Adapting student practice placements in response to COVID-19: ‘Get there together’ a digital stories project for people living with dementia

ABSTRACT

The impact of COVID-19 has been harshly felt by occupational therapists in practice and students requiring practice education placements. A collaboration between Aneurin Bevan University Health Board (ABUHB) and Cardiff University enabled 10 undergraduate students to undertake their final placement by participating in a Digital Stories Project. This placement was innovatively designed to allow students to meet their learning objectives remotely, reducing clinical days in adherence to social distancing measures. The ‘Get There Together’ project was created by the national steering group after identifying the devastating impact COVID-19 had on people affected by dementia when accessing community occupations. The students collaborated with service users to identify areas that they wanted to visit, creating digital recordings explaining what to expect due to COVID-19 rules. This paper will focus on the conception and development of the Digital Stories Project, which helped increase placement capacity for occupational therapy students, during the COVID-19 pandemic.

KEYWORDS:

• Collaborative working
• peer learning
• creativity and innovation in practice education
• occupational therapy
• occupational therapy students

Introduction

The global pandemic of COVID-19 has had a major impact on all lives and has thrown up several challenges for Higher Education Institutions around the world. The need to provide practice placement opportunities for undergraduate occupational therapy students is a central part of pre-registration training (World Federation of Occupational Therapists [WFOT], 2016) and creative solutions were required to provide meaningful learning opportunities that ensure we have skilled professionals who are ready to enter the future workforce.

Reason for new practice

The impact of COVID-19 and the necessary social distancing measures have reduced the number of traditional practice placement opportunities for undergraduate occupational therapy students. Despite this, in 2020, the university required an increased number of placement opportunities to compensate for the number of placements that were automatically cancelled or withdrawn when the pandemic first emerged.

Working in partnership with colleagues in practice, several innovative possibilities were explored to help address placement capacity issues. One of these was the development of the Digital Stories Project placement, which was facilitated across South East Wales by the Aneurin Bevan University Health Board, in Gwent and supported by occupational therapy lecturers at Cardiff University. The Digital Stories project was designed to support a national ‘Get There Together’ project being delivered across Wales.

Background

The Get There Together Project emerged because of the devastating impact that COVID-19 was having on people affected by dementia accessing the community; Doctor Natalie Elliott, National Allied Health Professional Lead for Dementia in Wales, started to consider options to enable and promote greater participation and engagement in community occupations. Key issues identified included service user anxiety related to accessing their local area to engage in their traditional occupations, with people affected by dementia and their carers reporting loneliness and isolation (Alzheimer’s Society, 2020). Lack of confidence impacted upon engagement in self-care and leisure occupations, such as attending salons, doctor surgeries, pharmacies, cafes, and local shops. The Alzheimer’s Society (2020) established that people affected by dementia were experiencing difficulties with understanding the government rules surrounding accessing a range of community settings, and a national steering group developed by Doctor Elliott recognised that providing simple guides showing people affected by dementia what to expect when visiting local places that were significant to them could be of great benefit (Elliott et al., 2021). The National Steering Group membership consisted of representatives from a broad range of organisations including Health, Social Care, housing, dementia-friendly community leads, the Alzheimer’s Society, shopping centres, emergency services and individuals affected by dementia and their carers. The Get There Together Project is supported by the Bevan Commission under their exemplar programme.

Reason for occupational therapy

The Get There Together Project was established by the national steering group to explore possible solutions to community access issues. The COVID-19 pandemic was clearly inhibiting engagement and participation in occupations for people living with dementia (Alzheimer’s Society, 2020), which has been recognised to be intrinsically linked with the promotion of health and well-being (Whalley Hammell, 2017). Aneurin Bevan University Health Board occupational therapists acknowledged that the Get There Together project aims fitted perfectly with occupational therapy philosophy. Occupational therapists can offer a wide range of rehabilitation services, using carefully planned, evidence-based interventions to promote community access and social inclusion (WFOT, 2020).

The Aneurin Bevan occupational therapists approached the Practice Education Team at Cardiff University to explore the potential of the project and how this might meet the essential learning objectives for students on their final assessed practice placement. Part of the core skillset of occupational therapists is the ability to analyse activities and occupations, breaking down key tasks into their component parts (Dancza et al., 2018), which would prove to be a vital skill needed in this project.

The steering group decided that simple, digital resources consisting of short videos would be an engaging and interactive way of showing people affected by dementia what to expect when accessing occupations in their local communities. Developing and sharing digital videos of places of interest within Wales would be a huge task, especially due to the government advice and regulations constantly changing. Resources across Gwent in terms of staffing levels and time were at maximum capacity and consequently, there was limited opportunity for staff to engage with the project. Simultaneously, the practice education team at Cardiff University was appealing for local health boards and third sector organisations to offer placements that could be completed by occupational therapy students safely during the pandemic. Health Education and Improvement Wales (HEIW) issued its’ All Wales COVID-19 Placement Recovery Principles (2020) emphasising the importance of practice education placements continuing. HEIW (2020) directed the need for both adequate risk assessment and innovation to expand placement availability due to social distancing guidelines reducing capacity for traditional placements. The need to be creative to address these directives was acknowledged and all parties would be required to collaborate so that students would be able to attend placement. This prompted an open dialogue between the health board and the university practice education team regarding a project placement, with an increased emphasis on remote learning. It was established that students would be able to work on a Digital Stories Project remotely whilst also integrating some face-to-face clinical practice to meet all the learning objectives successfully. This meant that more placements could be offered by the health board, with less time spent onwards and in offices allowing adherence to COVID-19 safety guidelines. Ten students were carefully matched to proposed placements in five locality areas across Gwent, with placement allocators considering the five HEIW placement recovery principles (HEIW, 2020), as well as the skills required for working on the Digital Stories Project.

Pre-placement planning

Prior to the practice placement, planning was required to ensure that it offered both the students and the service the right experience. As Aneurin Bevan University Health Board covers five counties across Gwent, parity was ensured by having students placed in all five areas and having two students to represent each borough (2:1 model), which offered opportunities for peer learning to increase confidence, resourcefulness and proactiveness (Price & Whiteside, 2016).

The purpose of the placement was agreed with key stakeholders in the health board and university. The idea was then pitched to all occupational therapy practitioners working in older adult mental health to seek volunteers to support and educate students on placement. Initially, some educators felt apprehensive due to this not being a traditional placement, and it was agreed that three-weekly educator meetings could be established to support staff to navigate challenges that the placement might present. Twelve occupational therapists were recruited as educators to support the placement.

A split placement structure was chosen, with three days a week spent working on the project and a day and a half a week working alongside a clinical educator in the practice setting. Students are also allocated half a day of study time weekly. This structure ensured that the students had the opportunity to develop the clinical skills required for working within older adult mental health occupational therapy services, while also offering the educators the opportunity to learn and develop from the students work on the project. This would promote reciprocal learning and the facilitation of opportunities to share experiences (Rodger et al., 2014).

Whilst ensuring that the students felt supported, it was essential for the students to have the opportunity to meet as a project group to share progress and problem-solve difficulties as they arose. As such, weekly group supervision sessions were established, supported by occupational therapy staff from the health board and university.

After the university placement team had matched students to the placement, a group pre-placement meeting was held via Microsoft Teams to explain the placement and project to them and to answer any questions or concerns that the students had from a health board and a university perspective. Mapped learning outcomes were shared with the students which suggested creative ways of meeting these, for example, rather than restricting gaining an understanding of models and approaches to traditional occupational therapy models, encouraging project management models and techniques to be explored.

Implications and impact

Training and development needs

To create the digital stories, Digital Communities Wales (2020) provided a bespoke group online training session on the use of appropriate software and how to ensure the digital stories were accessible for individuals living with dementia. Additional training was also completed to enhance the students’ understanding of dementia and how it can impact on people’s lives. This included Dementia Friends training (Alzheimer’s Society, 2017) and use of Positive Approaches to Care (Snow, 2020) online resources. The National Steering Group developed resources to support the placement by providing templates for the Digital Stories and ensuring the resources produced were consistent. Examples of these templates included guidelines, consent forms, branding, and an example video. Additionally, resources from the Dementia Engagement and Empowerment Project (2020) were also used.

Assessment

Assessment forms part of the traditional approach that occupational therapists use when working with service users to enable us to gain an understanding of our clients and their occupational needs (Forsyth, 2017). Part of the difficulties identified for people living with dementia was their ability to engage in occupations undertaken in their local communities. The need to follow government guidelines as a direct result of COVID-19 caused increased levels of confusion and anxiety (Alzheimer’s Society, 2020) for members of this population.

The National Steering Group recognised that creating digital stories for all local amenities in Wales would be an impossible task. It was vital that the most pertinent venues for individuals living with dementia were identified, so that these premises/locations could be prioritised. These factors needed to be considered and with this in mind, the National Steering Group developed a non-standardised Community Needs Assessment Questionnaire, which asked individuals affected by dementia to identify the community locations that they previously frequented and those that they were most keen to return to but felt anxious about. The students were able to complete these questionnaires with service users both in person in clinical settings, as well as over the phone and via virtual video calls to reduce patient contact due to COVID-19 infection control. Prominent places of interest identified included supermarkets, doctor surgeries, cafés, and hairdressers.

Administering the Community Needs Assessment Questionnaire linked to several of the student learning outcomes for assessed practice placements. Therapeutic and communication skills were developed through undertaking the assessment, enabling opportunity to establish rapport, gain relevant information and adapt communication skills to suit each individual service user’s needs. Additionally, organisational skills were required to arrange and plan the assessment with the service user, ensuring that all materials needed for the assessment were available. The occupational therapy students worked in collaboration with a range of other professionals and agencies, including the Gwent Sub-Group, Alzheimer’s Society, and Memory Assessment Services to identify individuals and their family members in need of assessment.

Planning

Planning is a key element of the occupational therapy problem-solving process (McCullough, 2014) and involves the setting of client-centred goals. Using the outcomes of assessment, the students were able to explore how to use available resources effectively so that occupational goals could be addressed through the creation of digital stories. Initially, businesses had to be contacted either in person, on the telephone or online, to provide them with information about the project and to gain consent for their participation. Planning was also needed when taking photographs of the changes made at specific locations due to COVID-19 guidelines, showing the key messages that needed to be portrayed in the digital stories. When creating the digital stories, planning was used to create the script and subtitles, ensuring they were appropriate for the target audience, which were amended accordingly if needed. As well as on an individual level, planning also took place at group supervision sessions when discussing project development and working collaboratively to problem-solve any barriers. Communication with other professionals, external services and businesses were needed to effectively involve relevant locations in the project. The ability to be self-directed was essential when working autonomously on the project, which required organisation and time-management skills. Planning was a core element of the project and contributed to its’ smooth running, ensuring deadlines were met and meaningful digital stories were created. Reflective skills were utilised within each group session, providing opportunities to review what had been achieved and what the next steps would be.

Intervention

The intervention process involves occupational therapists working creatively to empower and enable individuals to achieve their occupational goals. During intervention, the therapists will consistently evaluate whether the interventions are meeting the needs of the service user and consider whether modifications need to be made (McCullough, 2014). The intervention process within this project involved using localities identified by individuals to create the digital videos and information leaflets, in both the English and Welsh languages. As a key aspect of ensuring that the digital stories met the needs and abilities of the service users, the occupational therapy students ensured they consistently involved service users and carers with the production of these technological resources (O’Connor, 2019).

The digital stories recordings were developed using Adobe Spark and focused on one locality per recording. These recordings were then added to by supplying voice-overs, where it was essential the students spoke clearly and at a measured pace, using simple language to create a calm, comfortable and relaxed atmosphere (Stenhouse et al., 2013).

The recordings were supported by developing information leaflets that were distributed as paper resources. These had to be designed as an easy-to-read format by using large font, supported by pictures and diagrams alongside the text, which needed to be easy to understand and avoided the use of jargon.

To maintain the consistency of the recordings, a template opening image was provided by the National Steering Group, and the group’s logo had to be clearly displayed on both the start and end slides. The completed digital stories were then shared with individual service users so that they could be viewed before they accessed the specific location, they had identified during the assessment process. Each recording was also shared on a website for use by other individuals who may find them helpful in preparation for accessing their local communities.

Evaluation

Evaluation is a core component of the occupational therapy process, used to draw meaningful conclusions about the effectiveness of practice. The outcomes of evaluation should be continually used to review and consider the occupational therapy problem-solving process, enabling therapists to refine, adapt and improve practice (Breckenridge & Jones, 2015).

The placement required consistent reflection in action (Schon, 1983). Informal reflection held significant importance and allowed constructive evaluation of changes implemented throughout the project. Reflective discussions allowed students to problem-solve and adapt to changes caused by the ever-changing lockdown rules and the implications local lockdowns had on contacting community agencies and businesses. During the weekly group supervision sessions, students shared their digital stories and gained constructive feedback from their peers, health board occupational therapists and members of the university practice education team. These supervision sessions provided a safe space for students to discuss and share ideas, review progress, and evaluate the effectiveness of their digital stories. It further enabled all parties to discuss how their experiences related to the practice placement assessment learning outcomes, in terms of communication, therapeutic, organisational and reflective skills. Additionally, the students attended Gwent Sub-Group meetings, sharing updates on the resources created and the progress being made on the project. The health board occupational therapists also facilitated a collaborative learning session on the use of evaluation in occupational therapy practice and as a tool within the project.

An evaluation form was developed by the students to utilise with clients, their families and MDT members to assist in evaluating the overall project. The final digital stories and information leaflets were also circulated with members of the Gwent Sub-Group and the National Steering Group. Positive feedback and praise were received, highlighting the effectiveness of the digital stories and the high standard of the resources created. It was also acknowledged that the resources developed could be used with a much wider range of service users, something that will be explored further in the future.

Leadership skills

The Royal College of Occupational Therapists Career Development Framework (RCOT, 2017) outlines four guiding principles for the development of those working within occupational therapy across all stages of their career, from novice individuals working in occupational therapy to experienced practitioners. This placement offered opportunities to develop knowledge and skills in each of the four pillars of practice, professional practice; facilitation of learning; leadership and evidence research and development.

This project offered a variety of ways to contribute to and enhance the development of student’s leadership skills in line with the RCOT framework (2017). The project was undertaken remotely due to the everchanging COVID-19 restrictions, thus requiring a considerable proportion of time spent working independently. Students were therefore expected to manage and prioritise their own designated workload and did so effectively within complex and changing systems, in line with the leadership pillar of practice (RCOT, 2017).

Students were encouraged to take on leadership roles within group supervision meetings, acting as chair or scribe, thus allowing them to direct the discussion. Meetings were carried out efficiently with professionally written minutes provided by the designated student. Each student nominated themselves for one of these roles at least once and in turn demonstrated their leadership skill development through facilitating teamwork and enabling the implementation of required actions. Additionally, the group supervisions offered a style of peer support not always available during practice placements. This offered a unique opportunity for students to support one another with the challenges that arose, allowing the students to problem solve together and consider different ways of working, while helping to develop and enhance each other’s knowledge and skills. Student leadership skills were also developed through attendance at regular meetings held by the regional project sub-group to provide feedback on progress, while providing feedback to other professionals within their clinical settings. This offered space for them to promote the occupational therapy profession and its’ unique contribution to health and well-being and to create and maintain meaningful relationships across organisations and professions (Alotaibi et al., 2019).

Facilitation of learning

Within the RCOT framework, facilitation of learning involves individuals taking responsibility for their own continuing professional development as well as supporting others to learn new techniques or skills (RCOT, 2017). The students were able to utilise their skills in creating digital stories, not only to create the intended videos for the project but in other aspects of their practice. They were able to share their knowledge with the wider team in the clinical setting, creating videos to summarise feedback to their educators and making recordings of intervention plans for service users with memory problems. The students also spent time creating case studies; promoting the role of occupational therapy; using digital stories as a tool for personal reflection; and creating training resources for specific occupational therapy assessments used within the service.

Involvement in the project offered students the chance to work with a variety of businesses and services in the community, where they were able to promote both the Get There Together project and the role of occupational therapy. The students attended regular meetings with members of the Gwent Sub-Group, many of which had limited experience of occupational therapy and, therefore, may not have understood the role that occupational therapists could play in developing the digital stories. The students were able to offer their own occupational therapy perspective on how the digital stories would be able to assist individuals living with dementia access their local community, whilst also ensuring that the stories remained occupationally focused, raising the profile of occupational therapy within these organisations.

When working to develop digital stories of community locations, the students were also able to share their knowledge from the dementia-related training they had attended. For example, when approaching businesses that were part of a national chain, it was noted that many had already developed national adverts to reflect the changes in stores. Nonetheless, the students were able to speak directly to local stores to explain the importance of providing more specific guidance for people affected by dementia so that they could access the community with less anxiety.

The group meetings allowed students to improve their ability to link theory to practice by critiquing and debating the use of a range of occupational therapy models of practice to explore the impact that lockdown measures may have had on individuals living with dementia. Students reflected on the challenges that individuals and their families may have faced during the COVID-19 pandemic and how the project could be used in relation to each model to help individuals and their families overcome barriers. The students shared their understanding and knowledge with other students, lecturers, and occupational therapists during group meetings, contributing positively to the facilitation of learning for a range of affiliates.

Group supervision sessions

Literature identifies a range of benefits from the use of group supervision in professional practice with positive factors such as supporting individuals in their professional roles and responsibilities, sharing, and learning from each other’s experiences and developing team-working and leadership skills being cited (O’Keeffe & James, 2014; Snowden et al., 2020). Group supervision was facilitated once a week using a tripartite approach where the students, project leads within the health board and two university practice education members met to reflect on and share progress and address learning needs. As the project participants were located throughout all geographical areas served by the health board and all had to observe COVID-19 safety guidelines, this was facilitated via a weekly synchronous on-line meeting using Microsoft Teams, and promoted collaborative learning as postulated by Vygotsky (1978; cited in Hanson & DeIuliis, 2015).

Peer collaboration has been identified as a means of promoting and developing creative and critical thinking skills (Gokhale, 2012), something that was observed throughout the duration of this placement. The weekly meetings provided an opportunity for students to give and receive constructive feedback, a necessary skill for professional practice (Cushing et al., 2011). Students were able to acquire skills such as how to chair meetings, scribe minutes, disseminate information, and develop leadership skills, all of which contributed to their personal and professional development within the context of this changing face of practice.

There was flexibility within the sessions, which allowed for the development needs of the students to be addressed through working collaboratively to ensure the essential learning outcomes for the placement were achieved and evidenced. Opportunities to explore and critique how models of practice could be applied to this creative model of working were debated and additional learning opportunities were offered to help the students think about how they could develop their individual learning contracts to address their own learning needs within their final assessed practice placement. These were new and challenging ways of working for everyone involved; the students grasped every opportunity available to them, producing evidence of their learning that promoting creativity and innovation in the way they communicated with and addressed service user needs. This empowered people living with dementia to access community resources, enabling individuals to meet their self-care, productivity, and leisure occupational goals.

Case study example

To illustrate the use of digital stories in practice, this case study was identified as an example of the positive impact experienced by a service user living with dementia. Dewi Jones (pseudonym) is a 75-year-old man who was diagnosed with mixed dementia over three years ago. He is a sociable person, but since the COVID-19 pandemic and the closure of all non-essential businesses, including pubs and restaurants, he has found it difficult to stay at home and not be involved within the community. Dewi has experienced a decline in his cognitive abilities and was aware that he was becoming more forgetful.

Dewi would often visit his local social club and rugby club, where he enjoyed having a drink and meeting his old rugby friends. Dewi lost his wife a year before his diagnosis of dementia and has since found that accessing his local community is where he finds the most comfort and feels a sense of belonging (Gruhl et al., 2018). Dewi has food deliveries and goes to his local convenience store for his essential shopping.

Using the Community Needs Assessment Questionnaire, Dewi was able to identify the specific settings that he wanted to access in the community, prompting the creation of a digital story of this location.

Since the reopening of non-essential businesses, and the new rules and regulations that have been put in place to protect the public. Dewi had reported feeling anxious about accessing his local community as he was worried that he would not be able to remember what was expected of him. He was especially concerned about going back to his local social club, a place that he identifies as giving him a sense of belonging.

Meaningful occupations are unique for each individual and being able to address these and promote engagement in such occupations ensures client-centred practice is achieved. A digital story was designed to empower Dewi, enabling him to access purposeful and meaningful occupation in his local community social club, with increased confidence. By ensuring that we practice holistically and work collaboratively with Dewi to set personal goals, we were able to support Dewi to feel a sense of fulfilment and social inclusion, which is especially important for an individual living with dementia (Kielsgaard et al., 2021).

Reflections

Reflective practice and engaging in formal and informal reflections were a key element of the Digital Stories Project, from conception to completion. Using a tripartite approach, reflections from each affiliation are included.

Students perspective

At the end of the project, we all reflected that it was a fantastic and unique placement opportunity and working on the project remotely allowed us to take ownership of and be actively involved in guiding and contributing to service development as it was happening. Due to COVID-19 restrictions, it was necessary for services to adapt to the changes; developing digital stories allowed us to be involved in implementing these service changes, giving us a sense of purpose and satisfaction in our student role.

Clinician perspective

Educators in the health board reflected they would have liked to have had the opportunity to provide students with a broader wealth of clinical experience during the placement. Nonetheless, they have also highlighted many benefits to the service and service users. This includes raising the profile of occupational therapy across health, social care and third sector partners, which included promoting the benefits of occupation to health and well-being of individual and community populations. We were able to provide 10 student placements, enabling us to meet our commissioned placement numbers at a time where the capacity for traditional clinical placements was limited due to COVID-19 guidelines.

University perspective

Working collaboratively with students and partners in practice has provided a unique opportunity to explore placement provision during a stressful time for Wales and the world. Something that we are immensely proud of is the growth our students have demonstrated through working with their peers, developing their core occupational therapy skills, and aligning their own learning with the RCOT Career Development Framework (2017). Our students have shown initiative, creativity and have adapted to a new way of working admirably. We hope to continue developing this placement model and are excited to see how this can be used in the provision of future placements.

Conclusion

The Digital Stories Project was created in response to issues raised by the COVID-19 pandemic and has helped to provide creative solutions for people living with dementia and their concerns and anxieties of accessing community occupations. Alongside this, the project also enabled increased placement capacity for Cardiff University occupational therapy students in their final year of study. Using a tripartite approach and through working collaboratively in this project, students have been able to not only address the essential learning outcomes required for their final assessed placement but have also developed additional knowledge and skills that will contribute to their future practice.

Collaborative learning in this way provided a safe arena where students could gain insight and knowledge from working with each other (Boniface et al., 2012) that would enable them to develop knowledge and skills through their experience of working in a clinical setting that caters for older adults living with dementia, and to work on a project together that would equip them with a wide range of transferable skills in preparation for their own professional practice once qualified. Working as part of a team, problem-solving together and celebrating each other’s successes were instrumental parts of the professional journey experienced by the students. These skills and unique experiences will enable students to feel more confident in making the transition from student to the qualified practitioner (where they could be viewed as pioneers) in a world where practice is ever-changing as a direct result of this global COVID-19 pandemic.

Disclosure statement

No potential conflict of interest was reported by the author(s).