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BACKGROUND: This study investigates the perceptions of safety among entry-level doctoral occupational therapy (OT) students during their Level II fieldwork and capstone experiences. The significance of safety, defined as emotional comfort and the ability to express oneself authentically, is emphasized in fostering learning outcomes and mental health. The paper highlights that institutions providing safe spaces enhance acceptance and conversely, a lack of emotional safety, often due to microaggressions, adversely affects student retention and mental health. METHOD: An author-created survey was utilized at the conclusion of the program to 45 third-year OT students. The 10-item survey assessed perceived physical and emotional safety during fieldwork/clinical rotations and capstone, occurrences of microaggressions, and possible solutions to improve student's sense of safety. RESULTS: The majority of respondents reported feeling physically (95%) and emotionally (72%) safe overall. However, Level II fieldwork/clinicals was identified as the setting where students reported the most frequent lack of safety. Six main themes impacting safety perceptions were identified: expectations, reflection/advocacy, education/preparation, communication, coping strategy, and the acknowledgment that some students may not require interventions. CONCLUSION: Findings suggest that allied health academic programs should take steps to ensure that the safe spaces created during didactic portions of the curriculum extend into clinical and experiential settings. This approach will not only improve learning outcomes but also support students' mental health and their ability to provide quality healthcare. Future research should focus on evidence-based practices to support student safety in clinical education. J Allied Health 2025; 54(4):e537-e542.
BACKGROUND: This study investigates the perceptions of safety among entry-level doctoral occupational therapy (OT) students during their Level II fieldwork and capstone experiences. The significance of safety, defined as emotional comfort and the ability to express oneself authentically, is emphasized in fostering learning outcomes and mental health. The paper highlights that institutions providing safe spaces enhance acceptance and conversely, a lack of emotional safety, often due to microaggressions, adversely affects student retention and mental health. METHOD: An author-created survey was utilized at the conclusion of the program to 45 third-year OT students. The 10-item survey assessed perceived physical and emotional safety during fieldwork/clinical rotations and capstone, occurrences of microaggressions, and possible solutions to improve student's sense of safety. RESULTS: The majority of respondents reported feeling physically (95%) and emotionally (72%) safe overall. However, Level II fieldwork/clinicals was identified as the setting where students reported the most frequent lack of safety. Six main themes impacting safety perceptions were identified: expectations, reflection/advocacy, education/preparation, communication, coping strategy, and the acknowledgment that some students may not require interventions. CONCLUSION: Findings suggest that allied health academic programs should take steps to ensure that the safe spaces created during didactic portions of the curriculum extend into clinical and experiential settings. This approach will not only improve learning outcomes but also support students' mental health and their ability to provide quality healthcare. Future research should focus on evidence-based practices to support student safety in clinical education. J Allied Health 2025; 54(4):e537-e542.
HEALTH SCIENCE student perceptions of safety have an impact not only on learning outcomes but also on students' mental health.[1] Safety-in the form of a "safe space"-can be characterized as possessing the qualities of emotional comfort and the security to express one's authentic self in a sincere and unadulterated manner.[2,3] Educational institutions that establish safe spaces conducive to student growth are able to foster accepting behavior and attitudes, particularly to students who experience marginalization, such as students of color, LGBTQIA+ students, students with disabilities, and feminine students.[1.4,5] Conversely, institutions in which students experience a deficit of emotional safety, often in the form of microaggressions, are likely to see decreases in student retention year over year.[6] For these reasons, it is clear that there are material repercussions impacting students, educators, and administrators when institutions fail to establish safe spaces. Further, in graduate health science education, feelings of safety are directly related to students' ability to provide quality healthcare to patients during fieldwork, preceptorships, internships, and residencies.[1]
At the level of occupational therapy, there is little research that corresponds with the impacts of student perceptions of safety and microaggressions. An opinion piece published in the American Journal of Occupational Therapy in 2023 indicates the necessity for occupational therapists (OTs) and educators to take microaggressions seriously, in clinical and classroom capacities.[7] As indicated by the authors, reducing the prevalence of microaggressions and providing individuals with emotional and social tools to navigate through microaggressions is necessary if diversity, equity, and inclusion (DEI) goals are to be met and sustained.[7]
In the researchers' entry level doctoral program, there are multiple measures put in place to encourage feelings of safety within the didactic portion of the curriculum. A diversity, equity, justice and inclusion cure riculum is embedded in coursework from the first to the last didactic semester. Currently there are five learning objectives associated with the curriculum. First, students learn how to practice self-awareness, understand shame culture, and recognize their own positionality within a greater culture of shame and oppression around health care. Second, students learn how to identify unconscious bias and practice cognitive empathy as a means of mitigating bias. Third students practice this with specific populations. Fourth, students learn structural awareness of the healthcare system and how they can affect structural change. And fifth, students learn skills in boundary setting, self-advocacy and self care. Students are also provided safe spaces to give program and faculty feedback through the use of class representatives and town hall meetings with the chair each semester. The program offers other supports such as free counseling and community building days to provide for emotional wellness. These concepts and objectives are reinforced during preparatory classes for fieldwork and capstone planning courses.
In broader health science disciplines, studies have found that microaggressions persist. For instance, "heteroprofessional" expectations prevent LGBTQIA+ health professionals from feeling safe in a range of healthcare-related workplaces.[8] Likewise, recent studies on microaggressions between students and supervisors in a genetic counseling program found that microaggressions directed at students by their supervisors impaired mental health and negatively impacted learning outcomes.[9] To the contrary, when regulatory bodies, institutions, or workplaces place safeguards to reduce microaggressions or instances of discrimination and harassment, students are better positioned to succeed, especially in navigating the power dynamic between themselves and supervisors or mentors.[10]
Considering the potential value for implementing safety measures in other health science curricula, the onus is on OT programs to ensure as much as possible that students feel safe from matriculation through graduation. This is especially important during student fieldwork and capstone experience and project where students are oftentimes outside the protective bounds of the institution and forced to rely on mentors who may or may not have received vital training on microaggressions and student support. A 2023 systematic review found that mentors' emotional intelligence is an important, predictive factor in fieldwork performance.[ 11] Additionally, supervisory workspaces lacking equipment or in which students feel inclined to rupture their work-life balance, produce work beyond their means, and work without proper supervision, all of which can contribute to decaying mental health.[12] Students from cultural and linguistic backgrounds differing from that of their mentors have also experienced alienation from their learning spaces and workplaces, both as a result of feeling misunderstood but also due to challenges communicating across language gaps[13]. Above all, studies find that students consistently feel that they are unsupported during fieldwork experiences.[11,12]
As such, OT and allied health programs should reconsider how various safe spaces created extend from the classroom and into fieldwork/clinical and capstone experience and project as a means to mitigate microaggressions and provide less alienating learning environments conducive to student success. Researchers sought to understand: what is the continuity of safe spaces from OT classrooms into Level II fieldwork (FW), capstone experience and project in the entry-level doctorate (herein capstone), and how do students perceive their safety during these experiences?
Methods
Study Design
An author-created survey was disseminated via the Qualtrics© survey platform. A survey method was selected to minimize the time commitment required of participants and gather focused information that may be useful in future cohort engagement. In the survey, participants reported their perceived emotional and physical safety while on Level I, Level II FW, or capstone. Participants identified their overall perceived emotional and physical safety, if they experienced any microaggressions during their clinical rotations, and which setting or experience this occurred (FW and/or capstone). This project received exempt status from the Northern Arizona University Institutional Review Board (2197984-1).
Survey Design
Authors collectively created the survey which consisted of 10 questions total: 4 yes/no or n/a, 2 Likert (0-10; Q3, Q6) regarding level of perceived feeling experienced ("0" feeling completely safe to"10" feeling completely unsafe), 2 questions identifying the participant experiences involved, 1 optional free response to share solutions( Q10), and 1 Likert question (0-10; Q9) regarding importance of providing education on microaggressions to FW educators and capstone mentors ("0" not important to"10" extremely important). Question 10 was an open-ended question which asked participants: "reflecting on your experiences, what solutions come to mind to address microagressions during clinical experiences?" The survey is presented in the Appendix.
Participants
Participants included 45 third-year OT students enrolled in an entry-level doctorate with FW placements throughout Arizona. Students were invited to complete an anonymous and voluntary survey. Participants had completed all didactic course work, FW, and capstone.
Data Collection
Participants were emailed a link to an anonymous survey Qualtrics© as part of routine program evaluation at the conclusion of the program. Responses were anonymous and students were not required to complete the survey. Perceptions of safety while on FW or capstone were measured at a single point at the end of their OT program as well as any potential solutions. Demographics for the cohort were collected as part of the program evaluation and were used to describe this cohort.
Data Analysis
Data collected were analyzed by the secured and encrypted survey platform Qualtrics© and were reviewed by the investigators. Descriptive statistics and tables represent the quantitative data. Two researchers met and used rapid analysis methodology to condense the open responses from participants into broad and specific codes.[14,15] Codes were reviewed by the two remaining researchers for agreement.
Results
Forty-five students were invited to participate through an email link and 39 participants completed the survey. This represents an 86.7% response rate. Demographics of the entire cohort are presented in Table 1.
Overall, the majority of participants indicated they felt physically and emotionally safe during FW and capstone (n=37 and 28 respectively). Responses indicate that FW II is the setting (n=11) where participants indicated they felt the most unsafe and data are presented in Table 2. Examples of unsafe experiences provided by participants include feeling taken advantage of, microsaggressions, lack of clarity in roles, inadequate mentorship, and implicit bias. Survey questions 3 and 6 (Likert scale) asked participants to rate their perceived levels of emotional and physical safety, respectively. However, no responses were received for these questions, leaving no data to report.
Of the 40 participants surveyed, 36 responded to survey question 10 (90% response rate) with the mean response = 8.89 (range: 3-10). The open text responses regarding potential solutions yielded four responses. However, upon review, the responses were unrelated to solutions and did not directly address the question (Q10) as intended. As a result, they were excluded from further analysis.
Open text/free responses were analyzed and condensed into six themes: expectations, reflection/advocacy, education/preparation, communication, coping strategy, and no solution needed. The six child themes were roles/responsibilities, student education collaborating with school or program, microaggression and bias training-FW educators/capstone mentors/studentpreparation, faculty and CI communication/opportunity for anonymity (student), and student reframing.
Discussion
The survey results from the cohort of 39 respondents reveal a positive perception of safety in FW and capstone experiences. With a high response rate of 86%, the data demonstrate that participants feel both physically (95%) and emotionally (72%) safe overall. FW II emerged as the setting where participants reported feeling the most unsafe, with 100% of those who reported feeling physically unsafe (n=2) and 9% of those who felt emotionally unsafe (n=1). Of note, FWII rotations and capstone experiences are when students are away from the program the longest and may experience being out of touch with campus resources (counseling services, faculty meetings, peer support) to support their coping. Participant responses also indicated a high mean (8.89) of importance for the program to provide education on the topic of microaggressions. These findings align with the literature and suggest that addressing microaggressions through education is a priority for the program's com- munity partners and highlights the need for targeted efforts to foster inclusive practices in collaboration with community partners.[16,17]
The qualitative analysis of open-text responses highlights six main themes impacting the student's sense of safety: expectations, reflection/advocacy, education/ preparation, communication, coping strategy, and the idea that no solution is needed. Although the participant responses and resulting themes do not explicitly address safety, they provide background and a foundation for building safety into clinical experiences that can be shared across allied health programs.
Expectations: This theme pertains to the alignment between students' anticipations and their actual experiences as well as the FW/clinical educator and capstone mentors' alignment of expectations. Several students emphasized the importance of clear expectations between instructors and students, with one student noting that their mentor assigned a full caseload by the sixth week but later expressed concerns about their performance, which contributed to feelings of insecurity and lack of support.
Reflection/Advocacy: This theme involves the role of self-assessment and support systems available to students and FW/clinical educators and capstone mentors. Suggestions provided indicate that students value faculty support as well as site support. Some students indicated that advocating for themselves when faced with challenging situations, such as microaggressions or overburdening tasks, helped them gain a sense of control and security. One student described practicing selfadvocacy strategies, including addressing microaggres sions directly and expressed concerns to their mentor.
Education/Preparation: This theme focuses on providing students with specific tools to use as well as preparation with faculty and trusted educators prior to fieldwork that may enhance their ability to respond in the moment if needed. Examples of safe spaces curated and provided at the broader institutional level include campus resources such as counseling services, advising, equity and access resources. Classroom interactions also contribute including peer support, use of current student panels for review of clinical experiences, and alumni panels for overall program understanding. Also, providing opportunities for FW educators and capstone mentors to learn about bias may be beneficial. Roberts and colleagues highlight that innovative education programs build trust with programs and sites and can help retain and sustain qualified clinical educators.[19]
Communication: This theme highlights that consistent and clear feedback and communication between students and FW educators and capstone mentors can enhance a student's feeling of safety. A similar finding that educators can work in the curricula to create a culture of safety was reported in the 2018 scoping review in the related health field of nursing.[18,19]
Coping Strategy: This theme focused on how students choose to deal with challenging situations. For some students this meant reframing the experience:
For me it came down to am I going to let this person scare me into thinking I was not capable of being an OT or do I take this situation and switch into a positive. I chose to see it as a learning experience, an opportunity for me to rise above it and prove that I'm knowledgeable and I have the skills to learn and grow in any environment. After I viewed that person differently I had a great time and I learned a lot.
No Solution Needed: This theme highlights that there is variation in student experiences. This acknowledgment that some students may not require support or interventions reflects the diversity of experiences and the importance of individualized support.
Authors recognize that these themes are multifaceted and underscore the importance or relevance of comprehensiveness in maintaining and enhancing students' sense of safety during their OT clinical and experiential rotations.
Limitations
First, the use of a convenience sample limits the overall generalizability of the work. Demographics provided herein are based on the cohort overall rather than the survey itself, and therefore the researchers are unable to ascertain if race or gender influenced any perceptions of experiences. As a self-report questionnaire, there are inherent biases and limitations. Due to wording in the survey, authors did not capture the participant's ideas for solutions which would have provided another layer of insight into their first-hand experiences. Rather than providing solutions, participants reported their experience( s) in Question 10. Finally, the surveys were completed anonymously by participants, so the researchers did not have an opportunity to validate the responses or feedback.
Conclusion
Allied health programs should consider how the safe spaces created in didactic portions of curriculum extend beyond the classroom. Fostering a sense of safety for students during their fieldwork/clinical and capstone experiences may ensure the continuity of safe spaces and maximize student learning while on clinical rotations. This comprehensive approach safeguards mental health, ability to provide quality services to clients, and addresses a student's sense of safety throughout all of the learning environments. The findings of this work indicate that a majority of students felt physically and emotionally safe, yet concerns arose during clinical rotations/FW II where the highest incidences of perceived unsafety were associated. Enhancing safety measures in OT and other allied health education not only stands to improve learning outcomes, but also prepares students to deliver culturally competent care in the field. Future research and implementation of evidence- based practices for physical and emotional safety are essential to support students as they engage in the profession.
Implications for Allied Health Education
Opportunities exist to prepare students and FW/clinical educators, and mentors. Several implications for academic allied health programs to consider are:
* To address the identified theme of expectations a program might consider their own program specific fieldwork educator and capstone resources and include information on how students can access support services to address wellbeing. Creating resources aligns to the Accreditation Council for Occupational Therapy Education (ACOTE) Standard C.1.9 states: "Document a process for communication with the student and fieldwork educator throughout the fieldwork experience. Ensure all aspects of the student's progress and performance are addressed and the fieldwork educator is aware of resources that support student well-being."[20]
. Create and deliver clear expectations to students, FW educators/ clinical educators, and capstone mentors early and often in the programs.
™ Example: Use of cloud-based information or videos that can be easily curated, accessed, and updated. ™ Example: Use of mentor agreements for capstone.
. Consider resource provisions for students away from the campus and outside of traditional work hours. Provide links to resources for students, FW/clinical educators, and mentors on the academic program's website.
. To address the identified theme of coping strategy, may consider providing opportunities for students to provide anonymous feedback throughout experiences.
. Scenario-based workshops or online classes tailored to address implicit bias and promote cultural humility.
™ Ongoing bias training to create safer learning environments.
. Implementing tools and workshops to equip students with skills to navigate and mitigate microaggressions could enhance educational and mentoring experiences.
. Offer professional development units for the state and national level to FW/clinical educators and mentors that highlight the six main themes mentioned.
. Academic allied health programs can collaborate to share the work in presenting materials at the state and national conference level.
References
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