the profession of OT reflected their difficulty in communicating their sense of relevancy as developing practitioners, and according to Meyer and Land (2003), this could lead to a liminal stage of the students’ learning, wherein, comprehending the discipline was inaccessible to them. This experience occurs when learning to acquire knowledge on subject matter relationship whether with or without a choice of the subject matter. Engestrom (1999) describes this phenomenon as different sets of knowledge that are dynamic and always changing depending on what the student is embarking on; otherwise referred to as “troublesome” threshold that ought to be crossed to progress. For example, preparing for an examination, or getting onto a different level in the course program. However, according to Heidegger (1998/1967), anxiety is potentially an enlightening event. In its ontological form, anxiety is a necessity for students’ struggles to recoil into themselves to Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 57 find a new place to be. This can be the beginning of preparedness to move into a new level to learn and assimilate new knowledge. This earlier statement on “troublesome” threshold, however, exposes some limitations in the threshold concepts in attempting to identify what is troublesome enough that needed to be mastered before crossing to transformation. For example, Schunk (2000, p. 116) based an argument on this unclear distinction to remark that the dissonance notion is vague. Perkins (2006), however, worked to elucidate the concept in his work on theories of difficulties. Perkins’ exploration revealed a variety of reasons accounting for what makes certain sources of knowledge difficult for students (including threshold concepts); thereby revealing that a deeper understanding of one’s difficulties could help uncover powerful sources of transformation. Students’ anxiety at being unfit to be left alone again raises the argument by West and Chur-Hansen (2004), who contend how Universities play a weak role in PID. Both Pettifer and Clouder (2008) and West and Chur-Hansen (2004) question the efficacy of University’s role in facilitating PID because what students learn at universities can be undermined by what they observe at work. Generally, overcoming their anxiety by improving on their knowledge is supported by Sibbett and Thomsom (2008). These researchers postulated that, if students accepted that some degree of dissonance was necessary to stimulate development, then the troublesome nature of threshold concepts may be the very quality that triggered their sense to develop their inter-professional relationship potentials. Walkington (2005) supported this view when he discussed practitioners’ identities as being central to their beliefs, values, and practices, which guide one’s actions within and outside practice. For students, to understand the profession and to put knowledge into practice was a difficult task especially where practicing professionals were not readily available on the field to direct them. These situations made them occasionally indicate the desire to give up and stop studying the program. Their experience supported the work of Woodside et al. (2007) who identified that where participants commented on lack of career direction, it brought about self- doubt in learning to be a professional and increase in attrition rate among students. Students in this study however, had an attitude of active participation in teaching and learning which was highly encouraged by the adopted teaching style. The students’ attitude of active participation towards transformation was described by Dollarhide and Miller (2006) as immersion in a professional culture to learn professional attitudes, modes of thinking and problem solving. Generally, students’ approach to professional development appeared contrary to earlier proposal by Geijsel and Meijers (2005) whose work anticipated that the absence of images of practitioners could stifle students’ development because the Ghanaian students lacked the processes of reflection on such images to develop. Experiential Knowing as Threshold Concept This third construct discusses concepts that students encountered mostly in the advanced stages of their learning including their transition period as interns. Their passage towards the better understanding of clients was a complex process that related to what Cousin (2006) described as a process of new mastery self-image that permits feelings of personal adequacy and satisfaction in the performance of students expected roles. From their narratives, it could be deduced that students’ phenomenal change resulting from overcoming the threshold encountered was unlikely to be forgotten or could only be unlearned with considerable efforts as described by Meyer and Land (2003). Having improved on their knowledge in occupational therapy, students engaged more in discussing perceptions, opinions and experiences among themselves as well as with colleagues from other professions. This attitude created a supporting professional community 58 The Qualitative Report 2021 that helped them to reach a higher level of proficiency. At the end stage of their study program, the students appeared to have lost their old status and identity because they now serve as professionals who were eager to encourage other students to enroll on the occupational therapy program. Baltas et al., (2007) referred to such irreversibility of students’ new knowledge as impossibility of “forsaking the Eureka!” experience and returning to previous ways of understanding. This endless identity developmental mind-set demonstrated by students depicts the relationship between self, personal knowledge and professionalism in relation to the never- ending process of PID. The passage towards the better understanding of clients was a complex process that Cousin (2006), describes as a process of mastery that involved messy journeys back, forth, and across conceptual terrain. In this study, students related theoretical knowledge of medical, social or psychological conditions studied at school to clients’ situations in the clinical setting. This was referred to the broader literature on the concept of professional identity by relating to Ewan (1988), who defined professional identity as a self-image which permits feelings of personal adequacy and satisfaction in the performance of the expected role’. Studying together with other health professionals also exposed them to areas they found useful in their personal and professional development as indicated by Illingworth and Chelvanayagam (2007). Another dimension of students’ improved knowledge and their ability to skillfully demonstrate their transformed state is juxtaposed to the discursive’ aspect of the threshold concepts. Meyer and Land (2005) suggested that the crossing of a threshold will incorporate an enhanced and extended use of language. Students stated that, with their new knowledge and level of understanding, they were able to communicate their clinical reasoning to support their involvement with clients. As a limitation, the study was not meant to generate an exhaustive list of threshold concepts hence, there might be other threshold concepts that might not have been identified due to the situational context of the study. Conclusion Exploring students’ experiences in relation to PID reflected three constructs which included personal knowing, professional knowing and experiential knowing. Using the constructs, the study captured the association of the threshold concepts with the difficult processes that students went through in transformation from novice into graduate professionals. It was identified that PID, whilst being a unique experience for each learner, can be expressed through the process of navigating a number of thresholds. 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Ethical enculturation: The informal and hidden ethics curricula at an Australian medical school. Focus on Health Professional Education, 6(1), 85–99. Woodside, D., Carter, J., & Blackmore, E. (2007). Predictors of premature termination of inpatient treatment for anorexia nervosa. American Journal of Psychiatry, 16, 2277– 2281. https://doi.org/10.46743/2160-3715/2008.1579 https://doi.org/10.46743/2160-3715/2008.1579 Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 61 World Federation of Occupational Therapists. (2002). Revised minimum standards for the education of occupational therapists. World Federation of Occupational Therapists Bulletin, 46(1), 30-33. https://doi.org/10.1080/20566077.2002.11721124 Author Note Dr Peter O. Ndaa is a lecturer at the Department of Occupational Therapy (OT), School of Biomedical and Allied Health Sciences, University of Ghana. Peter is an experienced Occupational Therapist with over 10 years practicing experience in the UK prior to taking up a job in academia to coordinate a new BSc Occupational Therapy professional course in Ghana. Peter has a PhD in Occupational Therapy from Coventry University after having his MSc OT at Glasgow Caledonia University and, BSc OT from Northumbria University all in the United Kingdom. He is also the immediate past president of Occupational Therapy Africa Regional Group (OTARG) a regional representative for world Federation of Occupational Therapist (WFOT). Peter is an academic consultant with University of Gondar, Ethiopia and the Queen’s University, Canada. Peter is on the Editorial Board of the South Africa Journal of Occupational Therapists. Currently Peter is assisting to set up the first Occupational Therapy programme in Ethiopia. Aside his academia roles, Peter is passionate to seeing his clients in their maximum functional capability and able to participate meaningfully in activities of their choice. Among his many researches in enabling independence, Peter has recently conducted this longitudinal phenomenological research into the first cohort of Ghanaian OT students’ professional identity development as they progressed through this new professional course programme. Please direct correspondence to: pndaa@chs.edu.gh Prof. Katherine Wimpenny, PhD, MA, DipCOT, Cert Ed, is Professor of Research in Global Education and Theme Lead for Global Learning: Education Without Boundaries, in the Research Centre for Global Learning: Education and Attainment (GLEA), Research Institute of Global Learning, at Coventry University (CU). Katherine worked as an occupational therapist for 10 years in health followed by 10 years as an academic on the undergraduate and postgraduate occupational therapy programmes within HLS, CU. She was awarded her PhD in 2009 and partnered with several NHS Trusts facilitating knowledge transfer through participatory action research methodologies. Since 2010 she has held a full-time research role, initially as Research Fellow in Learning Innovation and then for four years in the Disruptive Media Learning Lab (DMLL) CU, where she was Conferred as Reader in Education Research and Pedagogy. In August 2017, Katherine started in GLEA having helped shape the business plan along with Professors Lynn Clouder and Christine Broughan. Katherine was Conferred as Professor of Research in Global Education in 2018. She works with a diverse range of national and international partners and has a track record in the design and coordination of research and innovation projects, both nationally and internationally, and is widely published in the academic literature. She is Visiting Professor at An-Najah National University Palestine. Dr. Rebecca Khanna has extensive experience working in the statutory sectors of health and higher education as a senior manager and service evaluator. After qualifying as an Occupational Therapist in 1984, she gained a variety of experiences as a senior clinician working across mental health and physical rehabilitation services in a number of NHS Trusts within the UK. In 2000 she commenced working in higher education at Coventry University, where she held several senior roles at department and college level connected with course leadership, curriculum review and quality enhancement. Rebecca undertook project work within the Centre for Excellence in Inter-Professional E-Learning. Before leaving Coventry University she was seconded as project lead for a cross college project involving the concurrent major review of 12 pre-registration courses. In 2013 Rebecca joined Sheffield Hallam University as College Head of Quality working in Health and Wellbeing. Subsequently, in https://doi.org/10.1080/20566077.2002.11721124 mailto:pndaa@chs.edu.gh 62 The Qualitative Report 2021 2015 she became Assistant Dean, Academic Development. Rebecca is keen to pursue her ongoing interests of innovative curriculum models, inter-disciplinary working and maximising accreditation opportunities. She continues to work at national level as an HCPC Visitor and Accreditor of Occupational Therapy programmes, alongside serving on several national committees. She is also reviewer for the British Journal of Occupational Therapy and works as an External Examiner and invited panel member. Rebecca provides supervision to doctoral and MSc students. Dr. Simon Goodman is a Senior Lecturer in Psychology with Faculty of Health and Life Sciences, School of Applied Social Sciences at the De Montfort University, Leicester. Dr. Goodman is an expert qualitative researcher. He uses discursive psychology to address a number of issues. Much of this research explores the discursive construction of asylum seekers and refugees in which he has focused on the ways in which potentially prejudicial arguments against asylum seekers are presented as reasonable and non-prejudicial. In addition, his work focuses on what is, and what is not, considered to be racist particularly with regard to asylum seeking. His research also explores the (largely negative) experiences of asylum seekers in the UK and the ways in which they make complaints and resist their negative presentations. His other interests include online hate speech, the British public’s understanding of income inequality and high earners, as well as the ways in which the far right attempt to present their policies as acceptable and non-racist. Prof Ajediran Idowu Bello is an Associate Professor of Musculoskeletal Physiotherapy at the University of Ghana. Prof Bello’s research interests have always entailed modification of therapeutic exercises and other adjunct physical modalities in the remediation of musculoskeletal impairments and disability, as commonly experienced by individuals with musculoskeletal dysfunctions such as osteoarthritis. His research focus underscores the quest for data in support of best strategy to restore optimal body functions. He has often directed his efforts toward exploring impairments and disabilities (as rehabilitation potentials) in most non- communicable diseases. He has executed a couple of investigator-led and seed grants either as principal or co-principal investigator, and his research outputs on musculoskeletal dysfunctions are reflected in a host of publications. In addition to his over 10 years of teaching experience in musculoskeletal physiotherapy courses, he also led a team constituted by the Ghana Physiotherapy Association to develop practice guidelines for the rehabilitation of patients with COVID-19. Acknowledgements: We acknowledge the maiden cohort of BSc occupational therapy students in Ghana who willingly agreed to participate in the project. Other appreciations go to Dr. Louis Connolly who helped to formulate the research idea. Funding: This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors. Conflicts of Interest: Authors declare no conflict of interest. Copyright 2021: Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, Ajediran I. Bello, and Nova Southeastern University. Peter O. Ndaa, Katherine Wimpenny, Simon Goodman, Rebecca Khanna, and Ajediran I. Bello 63 Article Citation Ndaa, P. O., Wimpenny, K., Goodman, S., Khanna, R., & Bello, A. I. (2022). Exploring students’ experiences in occupational therapy education: A phenomenological study of professional identity development. The Qualitative Report, 27(1), 44-63. https://doi.org/10.46743/2160-3715/2022.5162 A Open Access Coversheet (1) (1) Exploring Students_ Experiences in Occupational Therapy Education Exploring Students’ Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development Recommended APA Citation Exploring Students’ Experiences in Occupational Therapy Education: A Phenomenological Study of Professional Identity Development Abstract Keywords Creative Commons License Acknowledgements tmp.1641222830.pdf.f7oYv