ARTICLES

 

Fieldwork education in health contexts: Experiences of fourth-year bsw students

 

 

Anna-Marie Beytell

Department Social Work, University of the Western Cape, Bellville, South Africa

 

 

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ABSTRACT

The Social Work profession experiences various challenges in practice that influence the practice education of students. Educators, practitioners and the experiences of students should inform practice education in curriculums. The aim of this study was to explore the experiences of fourth-year BSW students at the University of the Western Cape doing their fieldwork education in healthcare contexts. Integration of social work theories, the types of client problems, emotions caused by fieldwork and ethical dilemmas were challenges to students in health contexts. Supervision was emphasised by the students as a positive experience during fieldwork.

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INTRODUCTION

The social work profession faces many challenges in practice and these have an influence on the fieldwork education of students. Social work organisations are challenged with a lack of material and human resources, but the demands in terms of service rendering increase as a consequence of major social concerns, for example, poverty, physical and sexual abuse, violence and disease, and this is occurring in complex contexts where cultural sensitivity is a necessity. Legislative changes in other professions such as medicine and teaching, as well as the attention of the media, contribute to higher expectations from social workers. Fulcher (2008:66) regards some of these demands as "unrealistic and a burden for the profession." This tendency exists not only in South Africa, but globally. Globerman and Bogo (2002:7) focus on changes in healthcare in Canada, where social workers face increasingly complex volumes of cases along with staff reductions and less time to work with patients because the length of hospital stays is decreasing.

These demands have an impact on the profession and on field education, but little research has been done on this topic. The focus in curricula is primarily on course content, and thus practice education programmes are not the primary focus, as they should be if the demands of social work are taken into account. In addition, educators are faced with the challenge of deciding what is relevant and appropriate when designing curricula that address complex societal and educational demands (Bogo & Taylor, 1990; Fulcher, 2008; Teigiser, 2009; Vourlekis, Ell & Padgett, 2001).

Fieldwork education is of utmost importance in order to integrate theory and practice in the workplace. The Council on Higher Education (2011:18) emphasises the fact that integrated learning should enhance students' learning, especially for professional qualifications. To achieve a balance may be difficult, especially because professionally orientated education focuses on professional concepts and skills for students, and uses diverse methods of teaching and assessment appropriate for the degree outcomes. Knowledge development is organised in different university courses, while professional practice means knowledge is acquired in a more integrated manner. Teigiser (2009:140) argues that the integration of theory and practice in social work is dated, and that practice should be theory-based, but theory should be introduced according to practice reality. The Council on Higher Education (2011:9) concurs with this and proposes alignment between the academic field, where new knowledge is created, the education field, where students are educated in discipline-orientated concepts, professionally orientated education, where profession-specific education is carried out by enhancing professional concepts and skills, and professional practice, where knowledge is transformed into practice contexts. This is a complex process. Barnett and Hallam (cited in Walker, Crawford & Parker, 2009:32) describe practice education as "super-complex" because of the various standards, purposes, types of knowledge and consumers. The knowledge acquired at university is mostly not dependent on the context, but in practice it is context-specific, and students have to make decisions in complex and unpredictable situations in which they experience difficulty in integrating theory and practice (Council on Higher Education, 2011:11).

Litvack, Bogo and Mishna (2010:228) do not accept the above arguments and emphasise that the goal of practice is the development of students' self-awareness and the integration of personal and professional identity. Students develop emotional and personal values when they deal with their practice, the dynamics with clients and ethical dilemmas. The students' original identity is therefore not demolished and a new professional identity is not created in practice, but practice contributes to further enrichment of identity. The interpretations of Walker et al. (2009:31-32) include a combination of these perspectives and differentiate between knowledge, action and the self. Theories, policies, practice, recognition of multiple perspectives, different levels of analysis and constant enquiry are knowledge-based. Action encompasses skills which are based on an awareness of context, and that challenge structural disadvantages and work towards empowerment, as well as being utilised when negotiating understanding and interventions, and the self should be engaged in questioning personal assumptions and values, and increasing self-awareness.

The Professional Council of the profession significantly influences fieldwork practice (Council on Higher Education, 2011:14). The Bachelor in Social Work (BSW) degree in South Africa includes fieldwork education in all year levels, and certain exit-level outcomes have to be attained to comply with the requirements of the degree. Different learning methods are used, depending on the various year levels, and they may include action-learning, problem-based learning, inter-professional learning, workplace observation and practicum placements where workplace learning can take place. However, the SACSSP (South African Council for Social Service Professions) has not developed specific exit-level outcomes for practice education, and a task team was introduced in 2011 to examine and design these requirements.

The most important consideration when designing and developing fieldwork curriculums should be the students, who have to work- in unfamiliar but real contexts, which they sometimes actually fear. They have to work with the challenges of social work, as well as with clients from diverse backgrounds and with diverse problems. Fieldwork education should therefore have a learner-centred approach, and students' feedback is important for curriculum development (Council on Higher Education, 2011; Fulcher, 2008). This concurs with the argument of Bolzan, Haycock and Hughes (in Lewis & Bolzan, 2007:142), who propose a postmodern perspective to social work education where students' lived experiences inform education. These authors emphasise the importance of student participation by stating that "what is offered by a postmodern perspective is the imperative of listening to students about their experiences and the negotiations they make between the education they receive in class and the demands of field placements".

Fieldwork education is influenced by the various factors mentioned above, and students are placed in fieldwork settings according to their availability and suitability for students' learning needs. Educators have to plan carefully in order for students to benefit from fieldwork placements, especially with the larger demand for fieldwork placements and the challenges in the social work context. Walker et al. (2009:123) list the factors which should be considered in fieldwork planning as agency and personal capacity; service users' needs; opportunities for student learning; university requirements; and students' qualities, interests and experience.

The University of the Western Cape has 60-80 fourth-year BSW students per year, who need to do fieldwork education. The resources for fieldwork placement in the Western Cape are shared with Stellenbosch University and the University of Cape Town, and more recently with social auxiliary workers' training. The fieldwork educator at the University of the Western Cape in third- and fourth-year levels contacts or visits all the available and relevant resources annually in order to ascertain whether they comply with the requirements of practice in terms of integration of theory in practice, working conditions, clients and supervision before placing students for fieldwork education. Student requirements from the University are also taken into consideration. The students can indicate in which context they would like to do their fieldwork. The fieldwork placements are finally chosen in collaboration with individual students based on their learning needs and on an assessment of their ability to function within the context. This has resulted in students doing their fieldwork placements in healthcare contexts, which include not only health settings but also non-governmental organisations working with specific health-related issues, for example, autism, muscular dystrophy, Down syndrome, HIV/Aids, physical and mental disability, and substance abuse. Questions have been raised about the suitability of healthcare contexts for fieldwork education as it has been seen as a specialist field of social work and some social work educators were of the opinion that generalist social work practice and working with families should be the focus of fieldwork education on undergraduate level. These views are dependent on an understanding of what generalist and specialist knowledge encompasses.

There is no precise definition of generalist social work practice (Bogo & Taylor, 1990; Kirst-Ashman & Hull, 1997; Kirst-Ashman, 2013; Teigiser, 2009). Kirst-Ashman (2013:107) defines generalist practice as "application of an eclectic knowledge base, professional values and a wide range of skills to target individual, familial, group, organizational or community systems for change". Primary processes which should be followed when using this theoretical framework include: an emphasis on client empowerment; working under supervision in an organisational structure; having a wide range of professional roles; following evidence-based practice, and the application of critical thinking skills in planned change processes (Kirst-Ashman & Hull, 1997; Kirst-Ashman, 2013). Teigiser (2009:140) emphasises the different meanings of generalist social work practice and indicates that it can mean the different levels of practice, which include micro, mezzo or macro practice, or it can mean the various environmental influences on individual and family functioning.

Healy (2005:2) maintains that there are different constraints, requirements and rules with regard to social work depending on their historical, geographical and institutional contexts. The primary tasks and roles differ, because they are determined by the employer and the nature of the client system. The tasks and roles of a social worker in a health context will therefore differ depending on the level or specific focus of care. Decentralisation of services in the Department of Health complicates this even more, as social work roles and tasks are determined by the specific management of the institution, which will then result in different roles and tasks, irrespective of level of care and specific focus. In many instances this results in tasks and roles being assigned with an emphasis on the medical model or on perceptions of what constitutes social work.

When the above arguments are considered, it is clear that social work students doing fieldwork in healthcare contexts are actually doing generalist practice, but their roles and tasks are influenced by the institutional contexts. Bogo and Taylor (1990:79) concur that students must have generic knowledge about people as well as family functioning, dynamics and processes, but it must be adapted to the healthcare context. The knowledge base includes generic social work areas, for instance, knowledge about human behaviour, the social environment, social work policy, and programmes and practice. The health-specific knowledge base focuses on knowledge about the client population and on the nature of health problems in the context, as well as treatment and management of disorders from the medical and bio-psychosocial perspectives. The focus and nature of assessment and intervention in health settings are influenced by the medical model, and focus on health and illness (Fort Cowles, 2003; Healy, 2005). Kirst-Ashman and Hull (1997:9) state that a generalist practitioner should work in an organisation "with all its constraints, requirements and rules".

 

PROBLEM STATEMENT

When the importance and challenges of fieldwork practice, the debates with regard to undergraduate students doing their fieldwork education in health settings, as well as the importance of fieldwork practice in the curriculum and a learner-centred approach to fieldwork education were considered, it was evident that research with students about their experiences during fieldwork practice in healthcare contexts could be helpful in clarifying the situation. This information can then contribute to informed decision making and enhance not only practice education but also the social work curriculum. It was therefore decided to do research with fourth-year students at the University of the Western Cape doing their fieldwork in healthcare contexts. The important research question which needed to be answered was: What are the experiences of fourth-year undergraduate students doing fieldwork in a healthcare context?

 

RESEARCH METHODOLOGY

The research goal was to explore the experiences of fourth-year students at the University of the Western Cape doing fieldwork education in health contexts. A qualitative research approach with in-depth interviews was adopted, as well as undertaking document analysis of reflective documents during fieldwork. Non-probability purposive sampling was done from a population consisting of students at primary, secondary and tertiary levels of care.

Findings on students' experiences doing fieldwork education in healthcare contexts

Themes included the healthcare context; working with clients; emotional experiences; teaching and learning; supervision and ethical issues, as illustrated in Table 1. These themes are addressed in more depth with the literature to give more prominence to them in the text following Table 1.

Healthcare context

The organisational context contributed significantly to students' emotional experiences during fieldwork. The physical setting, fear for personal safety, feeling marginalised, disrespected and humiliated, and observing unethical behaviour of staff contribute to cynicism in the social work profession (Litvack et al., 2010). In a study of criminology students doing fieldwork in various contexts, journal comments and reflections on learning and environmental challenges were analysed and the findings were: things happening at a fast pace; crisis intervention needing to be done; a lot of responsibility; working with others; and mediating between the university and fieldwork placement (Council on Higher Education, 2011:23).

The students in the present study experienced challenges in the healthcare contexts which were similar to what Healy (2005:3-4) describes when she stresses that social workers' practice and role are determined by the institutional context in which they work, as well as dominant discourses and policies. For the present participants there were also positive experiences, which contributed significantly to their fieldwork education.

Medical versus social work discourses

The students experienced the specific setting where they worked, as well as the medical discourse, in many instances made the role of the social worker a challenge. This discourse expresses conflicting ideas in comparison with the social work theoretical frameworks in which students are educated, for example, the strengths-based approach, as well as social work principles. This is reflected in the following comments from students.

A student working in the renal unit experienced difficulty working in an environment where the role of the social worker was challenged and expressed her experience as: "I worked in the renal unit ... it was not a nice experience. "

Another participant emphasised the conflicting ideas between the strengths-based approach and the medical model. "In social work we never ever use terms like diagnose and prognosis, clients not patients. Those words I remember hearing in my first few weeks of lectures. "

Two students expressed the focus on the medical model by stating: "I have learned and acknowledge the client as patient because it is endorsed by policy; " "...patients and the pathology because they have been diagnosed... that led to referral from a pathological point of view. "

Many social workers and social work discourses oppose the medical model with its focus on pathology with, for example, the strengths perspective (Saleebey, 2009), as well as postmodern theories of narrative and solution-focused therapy (Healy, 2005; MacDonald, 2007; Milner, 2001; Sharry, 2007). Students at the University of the Western Cape are introduced to the strengths perspective in their first year, and postmodern theories, which include narrative and solution-focused therapy, are the focus of a fourth-year theoretical course, advanced intervention, which is applied as a section of the practice education course. It is therefore important that students engage in reflective learning as a component of their practice education, where they critically analyse and reflect on these theories and their introduction to healthcare contexts (Oko, 2008; Parker, 2010; Walker et al. 2009).

Positive developmental environment

Two students experienced the health context as a positive environment for their development. "Being at the hospital was the highlight of my student life "; "Entering the health facility has been challenging ... and yet an experience I have learned to cherish. "

The significant contribution which the debate on theory and practice and the multidisciplinary team makes to learning in such a context should be recognised. This can contribute to understanding that theory can be used in various ways in practice (Parker, 2010:25). A study by Litvack et al. (2010:233-234) corresponds with the students' experiences, finding that students experience an organisational positive where they and clients are valued, their strengths are acknowledged, and there is positive feedback on areas of development, as well as where they recognise their own mistakes.

Distribution of power in healthcare context

The distribution of power in the medical model was a challenge to students because they were aware of the position of power from a social work perspective.

A student emphasised the power of the doctor in the medical model, which indicated that the patient and social workers' opinions are subordinate. "The doctor noting the problem on behalf of the patient is challenging when it comes to selecting the type of intervention. I identify social circumstances that are different to the doctors ' referral. "

A student experienced the role of the social worker expected in a specific medical context as stressful and unjust. "I think they are putting too much pressure on the social workers, as they must do the assessment and recommend/motivate whether the person is the best candidate for the procedure. It is not fair. "

Healy (2005:22) refers to "power and expertise" in the medical discourse; these are determined by expertise and knowledge about the biological basis of health and illness. Students are observant and sensitive to power dynamics and communication in the organisation; these include the fieldwork supervisors' conflicts and status in the organisation. Students experience difficulty in managing these dynamics and in balancing alliances to deal with power issues (Litvack et al., 2010:234).

Medical terminology

All the students in the study experienced medical terminology as a challenge. A student in a secondary setting who had to write in a medical file expressed this by noting: "A challenging issue is the language ... I have to grapple to record such terminology. "

Another student expressed his experience during ward rounds with the multidisciplinary team by stating: "The medical terms are extremely hard to comprehend and often confusing."

A student worked in a primary health context and expressed his confusion: "I had to counsel all the patients with high cholesterol. Initially I didn't understand why but then the social worker informed me about the high incidence of this and heart disease in our area. "

Students become anxious and feel overwhelmed if they do not understand the common language, and medical technology and procedures, and it is important that they have at least some knowledge of basic concepts, risk and risk factors as well as being proper prepared before they do their fieldwork in a health setting (Bogo & Taylor, 1990; Fort Cowles, 2003; Healy, 2005; Vourlekis et al., 2001).

The experiences of students with regard to challenges in the healthcare context, as well as the generalist versus specialist knowledge, make it clear that the curriculum should prepare students sufficiently for practice to be able to identify resources, which can assist them with medical terminology and procedures. These should include the multidisciplinary team, literature, peers and supervision. The experiences of students should inform the curriculum, and teaching and learning should contribute to effective development of students as social work professionals.

Teaching and learning

Insufficient preparation

Preparation for practice in healthcare settings was mentioned by various students as an important component in fieldwork education. There is a strong correlation between students who were not well prepared for fieldwork education and negative emotions, anxiety and poor performance, as well as stressful supervision and low satisfaction (Gelman & Baum, 2010; Gelman, 2004; Leveridge, 2003; Maidment & Crisp, 2011).

Two students mentioned that: "The training we received ... is not nearly enough to set foot in that environment; " "I have a constant nagging voice in my head telling me that I am not well enough prepared. "

A student working in a tertiary context stated: "There is such a variety of problems where I have to get more knowledge and I don't always have the time to read on all. Now it is a patient with burns, then someone who is dying and then again something new."

A student experienced confusion because the medical and bio-psychosocial model has been implemented in the context and the focus in his training was on the strengths-based and other models not propounding the same principles: "It's the lack of training and clashing of things which we have been taught versus how things are expected to be done at the university and hospital. " This comment refers not only to the social work theoretical frameworks versus the medical model, but also social work practice in the health context versus theoretical knowledge as an element of the social work curriculum, as discussed above. It also refers to the (lack of) integration of theory and knowledge, which will be discussed in the following section, as well as the difference between theoretical and practice knowledge.

Healy (2005:5) refers to the formal professional base of social work versus the framework of practice, which includes formal and informal "on-the-job" knowledge and skills. Lewis and Bolzan (2007:139) describe this as a more complex situation, where there is a theory/practice divide and students "struggle with the complexity and multiplicity of trying to put into practice a working definition of what social work is while on placement." It is therefore important that the role of the social worker should be contextualised depending on the placement rather than the general social work domain.

Lack of bereavement training

Several students experienced a lack of training in dealing with bereavement and dying patients, especially students working with terminally ill patients, but also students who worked at community health centres. A student in paediatric oncology realised her lack of knowledge to assist patients and their families appropriately and mentioned: "I really think it would have been better if we have a course in dealing with death and dying. I have contacted hospice but they only have a course at the end of the month."

A student in a primary context experienced lack of knowledge and skills and expressed her concerns: "I had a patient who has breast cancer at the clinic and didn't know how to deal with it. "

A student experienced difficulty emotionally in dealing with death and mentioned: " I had to interview a mother with a dead baby on her lap and that was difficult for me. "

Students should not only be well prepared for fieldwork but should also be equipped with a theoretical framework, skills in management of indirect trauma, and coping with painful issues, all of which they can apply in the specific context in which they work. This is especially necessary when they work with bereavement and dying patients (Barlow & Hall, 2007; Corr, Corr & Nabe, 2006; Teigiser, 2005). Teaching in death and bereavement must be done in a sensitive and compassionate way, because students might have experiences with death in their own lives. The goals of bereavement education should not only be to inform and guide students to interrelate with death issues, but to enrich their personal lives (Corr et al., 2006:9).

Integration of theory and practice

Students had different experiences with integration of theory in practice, because the focus of social work practice was different from the requirements of the university.

A student mentioned: " The hospital focuses much on micro work, which gave me very little time to do other interventions."

Another student experienced challenges in the implementation of a theoretical framework, because the ways in which social workers were doing practice differ. "The postmodern theories were a bit of a problem ... The hospital setting focuses on how the client feels about their illnesses and what has led to the problem. "

Other students could, however, implement various theoretical frameworks in contexts, as described: " I have managed to use interventions, for example, solution-focused and narrative therapy with patients with whom I have had more than one session with great success;" "I was happy to get a chance integrating theory withpracticum;" "I am able to appraise the principles and ethics of care in the health sector."

Different learning activities contribute to the quality of field instruction, student satisfaction and performance in practice. Students are able to identify learning opportunities that they are exposed to, which is important to their development. Contributing to this is having a conceptual framework linked to their field experiences, which includes integration of theory in practice realities. This can be done during the teaching of theory by using tools such as process recording, audiovisual tapes and case conferences to integrate practice realities, and also through explanation by field instructors and by developing critical thinking skills (Carey & McCardle, 2011; Fortune, McCarthy & Abrahamson, 2001; Kanno & Koeske, 2010; Petersen, 2010; Teigiser, 2009).

Petersen (2010) has done a study on challenges faced by third-year students at the University of the Western Cape and Nelson Mandela Metropolitan University, which included integrating theory and practice. Findings indicated that there was "a huge gap between theory and practice" (Petersen, 2010:82). Students mentioned that supervisors were not familiar with the theoretical frameworks and were not able to guide them in implementation of theory and practice. These comments emphasised the fact that the framework for practice includes formal social work theories, but practitioners can challenge and transform these theories. Social work theory, which is knowledge-based, and practice, which is context-based, can be in opposition because theory emphasises the ideal, whereas practice realities involve complex and critical incidents with clients, tension between control and care, stressful working conditions with limited resources, and social workers who have a low professional status and autonomy in some organisations (Lewis & Bolzan, 2007). These factors contribute to the difficulty in making a link between classroom theory and practical experience. Students need more critical thinking skills and self-awareness to tolerate uncertainty when faced with ethical dilemmas and the application of knowledge from various sources. Finding a balance between agency, an academic programme and an engaged student develops critical thinking skills. These three components challenge, interact with and clarify theoretical and practical understanding and critical processes (Carey & McCardle, 2011:358).

The role of clients during fieldwork

The type of clients, as well as a lack of knowledge and skills, contributed to the experiences of students during fieldwork.

Misconceptions about the types of clients

Students should be prepared for their fieldwork contexts especially in health or mental health contexts, as mentioned above. Preparation must also include preparing students to work with specific types of clients. Students must be able to integrate their knowledge obtained in other subjects - for example, Psychology - and apply it when they enter fieldwork contexts. Experienced practitioners working in health contexts and who have introduced social work theoretical frameworks successfully can be consulted to orientate students in the practice contexts.

Experiences of students in mental health contexts indicated that they had misconceptions regarding psychiatric patients and this might be a result of insufficient preparation: A student mentioned: " I had a mentality that in a psychiatric hospital clients will not be able to cooperate as normal people." Another student said: "I felt I must try by all means to communicate with such people to get experience of working with mentally challenged individuals."

Le Riche (cited in Carey & McCarle, 2011:359) suggests that students should do observations before they implement their knowledge and skills. This will result in better prepared students and better application of critical thinking skills, and this should help to prevent misconceptions.

Clients' problems

Students experienced anxiety because they thought they did not have the knowledge and skills to work with certain types of clients or problems. A student mentioned: "I see a lot of suicide attempts and it is difficult for me because the doctor does not discharge them until I say they can go home. " Several students worked with dying patients, and some worked with patients with burns or other severe illnesses. These experiences will be discussed in the section on the emotional experiences of the students, as they are related.

Working with clients who are vulnerable and overwhelmed, as well as intra- and interpersonal events with clients, can have an effect on the personal and professional development of students. Students can experience various degrees of emotional distress, burnout, compassion fatigue and emotional exhaustion when they are involved with clients, especially clients who react with anger and resistance (Barlow & Hall, 2007; Gelman, 2004; Kanno & Koeske, 2010).

A study by Gelman (2004:45) has found that students were afraid that they might harm clients, and that clients were disadvantaged because the students did not have the expertise to help clients. They were sensitive to clients' reactions and were strongly affected by rejection unless they had support from the supervisor. Students feared some clients and some thought they betrayed clients. They also experienced various forms of resistance and aggression, and could experience verbal and physical assault from clients. Knight (cited in Gelman, 2004:49) cautions that these students should get direction, and the which in which this is given can influence the future career of a student.

Safety

The South African context is marked by various forms and degrees of violence, which is extremely significant when practice education is considered. Inter-personal violence, which includes family and intimate partner violence, and injury-related deaths on roads utilise 80% of the Western Cape governments' health budget, according to the Western Cape Integrated Provincial Violence Prevention Framework (2013:2). Students in health contexts attend to these conditions and are therefore exposed to the effects of violence and even to violence. It is interesting, however, that the students who experienced risks to their safety were all placed in psychiatric contexts.

A student in a mental health facility stated: "I was challenged by the fact that I had to go first through security when about to conduct an interview . but is was the best to do for my safety." Another student working in another mental health context responded: "I was scared because he killed someone." A student working in a forensic context in mental health mentioned: "I work in a unit and there is this patient who has HIV/Aids and could not be circumcised and he then killed a child because he said it is then not necessary for the procedure. I am scared when I am with him. "

Students feel at risk when they work in specific contexts, or if clients are under the influence of substances, even if they are not directly threatened (Barlow & Hall, 2007:405). The experience of violence differs in terms of contexts and countries. A study by Knight (in Gelman, 2004:49) with 258 BSW Schools in the United States indicates that a fifth of the participating students were physically and verbally abused, while a study by Criss (2010) with a sample of 1500 students in the United States found that 41% of the students experienced direct client violence, 37.5% verbal abuse, 3.5% physical assault and 62.2% indirect exposure to violence. Barlow and Hall (2007:405), working with 35 social work students in Canada, had a third of the students stating that they experienced potentially dangerous situations, and another study by Maidment (2003:53-53) in Australia found that 31% of students were verbally abused and 36% of students did not have safety procedures and protocols in place when they started the placement. Social work educational institutions follow lengthy processes to address these problems, but they are seldom dealt with in practice, as indicated in a survey with directors of social work programmes by Wettkin, Cherrey and Reaser (in Gelman, 2004:49). Only 12% of programmes had formal written policies, 38% had safety training, and 86% agreed that more emphasis should be placed on student safety. It is clear from the above that student safety should be a priority during fieldwork education, and this is especially necessary in the South African context. Maidment (2003:51) emphasises the need for safety by stating that teaching students should not only include social work theories, but "teaching them to negotiate and survive in workplace cultures."

Students' countertransference

Countertransference emerges as a result of clients discussing issues which are unresolved by the therapist. The therapist's needs are met and not the clients' (Berzoff & Kita, 2010; Rosenberger & Hayes, 2002). Countertransference can result in defensive behaviour or avoidance of the situation. This might influence the relationship with the client, and have an impact on the session and the therapist's perceptions about his/her characteristics to assist the client (Rosenberger & Hayes, 2002).

Berzoff and Kita (2010) distinguish between countertransference as a result of unresolved issues by the therapist, and compassion fatigue as a reaction of countertransference, where the client and therapist mutually influenced each other. Compassion fatigue is a result of overexposure to client's suffering and the therapist is emotionally involved in a manner that negatively impact personally and professionally.

A positivistic paradigm views countertransference in the past as negative and something that therapists should avoid. The current postmodern stance, however, is that countertransference is omnipresent in the relationship between the therapist and client and vital as part of the treatment process. This contributes to empathy towards the client's situation (Berzoff & Kita, 2010). Kanter (cited in Berzoff & Kita, 2010:343) mentions that personal aspects, expectations, as well as the context and training of the practitioner influence how he/she experiences countertransference. The author states: "How we experience countertransference varies; that we experience it does not. "

Students in a study by Litvack et al. (2010:232) indicated that their own past emotional relationships and childhood experiences influenced their work with clients. Some students stated that they could not focus on the clients when this happened, and they had to remind themselves constantly that the client was a different human being. Other students were of the opinion that their own experiences resulted in their being more empathetic towards their clients. This happened with a student who had had a mastectomy and had to see a patient with the same problem at a community health centre. "I didn't know what to do when the patient told me she had a mastectomy but then told her I had the same and I understand her situation. " A student with children who had difficulty working with mothers of dying children expressed her experience as: " It was difficult seeing this mother with a dying child and I was thinking about my own children."

Strong emotional experiences during fieldwork

Emotions influence the attitudes as well as the academic development of students, and also the ultimate achievement of learning outcomes of students during practice. Educators should take cognisance of these emotions in order to equip themselves to shape admission criteria, reassure students where appropriate, and address gaps in the curriculum. The correct intervention can be followed up by fieldwork instructors and lectures (Gelman, 2004; Litvack et al., 2010; Maidment & Crisp, 2011; Peterson, 2010).

Fluctuating emotions

Students can experience a range of emotions, for example, anger and frustration, because of their lack of control regarding their placement, and different degrees of anxiety and stress with regard to their competence and their personal circumstances (Maidment & Crisp, 2011:418). A student described these fluctuating emotions as: "Feelings are not the same - they differ as time goes on."

Anxiety and fear

Challenges and responsibilities associated with the unfamiliar contexts caused anxiety and fear in students. A student even experienced applying skills which he was familiar with as a challenge in the new context: "I was scared and afraid of even conducting interviews with patients." Another student felt challenged by her own beliefs and described her experience as: "I did not feel comfortable telling people they were not the perfect candidates for the programme."

A student described the anxiety of making responsible decisions as follows: "I see a lot of suicides and it is difficult for me because the doctor does not discharge them until I say they can go home. It is a big responsibility and I am not always sure that I have made the correct decision."

Anxiety is a reality during fieldwork, but educators should distinguish between acceptable anxiety, which can lead to growth, and anxiety which can hinder development. Anxiety occurs when students carry out self-examination, testing of new competencies, and challenging previous ideas and their personal strengths and weaknesses in practice (Gelman & Baum, 2010:427).

Significance of fieldwork experience

Students have to reflect on their own competencies and this causes anxiety, as mentioned by Gelmand and Baum (2010:427). A student stated the following to illustrate the significance of this experience: "I felt like this is really serious ... I am now a professional and have to do things differently from what I used to do."

Romf (in Gelman, 2004:41) mentions that age and prior experience correlate with positive feelings of preparedness for fieldwork. A study with master's students in social work by Kanno and Koeske (2010:32) has found that students in their foundation year experience a great deal of anxiety in the beginning of their field placements, which can be revealed in mental and physical symptoms, but second-year students experienced higher levels of stress and burnout. According to Litvack et al. (2010:229), these findings correlate with findings about social workers that exhaustion increases as work involvement increases and accumulates, which may be caused by secondary trauma.

Contrasting emotional experiences with regard to workload and tasks

Students could experience anxiety, fear and doubt regarding their own abilities in terms of workload, tasks and requirements for practice from the agency versus the university. It was noteworthy in this study, however, that students' identified positive rather negative experiences as result of the workload, tasks and requirements from the agency.

A student expressed her experiences regarding the workload, tasks and agency requirements by saying: "at first I thought they were overworking me and that they treated me like a slave. " The same student, however, responded on the positive results of this experience: " When my mentor did a presentation about how matured I am and how much of a hard worker I was, I realised he meant well when he exposed me to different departments and I thank him for that."

Another student expressed how pleased he was about his role in the agency: "I had to work in the ward for a social worker who was ill, then two patients came to me and said: 'Where is the social worker? ' and I said: 'I am the social worker.' I was so proud that I was able to do the work."

Gelman (2004:46) has done a study with 61 students on the social work master's level with regard to their anxiety about fieldwork education. Anxiety about the amount of work to be handled was indicated by 70% of the students, 77% thought they lacked experience with the specific population with whom they had to work, 40% worried about planning and how they were going to balance fieldwork, academic requirements and personal obligations, and only 32% of the students were anxious about integrating theory and practice. Petersen (2010) concurs with some of these findings, and found in a study of third-year students' challenges in practice at the University of the Western Cape and Nelson Mandela Metropolitan University that the workload, time management, agency versus academic requirements, language barriers, access to resources due to financial difficulty, previous education and emotional intelligence contributed to students' difficulties during fieldwork. Students also worry about financial implications, care of their children, domestic tasks and the loss of paid work during practice (Maidment & Crisp, 2011:418).

Intense emotions from contact with disease and death

A significant number of students experienced intense emotions when they worked with specific diseases and death. A student working in an oncology unit commented on his experience: "I have seen something that was not very good for me. I had this patient, whom I saw in the morning and I wanted to go back the afternoon to talk to her but the curtains were closed and when I opened it I saw the wound and the patient was dying. I was shocked." Another student expressed her emotions by saying: "My patient died ... it breaks my heart."

Students working in paediatric units expressed their intense emotions as : "I had to interview a mother with a dead baby in her arms. That was really difficult for me; " "I had trauma debriefing with parents of children being in a taxi accident. I had to take them to the mortuary to identify the children. It was difficult for me."

Students in healthcare work with clients may experience intense emotions; they are exposed to unfamiliar sights, smells, death or bereavement and trauma. These issues and issues of violence, especially when children and families are involved, contribute to their feeling overwhelmed, worried and shocked, and this may trigger their own and painful memories (Barlow & Hall, 2007; Litvack et al., 2010).

Excitement

The practice experience contributed to positive emotions as some students expressed excitement: "I was so excited to finally experience a new way of doing things with people;" "a positive experience to know I'm in the league to be helpful to patients. "

Students may experience positive emotions of achievement and motivation, which contribute significantly to their learning. The emotional intelligence of students can enhance their development when they view emotions as a resource rather than a challenge (Maidment & Crisp, 2011:418).

Ethical experiences during fieldwork

Students are confronted with complex decisions regarding ethical parameters which are not clearly defined in the context, as well as types of clients and problems. Therefore "It is essential that students are able to recognise the moral implications of their work and develop a deep understanding about ethical issues and their personal responsibility for making ethical choices" (Gray & Gibbons, 2007:222).

The curriculum at the University of the Western Cape includes an advanced course in ethics during the fourth year, which deals with incidents involving ethical dilemmas, as described by Bozalek (2010). Students are therefore more aware of these during their fieldwork practice, especially in the healthcare context where decisions are sometimes ambiguous.

Range of ethical dilemmas

Students in healthcare contexts experience a range of ethical dilemmas, as one student mentioned: "There were lots of ethical dilemmas. " Maiss (2010:39) maintains that there are many ethical dilemmas, especially in psychiatric work and in prisons, and social workers making decisions without clear guidelines are affected by these. This author states that: "The gap between accountability to the client and to professional associations and the law may lead to an extremely painful experience for the morally aware social worker." This is indeed what some of the students experienced.

Ethical dilemmas as a result of the medical model and health context

Many of these ethical dilemmas derived from the medical model and the health context. Students expressed the following ethical dilemmas: "I was not happy having security around every time I attended to the client ... the client's confidentiality was not assured; " ''Sometimes I wonder if it is the doctor's choice to refer the patient without notifying the patient."

Contextual factors influence social workers' ethics in certain aspects of the medical field; for example, self-determination and the use of medication are mentioned. Social workers can reflect on what they can do best to promote clients' wellbeing in such situations and advocate that clients should be involved in decision making (Banks & Nøhr, 2012:81).

The role of the social worker contributing to ethical dilemmas

Ethical dilemmas were experienced regarding the role of the social worker in some contexts, and the students expressed this as follows: "I felt like I was playing God with people's lives; " "How do you tell a fourteen-year-old that he has been turned down due to non-compliance issues on his medication? What does a teenager know about compliance issues? " "We can't rule out that a person is not the candidate based on his/her social circumstances and illiteracy, THAT'S WRONG! "

A male student experienced an ethical dilemma when working with termination of pregnancy and stated: " I have only seen one father when the mother has come for a termination of pregnancy. What about the others? "

Decisions in the multi-professional team can cause ethical dilemmas, especially if they oppose the personal values of the social worker. All professional and personal values and opinions must be scrutinised and mutually agreed upon in terms of ethical decision making. Social work students working in multi-professional teams can benefit from such situations (McAulliffe, 2012). Gray and Gibbons (2007:223) summarise the advantages as follows: "By encouraging students to reflect on their own values and commitments, as well as their intuition and emotions, we lead them to exciting and perplexing discoveries about themselves and others."

Students experiencing ambiguity

Critical thinking and judgement, where students apply knowledge from various sources, and self-awareness are of the utmost importance when students experience ambiguity in facing ethical dilemmas. A student expressed insecurity in making a decision and mentioned: " I work with a child with cerebral palsy and the child died of neglect. The mother left and the father has gone to work and let the two younger children look after the patient. I am not sure who to blame or report to the police. Is it the mother or the father?"

Students expressed ambiguity when clients' made requests that contradicted agency policy and ethical behaviour as social worker. Students mentioned their ambiguity by stating: "A guy who was using a false name ... He told me this and I did not want to reveal it to the team. I didn't know what to do as I had to maintain confidentiality . at the same time I had a responsibility to conduct myself with integrity and be accountable to the agency;" " Some tell me that they use drugs but I must not write that on my assessment report ... I couldn't ... it is my responsibility to do a proper assessment." Students become aware of the ambiguities that are present in practice when they evaluate ethical dilemmas frequently, according to Carey and McCardle (2011:358).

A student expressed his indecision regarding assistance to a patient in a health context: "The patient struggles with their treatment apparatus such as tubes of drips that are falling. The patient is walking the corridor; it's a female dressed only in a hospital costume . do I walk past her or do I get closer to offer assistance or do I tell the nurse who seems to be busy with her duties or do I inform the security? "

A study by Litvack et al. (2010:235) found in their study that students did not want to share feelings with the fieldwork lecturers at the university because of mistrust within the power relations. Students were concerned about the influence which doing so might have on their results and the ability to finish the programme. These authors, however, found that students will first ask friends and families for support and assistance, because they feel accepted and it is a safe environment. Talking to peers is also important because they have the same concerns, but there are times when students felt their peers would not understand their emotional reactions. These findings influence the role of supervision during fieldwork.

 

Supervision during fieldwork education

Positive experiences

Students' experiences with the supervision they received influence their satisfaction with fieldwork. It is important that supervisors and students have regular meetings in order to provide support to the students. Students who receive positive feedback and direction are empowered and have more confidence, but when they do not receive it they are vulnerable to emotional exhaustion and unsatisfactory fieldwork experiences. Students prefer acknowledgement of their strengths and constructive feedback, as well as supervisors who are accessible, emotionally supportive, and maintain friendly but professional boundaries (Bennett, Mohr, BrintzenhofeSzoc & Saks, 2008; Kanno & Koeske, 2010; Litvack et al., 2010).

Students' in this study experienced fieldwork and campus supervision as positive events, as indicated in the following comments:

" I was encouraged by the supervisor to adapt."

''The supervisor was helpful in assisting me when I asked her."

"I learnt a lot from my supervisor and not even once I was treated only as a student. Working with him exposed me to a lot of new experiences.""

"I had a supervisor from heaven, she understood our difficulties, helped us."

"...was very supportive, encouraged me to always strive to do the best..."

" I was very happy as it was the first time in my student life that I get a supervisor as understanding and encouraging."

A study by Gelman (2004:46) on the quality of supervision indicated that 74% of students were concerned about the quality of the content and time of supervision, 54% about fair expectations, 25% about a solid relationship and 23% about communication with the supervisor. It is clear from these findings that the relationship and communication are subsidiary to quality of content, time and fair expectations.

A negative and stressful relationship between the supervisor and student has a negative effect on student learning; Litvack et al. (2010:234) go to the extent of describing it as "toxic" to student learning. Students did not give any negative comments about supervision and that might be because they were not comfortable doing so because of power dynamics.

Power dynamics and supervision

The power dynamics in supervision can be considered as an aspect of the vulnerability of students, even if there are good relationships. This is due to the fact that the students will be assessed and they might need future references for employment from the supervisor. Disrespect and misuse of power, a conflicting relationship between the supervisor and student, focusing on weaknesses and problems of the student, as well as crossing of personal and professional boundaries, contribute to a negative supervisory relationship without trust, as well as anxiety, avoidance and a negative fieldwork experience (Bennett et al., 2008:89-90; Litvack et al., 2010:233). The various forms of power between supervisor and student should be acknowledged and well managed.

A student mentioned her anxiety about the power relationship in supervision as follows: "I felt excited at the same time scared what would be done to me when I don't do things accordingly."

Brown and Bourne (cited in Walker et al., 2009:115) distinguish between various forms of power between the supervisor and the student. The role and position of supervisors give them formal power, but personal and professional attributes of the supervisor and supervisee as a result of the structural determinants can result in informal power. Power is therefore interpersonally, culturally, structurally and institutionally determined. These factors may be influential, especially in the diverse South African context, and supervisors and educators should take them into account during fieldwork.

 

CONCLUSIONS AND RECOMMENDATIONS

Social work practice education is a crucial component of student teaching, learning and professional development, and should get the necessary attention in the curriculum. The focus should not only be on implementing theory in practice, but also on practice informing the theoretical courses on practice realities. Student experiences can contribute significantly in developing practice, theoretical education and the curriculum. Health contexts are relevant to practice education, especially if the mutual association between health and social issues in our society is considered. It is also clear that social work in health contexts uses generic knowledge and skills which are relevant for undergraduate fieldwork education, but certain specialised knowledge and skills are also necessary, as indicated in the following section.

The health context

The experiences of students suggest that health contexts contribute significantly to positive as well as challenging fieldwork experiences and student learning. It is recommended that students should be prepared sufficiently for the practice contexts in which they work. Preparation should include knowledge of the medical and bio-psychosocial discourses. Students should be able to think critically, and reflect on how health contexts influence social work discourses and how social work discourses can be introduced into health contexts. Multidisciplinary teams and various discourses should be perceived as making positive rather than negative contributions towards students' learning. Sufficient preparation and orientation will also manage power issues within the context, as well as dealing with medical terminology.

Teaching and learning

These students experienced challenges as well as positives in integrating theory into practice. Lack of preparation about dealing with death, bereavement and painful issues was experienced by the students. It is recommended that partnerships between practices and universities be developed to contribute to better teaching and learning by students. Experienced practitioners working in health contexts and who have introduced social work theoretical frameworks successfully can be used to orientate students. Students at the University of the Western Cape have campus supervisors, who are practitioners with knowledge in theoretical frameworks implemented on the fourth-year level. They have supervision sessions with these supervisors once a week. It is recommended that the supervision groups should be context-specific, with a supervisor who has experience in the field, for example, in health or mental health. This can contribute to students sharing their experiences, and they can develop their critical thinking skills and self-awareness. Supervisors can get CPD training with regard to specific theoretical frameworks, if there is a need.

The role of clients during fieldwork

Some students experienced anxiety and uncertainty when they worked with client problems, for example, suicide attempts, death or severe illness, and they felt they did not have sufficient knowledge and experience to deal with them. Students had sometimes experienced similar problems to the clients', and countertransference could then be present. Student safety was a concern and should get attention in the South African context. Certain contexts where students do their fieldwork were marked by various degrees of violence. It is recommended that students get safety training, and that procedures and policies are put in place not only at universities but also at agencies to address such experiences if they occur.

Significant emotional experiences during fieldwork

Students were excited and some perceived this experience as the highlight of their student career. It is recommended that universities and agencies should be made aware that students are not familiar with specific environments with unfamiliar sights, smells, death and trauma, and with the multidisciplinary teams that work in such settings. All the students in the study were exposed to such an environment only in their fourth year. Supportive supervision is important, and students should be monitored in terms of the effects on their development. Reflective journals during practice are also a good tool to use during fieldwork.

Ethical experiences during fieldwork

Students in health contexts have to make complex decisions, and some of these are not clear, so ambiguity is experienced. It is important for students to understand their personal and professional values, and how to integrate these during decisions in the multidisciplinary team. Critical thinking skills, as well as support, are again of the utmost importance. A reflective journal, supportive supervision and group supervision where students can talk to their peers and share their experiences are recommended.

Supervision during fieldwork education

The students experienced encouragement, assistance, exposure to new experiences and the manner in which they were treated as positive during supervision. Only one student mentioned the power dynamics in supervision indirectly. It is recommended that supervisors consider the interpersonal, cultural, structural and institutionalised power dynamics during supervision. There should be regular supervision meetings, with clear professional boundaries, where strengths are stressed and constructive feedback is given to students.

This research on the experiences of students doing their fieldwork in health contexts has yielded valuable information, which should be implemented not only in health contexts but in the broader fieldwork experience of students. It is recommended that more research be done on aspects indicated in this document, such as safety of students, especially within the South African context.

 

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