Photographic Media for Pain Expression: Situated Learning with Graduate-Entry Masters Students to Develop Skills in Applying Theory-to-Practice

doi:10.4236/ce.2011.22013

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Creative Education

2011. Vol.2, No.2, 91-95

Photographic Media for Pain Expression: Situated Learning with

Graduate-Entry Masters Students to Develop Skills in Applying

Theory-to-Practice

Cary A. Brown, Mary-Lou Halabi, Kristen MacDonald, Lorena Campbell,

Robyn Guenette

Faculty of Rehabilitation Medicine, Department of Occupational Therapy, University of Alberta,

Edmonton, Canada.

Email: [email protected]

Received March 28th, 2011; revised April 20th, 2011; accepted May 10th, 2011.

Entry-level healthcare practitioners must be able to engage in critical thinking, life long learning and be

autonomous and accountable within the complex demands of healthcare in the 21st century. However, structur-

ing learning opportunities to foster these skills within the pre-qualification curriculum can be challenging.

To-date, little evidence exists in the literature to guide educators. This case report discusses how an elective

module in the therapeutic use of digital photography for Master of Science in occupational therapy (MScOT)

students was designed to enable students to develop an appreciation for, and ability in, scholarship and the ap-

plication of theory-informed practice. The elective module is used as an example to illustrate the potential and

relevance for Social Learning theory, Situated Learning theory and the concept of Most Knowledgeable Other

(MKO) to guide capacity building in scholarship and theory-based practice. This collaboratively written stu-

dent/faculty theoretical perspective, incorporating anecdotal evidence extracted from students’ learning assign-

ments in the module, supports our conclusion that these types of learning modules may offer a useful vehicle in

which situated learning can occur.

Keywords: Situated Learning, Social Learning Theory, Occupational Therapy Studen ts

Introduction

In 2009, the American Occupational Therapy Association

(AOTA) issued a position statement on Scholarship in Occupa-

tional Therapy, highlighting that therapists have successfully

embraced scholarly practice built on being reflective practitio-

ners (Rolfe, Freshwater, & Jasper, 2001; Schon, 1983) who

identify, critique and engage with the evidence-base (AOTA,

2009). AOTA goes on to point out that scholarly practice alone

is insufficient and that scholarship is also required. Scholarship,

as defined by AOTA, is the “knowledge resulting from study

and research in a particular field” (AOTA, 2009: p. 791). This

distinction between scholarly practice and scholarship is in-

triguing and we hope, th rough th is theo r etical p er sp ectiv e p aper ,

to advance the discussion within the occupational therapy pro-

fession.

The value occupational therapy practitioners hold for schol-

arship and t he the ory-driven res earch that schol ars hip requir es is

less clearly demonstrated than the profession’s valuing of evi-

dence-based practice. Contemporary occupational therapy theo-

rists propose that practitioners question the relevance of theo-

retical concepts to day-to-day practice. These theorists propose

that occupational therapists do not universally embrace the

importance of scholarship as a mechanism to drive practice

forward (Hammel, Finlayson, Kielhofner, Helfrich, & Peterson,

2002; Kielhofner, 2005). And yet, the ability to build practice

on a clearly articulated evidence-base is now, more than ever

before, the hallmark of competent practice (Ikiugu, Smallfield,

& Condit, 2009). To create evidence we must first articulate the

theories and models we will be testing. As the Canadian Asso-

ciation of Occupational Therapists (CAOT) points out, en-

try-level practitioners need skills that go beyond technical abili-

ties; they must also be able to engage in critical thinking, life

long learning, and be autonomous, accountable practitioners

within the complex demands of healthcare in the 21st century

(CAOT, n.d).

Objective

This theoretical perspective article will discuss how an elec-

tive module in the therapeutic use of digital photography for

graduate entry Master of Science in Occupational Therapy

(MScOT) students was designed in such a way that enabled

students to develop an appreciation for, and ability in, scholar-

ship and the application of theory-informed practice. The first

author was the instructor and the four co-authors were students

in the elective. The decision to write about the experience and

to include the students’ reflections was prompted by the quality

of the student written work submitted for assessment and the

consistently positive feedback about the module.

Background: The Relevance of Social Learning

Theory

Social Learning theory, as proposed by the Russian psy-

chologist Vygotsky (Wertsch & Sohmer, 1995), assumes that

we learn through working with others on common tasks and

challenges. From these interactions and relationships, we ac-

C. A. BROWN ET AL.

quire knowledge that may be generalized across other settings.

The learner becomes an active participant in the generation of

this knowledge. Wertsch and Sohmer (1995) comment that

Vygotsky’s Social Learning theory conceptualized that persons

who are perceived to have a better understanding or skill related

to the presenting task, (what he called the “More Knowledge-

able Others” (MKOs), will strongly influence the understanding

each learner constructs. How MKOs come to be perceived by

an individual learner to be either better informed or more skill-

ful in a given task is influenced by both social beliefs and per-

sonal experience. In the case of many occupational therapy

students, fieldwork preceptors and other practicing occupa-

tional therapists they meet during their studies hold MKO roles.

Fieldwork placements are experiential learning, where stu-

dents, often for the first time, actually witness what an occupa-

tional therapist does. From this perspective then, it follows that

the students’ experiences of active problem solving, within an

applied context that promotes a positive relationship with a

MKO, have a strong potential to be more powerful learning

experiences than purely scholarly learning based on theoretical

and abstract problem solving activities. Using Social Learning

theory, we can appreciate why students place high value on

techniques and skills acquired during clinical fieldwork place-

ments. However, this becomes problematic when experiential

learning is privileged over both the evidence-based and the-

ory-informed practice students are exposed to in the often de-

contextualized academic class-room setting.

A review of the occupational therapy education literature

shows that how students acquire an appreciation for scholarship

and theory informed practice is an under-studied area. After

some preliminary interest in the topic in the late 1970’s-early

1980’s (Reed, 1984; Shapiro & Shanahan, 1976; Van Deusen,

1986), there has been little research to guide those interested in

refining curriculum to better address the need for future clini-

cians to develop deeper scholarship and value for theory-in-

formed practice. We did find one seminal report written by a

team of occupational therapy educators and researchers who

addressed the challenge through curriculum design (Hammell et

al. 2002) based on principles of situated learning (Know-

ledgebase, 2009). Stein (1998) defines situated learning as cre-

ating an environment where adult students deal with situations

within the uncertainty and complexity of the lived experience.

He proposes that “participants will create their own knowledge

out of the raw materials of experience, i.e., the relationships

with other participants, the activities, the environmental cues,

and the social organization that the community develops and

maintains” (Stein, 1998).

Creating a Situated Learning Opportunity

The MScOT program requires students to take one-credit

elective modules that focus on content beyond the expected

entry-to-practice competencies. The first author used this op-

portunity to design a module with a visiting artist. In this mod-

ule, students would develop skills in using digital photography

as an expressive media for communicating pain. Digital pho-

tography as therapeutic media for pain self-expression has been

used successfully in outcome studies (Padfield & Hurwitz,

2003; Padfield, Janmohamed, Zakrzewska, Pither, & Hurwitz,

2010) and we had the unique opportunity to have the lead au-

thor/artist in these studies as a guest facilitator on the module.

Our objectives were for students to develop:

 an understanding for the therapeutic potential of the activ-

ity;

 a deep appreciation of the demands placed on patients by

this activity, and;

 an ability to carryout a theory-based activity analysis (Cre-

peau, 2003) from two different theoretical perspectives ap-

plied to the same activity.

This final goal of a theory-based activity analysis we saw as

a vehicle to help students deepen their appreciation for the

value of theory-informed practice and the scholarship of prac-

tice.

Module Description

The module was delivered over two days and ran for eight

hour each day. There were several short didactic lectures to set

the context and give background to the issues that make pain

difficult for patients to communicate. However, for the most

part, students were immersed in exploring a physical pain ex-

perience of their own and problem-solving how to represent

that pain pictorially. Students were asked to think of a past

experience (for example a toothache, migraine, or fractured

limb) before the module started and then to bring a digital cam-

era and any objects that might help represent their pain into the

module on the first day. Some students chose to focus on de-

picting an emotional pain instead of a physical event. All stu-

dents were cautioned to select experiences they were comfort-

able sharing with others and both instructors regularly checked

with students about comfort levels.

The students worked in pairs but also frequently made use of

others individuals in the module to seek assistance with object

positioning challenges and with technological questions related

to the cameras and picture editing software. Most of the stu-

dents used Picasa® which is freely available on the internet

(http://picasa.google.com/). Students were free to use the

available classrooms and lab space as well as any interior or

exterior public areas around the building. Examples of the im-

ages created during the module are seen in Figures 1 and 2.

Applying Stein’s definition of situated learning (Stein, 1998),

the elements we needed to design into the module included:

 uncertainty and complexity;

 the need to relate to other participants;

 and to create a sense of “community” which could be

maintained, at some level, over time.

Some of the strategies we used to achieve these objectives

are outlined below.

We created an environment immersing students in an expe-

riential learning activity (eight hours a day for two days on a

weekend). This brought the students together as a group, “a

community” with a bond unique from the one they shared with

their classmates in the program in general. Uncertainty and

complexity were introduced at a number of levels. From a

pragmatic perspective, the module had never run before so

students had no knowledge of what to expect from talking with

their classmates, the artist and the university faculty member

had not worked together before, and the artist was from another

country and not known to any of the students.

There was uncertainty as well as students made decisions

about what lived pain experience they wished to draw upon as

they acquired a new skill and explored how they wished to

C. A. BROWN ET AL. 93

Figure 1.

Student created pain image A.

Figure 2.

Student created pain image 2.

depict that experience.

Complexity was enhanced as the professional artist involved

in the module was able to challenge students to explore deeply

and move beyond existing skill sets. The complex and de-

manding nature of the task required students to form relation-

ships so as to assist each other in the many technical and

physical components of the task. It was additionally challeng-

ing because of the cognitive-emotional elements of depicting

feelings by the process of creating and editing digital images.

A consistent complexity that ran through all aspects of the

two days was the cognitive-emotional demand of moving be-

tween two roles. The first role was participating in the activity

of creating images to express one’s own pain. The student then

often needed to step back into the role of a therapist and think

from that perspective about what therapeutic potential the ac-

tivity provided and for which patient populations. Lastly, the

sense of community was fostered by a closing meditation/re-

flection exercise lead by the visiting artist at the end of each

day. To maintain the learning community links after the module

was completed, the faculty member prepared a large poster for

display in the Department with the images students had given

written consent to use. A group portrait, including the visiting

artist, was also displayed alongside the images.

Linking the Experience to Theory

The students’ assignment for the module was to carry out a

theory-focused activity analysis (Crepeau, 2003). The the-

ory-focused activity analysis (TFAA) guided the students in

thinking about the link between theory and practice and how to

look at therapeutic activities from multiple theoretical perspec-

tives (for example, biomechanical, Model of Human Occupa-

tion, rehabilitation) (Hagedorn, 2000). Each pair of students

completed two TFAAs. One of the TFAAs had to be from a

biomechanical perspective, the other was of their choosing. The

instructor selected the very straightforward approach of bio-

mechanics so as to build first year students’ confidence and

consolidation of the basic science knowledge they had recently

mastered.

The second TFAA was from any theoretical perspective the

students felt was appropriate. This choice allowed students to

demonstrate exploration, creativity, and higher level integration

of course content. The TFAA required students to name the

practice theory; explain how that theory defines function, dys-

function, and change; and discuss both grading and adapting the

activity from the perspective of the selected theory.

Findings

Most of the student pairs chose to use either the Canadian

Model of Occupational Performance and Engagement (CMOP-E)

(Townsend & Polatajko, 2007) or the Model of Human Occu-

pation (MOHO) (Kielhofner, 2008), and they were free to se-

lect an author within the foundational occupational therapy

literature of their choice to define the pre-assigned biome-

chanical perspective.

Learning Outcomes

This section draws on examples from the students’ assign-

ments to illustrate how they achieved the learning goals and

outcomes. The quotations (labeled Student 1 through 4) come

from the students who are co-authors of this paper. At the time

of writing there was no plan to prepare a manuscript and the

students wrote without the bias of possible authorship. Other

statements are composites of similar comments made by several

students. As such, they are not directly attributable to any one

student and breaches of confidentiality were avoided.

Students’ assignments demonstrated their ability to complete

a TFAA and, in more advanced students, to compare and con-

trast the two different theories. For example, students were

comprehensive in reviewing the biomechanical demands of the

activity.

 ...Ambulation and ascending and descending stairs were

C. A. BROWN ET AL.

necessary to relocate to environments of interest to get the

right backdrop for the photograph. In order to descend and

ascend the stairs, muscles responsible for hip flexion, knee

flexion, dorsi-flexion, hip extension, knee extension, and

plantar flexion were necessary. As well, to hold on to the

railing and maintain balance, shoulder abductors, elbow

flexors and extensors, finger flexors and extensors, as well

as the postural muscles were necessary. In order to walk,

the muscles mentioned previously for stair climbing, as well

as those responsible for trunk rotation and shoulder flexion

and extension were necessary. This task required a higher

level of muscle strength of a 4-as the muscles were working

to move through less than half the range of motion against

gravity and the resistance created by my body weight (Stu-

dent 1).

 The individual would need to be able to endure standing,

squatting, and sitting. These activities may need to be done

while carrying varying weights (depending on the props)

for a varying amount of time (depending on how long it

takes to set things up and take the picture). Light activities

for a 70 kg person such as standing require approximate 2

METs or 140 Kcals/hour; sitting would require approxi-

mately 1.4 METs or 100 Kcal/hr. Photography, I believe,

can be classified as a light activity, which according to the

classification would require approximately 50 to 200 KCals

per hour for a 70 kg person (Student 2).

Students were able to apply the theoretical principles of bio-

mechanics to identify opportunities for both adapting and for

grading the demands of the activity:

 Equipment such as scissors as well as paper thicknesses

could also be used to develop strength … If the client had

difficulties in fine motor movements, camera settings where

the digital camera takes the photograph on a timer, or a tri-

pod could be used (Student 1).

 By gradually increasing the weight of the camera or even

the weight of the props that need to be manipulated, the

client can increase their strength as well as their structural

stability (Student 2).

Students were also able to discuss the limitations and relative

merits of the biomechanical perspective.

 ...the biomechanical approach does not consider client’s

interests, cognition, motivation, or levels of pain. Therefore,

this approach to activity analysis is not ideal, as the activity

of expressing pain through art is a highly personal activity

which involves a high degree of emotional and psychologi-

cal aspects which are ignored by this model (Student 1).

Students proved equally capable when applying other theo-

retical perspectives. Student 3 reflected on the environment, as

defined by the MOHO (Kielhofner, 2008) in relation to her

performance of the photography task.

 The social environment included the instructors, my partner,

and other classmates. These factors influenced my motiva-

tion, interpretation, and performance of the activity. After

seeing what images others were creating, I was motivated

to work harder at my image in order to meet the high stan-

dards that were being set. Interpretations of my image from

others also influenced how I interpreted my own image and

how I altered it.

Students articulated an appreciation for multiple perspectives

so as to best match the therapeutic approach with the desired

outcomes.

 Through the activity analysis with the biomechanical and

MOHO theoretical approaches, we have an understanding

of the complex nature of the activity of creating an art piece

to express pain (Students 1 and 3).

 Not only can this activity address physical limitations, it

also has the potential to employ and challenge occupational

participation, the environmental and the personal (emo-

tional, cognitive and spiritual) faculties (Students 2 and 4).

And lastly, students were overwhelmingly positive in their

comments about this type of learning activity where personal

lived experience forms a foundation for developing clinical

skills and insights. The following comments are paraphrased

from the feedback students provided at the completion of the

module:

 I hope to encounter more learning opportunities like this

during my training

 I am strongly motivated to learn more about the subject

 It increased my understanding of the subject, especially

through the personal projects

 It was an advantage to have both the science/models and

the art parts of expression being combined in such a way

One of the student co-authors of this paper wrote the follow-

ing reflection on what it was like to use personal lived experi-

ence with pain as part of the learning activity.

 Given that the experience of depicting pain through pho-

tography was personal, it allowed me to get a better appre-

ciation of what my client may be going through. Not only

did this experience afford me the opportunity to develop a

stronger sense of empathy for my client, but it also allowed

me to brainstorm of ways to modify and grade the activity

from a therapist’s perspective (Student 4).

Discussion and Conclusion

We believe that this theoretical perspective article has met

both of our original aims. Specifically, we determined that situ-

ated learning opportunities can be afforded in the course mod-

ules required in the curriculum. Additionally, there is evidence

from the students’ work cited in this paper to support our con-

clusion that the module met the learning objective of develop-

ing scholarship and ability to apply theory-informed practice.

Much has changed in the 30 years plus since Shapiro and

Shanahan (1976) raised the concern about how educators can

develop teaching and learning strategies that help occupational

therapy students, ultimately practitioners, to value scholarship

and theory-informed practice. We now have access to a vast

array of educational technologies and have a diverse range of

robust theoretical constructs upon which to build. Additionally,

in many countries, our students are no longer undergraduates

but rather enter the profession at the graduate entry masters

level or clinical doctorate. And yet, the profession’s struggle to

both value and build capacity in theory-informed practice re-

verberates across this period of time.

We believe that Vygotsky’s (1962) concept that Most

Knowledgeable Others have a strong influence on the values

and practices of novice therapists holds important lessons for

occupational therapy educators. Shapiro and Shanahan (1976)

concluded their discussion of teaching theoretical concepts with

a quote from Vygotsky on the nature of effective learning de-

C. A. BROWN ET AL. 95

sign. Thirty years and many professional advancements later,

his words are still relevant. “A teacher who tries to do this

[present facts] usually accomplishes nothing but empty verbal-

ism, a parrot-like repetition of words, simulating a knowledge

of the corresponding concepts, but actually covering up a vac-

uum” (Vygotsky, 1962: p. 83).

These are both chall enging an d exci ting day s in educati on and

we look forward to the ongoing dialogue needed to insure we

continue to move towards theory-informed practices while still

maintaining the best of intentions for our students.

Acknowledgements

We would like to acknowledge the contribution to this paper

made by the other class members who participated in the module,

the assistance of Robyn Berry in preparing this manuscript, and,

particularly, the unique skills and vision brought to the experi-

ence by the artist, Deborah Padfield. We would like to thank the

Canadian Pain Society and SEARCH Canada for providing

financial assistance for Deborah Padfield’s visit to Canada.

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