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U:\Placements\Handbooks\BSc OT Student Practice Placement Hb 0914.doc 0

BSc (HONS) OCCUPATIONAL THERAPY

PRACTICE PLACEMENT HANDBOOK

SEPTEMBER 2014

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CONTENTS Page

1 GENERAL PRINCIPLES 1 1.1 Identification of Placements 2 1.2 Learning Outcomes 2 1.3 Assessment 3 1.4 Professional Suitability/Fitness to Practise 3 2 POLICIES AND PROCEDURES 5 2.1 Location and Selection of Placements 5 2.2 Preparation for Practice Placements 5 2.3 Practice Placement Visits 6 2.4 Hours 6

2.5 Sick Leave/Fitness for Practice 7 2.6 Criminal Records Bureau Check 8

2.7 Confidentiality and Informed Consent 8 3 ROLE OF KEY INDIVIDUALS INVOLVED IN PRACTICE

PLACEMENTS 9 3.1 Practice Placement Tutor 9 3.2 Academic Zone Tutors 9 3.3 Placement Co-ordinators 9 3.4 Practice Educators (Occupational Therapists) 10 3.5 Alternative Practice Settings 10

3.6 Your Responsibilities 10

4 STUDENT SUPPORT 12 4.1 Action Plan 12 5 MONITORING AND EVALUATION OF PLACEMENTS 13 5.1 Placement Tutors Forum 13 APPENDICES 14 Appendix 1 Staff Contact Details and Zone Tutors 15 Appendix 2 Programme Structure and Underpinning Academic Modules 16 Appendix 3 Stages of Study 23 Appendix 4 Practice Placement 1 Assessment Form 25 Appendix 5 Practice Placement 2 Assessment Form 33 Appendix 6 Practice Placement 3 Assessment Form 41 Appendix 7 Practice Placement 4 Assessment Form 49 Appendix 8 Final Placement Assessment Form 57 Appendix 9 Manual Handling Training Standards 66 Appendix 10 Occupational Therapy Placement Record 69 Appendix 11 Obtaining Informed Consent 71 Appendix 12 Placement Concern Form 75 DISCLAIMER The information contained in this handbook is, as far as possible, accurate and up-to-date at the time of printing. The express permission of Teesside University must be obtained to reproduce any, or all of this publication, other than for personal use or for those purposes permitted by law.

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1 GENERAL PRINCIPLES Welcome to the BSc (Hons) Occupational Therapy programme. This is the start of your three-year journey that will hopefully lead to eligibility to apply for registration with the Health and care Professions Council (HCPC) as an occupational therapist. It will be hard work at University and on practice placements, before you reach your goal. The teaching team and our practice colleagues are, however, committed to giving you as much support as possible along the way. Hopefully, participation in the three years will bring enjoyment, personal insight and new friends as well.

The Occupational Therapy programme at this University has been running since 1994. The programme that this handbook refers to was updated during 2008 and has been re-validated by the Health and Care Professions Council (HCPC), the College of Occupational Therapists (COT) and Teesside University in May 2009, as part of the five-year cycle of review. We have listened to the feedback from previous students, from our clinical colleagues, service users and carers, as well as our External Examiners, and have restructured the programme in response to their comments and our own research. We sincerely hope that you will find the structure and content of the programme as exciting and stimulating as we have intended in the planning.

The purpose of this handbook is to provide information which is specific to the BSc (Hons) Occupational Therapy programme practice placements. In the following pages you will find details of the placement structure, the aims and outcomes, and an explanation of our approach to learning, teaching and assessment. You should keep this handbook safe so that you can refer to it throughout your three years of study. The practical application of skills learned in the academic setting and the ability to understand the complexities of practice situations is an integral part of your learning experience. It is a requirement of both the College of Occupational Therapists and the World Federation of Occupational Therapists that students must successfully complete a minimum of a 1,000 hours’ practice placement experience. You are required not to just undertake the practice placement but also to pass it. The occupational therapy programme is designed to integrate practice experience and learning with academic modules. You are expected to use practice to enhance your understanding of the academic modules and to be able to demonstrate the ability to identify and apply the theory underpinning practice. Practice placements are organised in a variety of settings with people of differing ages and functional deficits, thus allowing you the opportunity of gaining experience across a range of occupational therapy services and geographical locations. Integration of academic and practice modules are paramount throughout the programme. This has been achieved by:

Close liaison with practice staff to ensure the programme content is relevant and reflects current practice.

Practice experts are involved in teaching specific areas of academic modules and in assessing practical skills.

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Practice Educators will be invited to assist with the Viva Voce assessments following practice placements.

Practitioners are invited to study certain academic modules and share learning experiences with students.

University staff visiting practice areas during placements.

The learning outcomes from academic modules relate directly to the aims and objectives of practice.

Students are required to use knowledge, skills and attitudes gained in practice as a basis for academic learning in future modules.

Liaison between University staff and practitioners occurs through the Clinical Liaison Panel held three times a year.

By invitation, University staff will hold workshops or attend staff/team meetings in the practice setting in order to disseminate information regarding the programme and to discuss issues pertinent to the practice experience.

Workshops and study days are held at the University to offer an opportunity for Practice Educators to reflect upon the student learning experience and the contribution which they make to this.

Regularly audited practice placement settings.

1.1 Identification of Placements You will be placed in a wide variety of placements in order to emulate the diversity of occupational therapy. Settings which may be used include acute hospitals, specialist clinics and departments, social services, Primary Care Trusts (PCTs), schools, charitable establishments and role emerging settings:

All new placements will be audited prior to the student being placed to ensure the placement will offer the student a relevant learning experience.

Members of the academic team will either visit or telephone the placement at the halfway stage. This will provide the opportunity for ongoing monitoring of the placement.

Students are required to fill in an evaluation form at the end of the placement. A copy of this will be forwarded to the Practice Educator to provide feedback from the student perspective.

1.2 Learning Outcomes

The learning outcomes of the academic modules provide a framework for the learning outcomes of practice (for details of the modules you will study before each practice placement, please see Appendix 2). The knowledge, skills and attitudes gained in each placement are cumulative, building on previous practice experience and academic modules. The outcomes have sufficient breadth to allow them to be related to any area of practice. The practice experience demands your active involvement, with the expectation that you will progressively take more responsibility for your learning throughout the programme (see course structure in Appendix 2).

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Practice education is therefore sequential and you must successfully complete Practice Placement 1 before progressing to Practice Placement 2. Practice Placement 2 must be successfully completed before you can progress to Practice Placement 3 and so forth. The final placement must be successfully completed before your programme is deemed to be complete.

1.3 Assessment Assessment should be ongoing with you being given regular feedback to enable you to develop and modify your approach during the placement. You will be formally assessed by the Practice Educator halfway through each placement and again at the end of the placement. This assessment will include professional suitability, interpersonal behaviour and an understanding and demonstration of clinical skills and clinical reasoning. The Practice Educator is not required to give a numerical grade but assess on a pass/refer basis with formative feedback. The Assessment Board will ratify the pass or refer grade. For all professional programmes you may normally be assessed in practice on two occasions i.e. be referred and offered one re-assessment opportunity on a maximum of two practice placements for the duration of a programme. You will be required to demonstrate learning through an assessed piece of written work upon return to the University. This will be assessed to give the practice placement a graded mark. You must pass both assessment components to be awarded an overall pass mark for the placement.

1.4 Professional Suitability/Fitness to Practise

Professional suitability is a responsibility of all occupational therapists and student occupational therapists. It is a professional regulatory matter which is demonstrated by the adherence of each individual to the Standards of Conduct, Performance and Ethics published by the Health and Care Professions Council (HCPC) and also the Code of Ethics and Professional (2010) (herein referred to as the ‘Code’) published by the College of Occupational Therapists. These standards provide values and principles by which occupational therapists and student occupational therapists must abide, for the protection of the public and to maintain high standards of professional behaviour at all times. Section 1.1.2 of the Code states: “You have a responsibility to act in a professional and ethical manner at all times. The Code provides a set of behaviours and values that are relevant to you, irrespective of where you work or your level of experience. The Code, along with the College of Occupational Therapists’ current professional standards provides you with a framework for promoting and maintaining good and safe professional behaviour and practice in occupational therapy.” (COT,

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2010, Pg2). You must be deemed to be professionally suitable to pass practice education and the Code can provide guidance for you and your Practice Educator throughout your practice education and at formative and summative assessments. If you have achieved all other learning outcomes, you cannot be deemed to have passed the placement unless the Educator is satisfied that the Code has been adhered to, with you demonstrating and maintaining ethical and professional behaviour throughout your placement. Consequently you may be deemed to be ‘professionally unsuitable’ and fail the placement by not adhering to the Code. At the first occurrence of unprofessional behaviour the Academic Zone Tutor or the Practice Placement Tutor must be notified and be involved in subsequent supervision discussions. Evidence of unprofessional behaviour must be documented in supervision notes and explained to you with learning opportunities offered to rectify your behaviour. Supervision notes must be dated and signed by both the Practice Educator and you. A significant change in behaviour may enable you to complete the placement. However, there may be instances where the behaviour is of such a serious nature (e.g. abuse, unsafe practice, negligence) that it warrants immediate withdrawal from the placement setting. This will then lead to a failure of the placement which will be subsequently ratified at a Module Board. Where you are deemed to be guilty of an act, practice or breach of conduct that contravenes a Profession Specific Code that may involve a patient, client, member of staff or other person with whom you are in contact and/or engages in behaviour, which is deemed to bring the profession into disrepute and/or engages in behaviour, which fails to demonstrate appropriate standards of professionalism and/or good character and/or is deemed to be a potential health and safety risk to self/public and/or staff members then the Fitness to Practise procedure (see School of Health & Social Care Student Essential Guide) may be instigated and you may be temporarily withdrawn without notice from a practice placement and placed on study leave.

2 POLICIES AND PROCEDURES

2.1 Location and Selection of Placements

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You are required to undertake a range of placements that will equip you with a broad base of experience and will include placements in the following practice areas:

Acute setting

Physical health

Mental health

Developmental delay - including paediatrics, learning disabilities and child psychiatry

Community-based placement including social services

The Practice Placement Tutor selects the placements according to your individual practice needs. Consideration will be given to the geographical location of the placement, the type and nature of the placement and your personal circumstances where possible. You will normally receive all placements within the Northern Region, primarily Northumbria, Tyne & Wear, County Durham, Teesside and North Yorkshire. Due to the geographical location of placements offered, travelling to placements is a requirement.

Allocation of Placements Placement allocations will be provided for you through the School of Health & Social Care Student Intranet, where the ARC log-in can be accessed via the button says ‘log into ARC for placement information and evaluations’. The link for this is: http://www.teessidepow.arcwebon-line.com/ Once logged in, type in your name and push the allocation button. This will give you the location of your placement. In exceptional circumstances (and within five days of a change in circumstance) a student may request to change a placement using the request to change placement form (available on the e-directory). Financial reasons would not be considered an exceptional circumstance. Please be aware that failure to attend an allocated placement will result in a refer/fail mark being awarded. 2.2 Preparation for Practice Placements Whilst aspects of preparation for practice occur in all modules, specific skills are contained in the module ‘Occupational Therapy Professional Practice’. This module allows you to develop a basic level of practical skill and have an understanding of health and safety issues in relation to practice e.g. principles of moving and handling. It encourages personal development to ensure you are able to present yourself in a manner appropriate to the environment. Professional development occurs throughout the programme. Through the development of an e-portfolio, you are encouraged to take responsibility for your own learning and to develop an awareness of your own strengths and needs. Emphasis is placed on the integration of theoretical and practice experience within the context of professional development.

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You will be expected to attend the practice briefing and de-briefing sessions relating to each placement. Prior to each placement you will receive a preparatory workshop during which information is given and issues can be explored in relation to the coming placement. Following each placement, you will be de-briefed either in a group workshop or individually. Prior to a Practice Placement you will arrange to meet with your Personal Tutor. This enables you to identify your strengths, needs and areas of interest thus ensuring that you have the opportunity to enhance their practice experience in a positive manner and establish appropriate learning objectives and outcomes for the placement. Manual Handling training is provided prior to going on placement (see Manual Handling Training Standards, Appendix 9, for details).

2.3 Practice Placement Visits All the academic team have an allocated ‘zone’ to visit and links with Practice Educators. The Zone Tutor will liaise closely with the Practice Co-ordinator to organise workshops, study days and road-shows. A member of the academic team will visit or ring you at least once during each practice placement. The visit/phonecall should take place shortly after the halfway assessment. Further contacts may be made at the request of either you or the Practice Educator. The visit/phonecall is pastoral in nature and does not contribute to the assessment but allows:

Support for the student and Practice Educator.

Discussion of the student’s progress and formative assessment.

Arbitration if there is disagreement between the student and Practice Educator.

Advice to be offered if the student appears to be failing the placement.

The opportunity to ensure that objectives and grading are at an appropriate level.

A written summary of all discussions should be signed, dated and a copy retained by all parties concerned. 2.4 Hours You are expected to work 37.5 hours a week. You will be expected to work a shift pattern and undertake some weekend work if this is the normal pattern of working of the establishment. To gain a BSc (Hons) Occupational Therapy degree you must undertake a minimum of 1,000 hours’ practice experience as required by the World Federation of Occupational Therapists. The BSc (Hons) Occupational Therapy programme includes 30 weeks of assessed practice - 30 x 37.5 hrs = 1125 hours.

A half-day (three hours) study period should be incorporated into the working week at a time agreed between you and your Practice Educator. The study

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hours are counted towards the total for the week. Any hours missed due to sickness or Bank Holidays should not be included in the total hours. It is your responsibility for ensuring that the professional practice hours form is filled in correctly, signed and dated. This must be submitted to the Practice Placement Tutor after each placement. At the end of the programme all practice hours need to be correctly totalled for registration purposes.

2.5 Sick Leave/Fitness for Practise The University has a duty to ensure that all students are fit and able to undertake practice placements. If you have had an illness or injury in the weeks before a placement you may be required to provide evidence that you are fit to undertake the practice placement. The Practice Placement Tutor, on behalf of the University, reserves the right to request an Occupational Health assessment to determine fitness. If you are deemed not fit for practice your practice placement will be deferred until such time as you are fit. Whilst on placement, you should adhere to policies in the work place regarding sick leave. You must inform your Practice Educator of absence and provide sick notes/doctors notes where necessary. You must also inform the Academic Zone Tutor and the Student Records Office (01642 384586) on your first day of sickness and on return to work. Copies of sick notes must be submitted to the University. It is your responsibility to ensure that you are fit to work whilst on placement. You can also contact the Student Records office by email at [email protected]. In the event of prolonged sickness, you will be withdrawn from the placement. The placement will be undertaken at the next available opportunity but must be in sequential order. For a placement to be considered viable the minimum time must be achieved as listed below:

Level 4 – Practice Placement 1 duration four weeks

Level 4- Practice Placements 2 duration five weeks

Level 5 - Practice Placement 3 duration six weeks

Level 5 - Practice Placement 4 duration nine weeks

Level 6 – Final Placement duration 6 weeks

Should you need to leave and not complete the placement due to ill health, you should provide evidence to the University that this has occurred. The Programme Leader/Placement Co-ordinator will advise on the appropriate University procedure to follow in these situations.

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The Practice Educator is also asked to complete the Placement Assessment form to give feedback on your performance up until you have left the placement. You are required to undertake an Occupational Health assessment prior to your commencement of the programme and you are required to inform the Programme Leader immediately should your health status change at any point during the programme. 2.6 Disclosure and Barring Service Checks (DBS) All students are given a DBS check for criminal convictions including exemption from Rehabilitation of Offenders Act (1974) and Protection of Children Department of Health Circulate (Ref: HC (88) 9). Any queries regarding police clearance should be directed to the School Manager in the School of Health & Social Care. You are required to inform the Programme Leader immediately should your DBS status change at any point during the programme. Should there be a change in your CRB then the School of Health and Social Care Fitness to Practise procedure may be instigated. 2.7 Confidentiality and Informed Consent Confidentiality and Informed Consent is essential in the health and social care setting, as maintaining confidentiality and gaining consent, promotes trust and individual choice for each client/patient. Please see Appendix 3 and the School of Health & Social Care Student Essential Guide for further information on confidentiality and consent.

3 ROLE OF KEY INDIVIDUALS INVOLVED IN PRACTICE PLACEMENTS

3.1 Practice Placement Tutor

The Practice Placement Tutor acts as a link between the University and the practice setting and as such is a point of contact for practitioners and students wishing to discuss issues relating to practice. The role includes:

Liaison with the Practice Co-ordinator and Practice Educator prior to placing students and after the placement has ended.

Supporting Practice Educators and students during the placement.

Briefing and debriefing students before and after placements.

Contributing to the education of potential Practice Educators.

Attending team/staff meetings in practice as appropriate.

Organising and contributing to workshops.

Working with Zone Tutors to organise student visits and liaise with practice staff as appropriate.

Identifying potential new placements and assessing their suitability as a learning environment.

Selecting suitable placements for the student ensuring that he/she has a variety of appropriate experiences.

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Maintain a database of placements, specialities and Practice Educators.

3.2 Academic Zone Tutors

Each member of the Occupational Therapy teaching team has been assigned a zone(s) to be a link between the practice setting and the University. Students who are on placement will be the responsibility of the Practice Educator and the Academic Tutor attached to the zone for which they have responsibility. The Academic Zone Tutor is an important point of contact for the Practice Educator and the student during the period of placement, particularly if queries or problems arise. The Academic Zone Tutor will complete the halfway visit for students in their allocated zones.

3.3 Placement Co-ordinators

The Practice Co-ordinators are the first point of contact for students when they are making contact with placement settings. Practice Co-ordinators identify staff in their area that have completed the Practice Educators’ workshop and who are able to offer student placements. In addition they represent their group of Practice Placement Educators at the Clinical Liaison Panel.

3.4 Practice Educators (Occupational Therapists)

Practice Educators have the day-to-day responsibility for the education of students whilst in practice. In order to be considered as a Practice Educator, occupational therapists are expected to:

Be registered with the Health and Care Professions Council.

Have completed a recognised Practice Educators’ course or be working towards one.

The Practice Educator role includes:

Providing the student with information regarding the placement including suggested reading.

Ensuring the student is introduced to the placement area. This should include the policies and procedures of the department, health and safety issues, emergency procedures, appropriate facilities and learning resources.

Compiling specific objectives with the student in relation to the practice learning outcomes contained in the assessment form.

Engaging in weekly supervision sessions with the student to provide feedback on his/her performance and amend objectives as appropriate.

Carrying out the halfway assessment and providing constructive feedback regarding the student’s strengths and needs.

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Completing the assessment form at the end of the placement to give feedback identifying areas of good practice and suggestions for development in the future.

3.5 Alternative Practice Settings/Role-emerging Placements

During your final placement you will be placed in a setting without the direct supervision of an occupational therapist. You will be supported by an on-site supervisor who is not an occupational therapist. You will also receive weekly supervision from a Practice Educator (occupational therapist) who will identify and negotiate the learning outcomes in conjunction with you and the on-site supervisor to ensure you are gaining the appropriate learning experience. The ‘workplace supervisors’ will be encouraged to attend workshops in order to gain an understanding of the occupational therapy programme and the requirements of students whilst on placement. 3.6 Your Responsibilities

Before the placement you must:

Attend the practice placement briefing session.

Bring to the attention of the Practice Placement Tutor any special circumstances to be taken into account, as far in advance of the placement as possible.

Write to the Practice Co-ordinator, introduce yourself and request information pertinent to the placement.

Inform the Practice Co-ordinator of any disabilities, difficulties or problems which may need to be taken into consideration during the placement.

Prepare appropriately for the placement.

During the placement you must:

Adhere to all departmental policies and procedures.

Act in a professional manner at all times.

Adhere to the Professional Code of Conduct at all times.

Make use of all learning resources.

Identify your learning needs and negotiate objectives for the placement.

Participate in weekly supervision sessions and respond to feedback.

Organise a suitable date and time for the halfway visit and confirm this with the Zone Tutor.

Recognise any areas of need highlighted during the halfway assessment and make appropriate adjustments in order to develop further during the second half of the placement.

Bring to the attention of the visiting Zone Tutor any issues with the placement as they arise.

Following the placement you must:

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Complete and submit the placement evaluation form.

Send a letter of thanks to the Practice Educator.

Reflect upon the experience and identify your personal strengths and needs.

Attend placement debriefing session.

Assimilate the skills and knowledge learnt and incorporate them into the academic and practice modules to follow.

Complete the evaluation form, assessment form, timesheet and travel claim form and submit them to the Practice Placement Tutor immediately upon return to the University.

4 STUDENT SUPPORT Student support on practice begins in the introduction week of the programme when you will be requested to complete a Personal Profile. This information remains with the Practice Placement Tutor and is used in conjunction with placement details to ensure that you receive a relevant practice experience (under the Data Protection Act, this information is not imparted to the Practice Educators). You are encouraged to divulge personal information to the Practice Placement Tutor and to Practice Educators if it could affect your practice. Support systems can then be put into place to ensure that you are not compromised whilst on placement.

You are allocated a Personal Tutor on admission to the University, who is responsible for the pastoral care and support. You can seek support from your Personal Tutor at any time and may wish to discuss practice placement issues with them. Should problems arise during a placement several avenues may be explored:

The Practice Educator and/or you should contact the visiting Zone Tutor immediately who will suggest a course of action depending on the nature of the issue.

The visiting Zone Tutor will visit to either offer advice or support the Practice Educator and/or you in a particular course of action. It is essential that the University be involved from the earliest possible moment if there are indications that you are failing (support is essential not only for you in this situation but also for the Practice Educator).

Independent student support in the form of financial advice, counselling etc is available at the University and these are accessible to you whilst on placement. It is not the Practice Educator’s responsibility to become involved in your personal problems.

Concerns regarding the structure or administrative aspects of the programme will be discussed with the individual raising those concerns. If appropriate this will be taken for further discussion, to the Practice Liaison Panel who may advise or recommend further action.

4.1 Action Plan

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If you have been identified as having particular difficulties on practice placements you will be offered an Action Plan to facilitate the remediation of these difficulties. The Action Plan will be individual to you and will be drawn up in collaboration with the Practice Placement Tutor and your Personal Tutor. The Action Plan may also require the involvement of future Practice Educators.

5 MONITORING AND EVALUATION OF PLACEMENTS Placements are monitored and evaluated on a regular basis by:

Student evaluation forms.

Informal discussions with students.

Placement visits by the visiting Zone Tutors and Practice Placement Tutor.

Undertaking a placement audit on a regular basis.

The attendance of Practice Educators at workshops and study days.

The monitoring of student progress whilst on placement by evaluating the objectives set and the quality of feedback given to students.

5.1 Practice Educators Forum (PEF) This is a formal forum that meets three times a year. Practice Co-ordinators are invited to attend and it is hoped that a representative from each practice area will do so. It is a forum for discussion concerning placement provision, assessment and module development. Students are invited to attend the meetings. This panel will:

Act as a forum for discussion for issues related to the implementation and improvement of practice education.

Identify areas of need in relation to the theoretical and practical preparation for placements.

Review the practice assessment process for students.

Evaluate and develop evaluation forms for students and Educators.

Identify new areas of experience or potential placement areas.

Information about decisions reached by the Committee will be disseminated to all Practice Educators, the programme planning team and the Occupational Therapy Programme Board.

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APPENDICES

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APPENDIX 1 STAFF CONTACT DETAILS AND ZONE TUTORS University Address School of Health & Social Care Teesside University Centuria Building Middlesbrough TS1 3BA

Staff Contact Details

Member of Staff Role Tel Number Email Address

Katie Atkinson Senior Lecturer 01642 384161 [email protected]

Claire Brewis Subject Group Leader Principal Lecturer

01642 384130 [email protected]

Eric Charlton Senior Lecturer 01642 384929 [email protected]

Sandra Cleminson Placement Tutor MSc Senior Lecturer

01642 384519 [email protected]

Mark Coates Admissions tutor BSc Placement Tutor MSc Senior Lecturer

01642 384536 [email protected]

Patricia McElroy Senior Lecturer 01642 384928 [email protected]

Christopher McKenna

Programme Leader MSc Senior Lecturer

01642 384191 [email protected]

Claire Smith Senior Lecturer 01642 384930 [email protected]

Cath Wright Programme Leader BSc Senior Lecturer

01642 738068 [email protected]

Debbie Horne Senior Lecturer Placement Auditor

01642 384928 [email protected]

Dawn Fraser Senior Lecturer Placement Tutor BSc Placement Co-ordinator BSc & MSc

01642 738138 [email protected]

Zone Tutors

Organisation/Zone Tutors

Tees, Esk & Wear Valley South (TEWV) Mark Coates & Katie Atkinson

Tees, Esk & Wear Valley North (TEWV) Durham / Darlington / Sedgefield Locality

Eric Charlton & Claire Smith

Sunderland & Northumberland Newcastle & Gateshead

Sandra Cleminson

Darlington Claire Smith

James Cook/IOTS, Middlesbrough Council, Redcar & Cleveland Council

Claire Brewis, Cath Wright, Dawn Fraser

North Tees Chris McKenna

North Tees and Hartlepool NHS Hartlepool Social Serivces

Trish McElroy

Hartlepool Debbie Horne

Redcar and Cleveland PCT Mark Coates

Whitby, Thirsk & Northallerton Cath Wright

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APPENDIX 2

PROGRAMME STRUCTURE

Year Term 1 Term 2 Term 3

1

Occupational Being (including Practice Placement 1)

Occupational Therapy Professional Practice

Promoting Independent Lives (including Practice Placement 2)

Principles of Occupational Therapy

Building Evidence for Occupational Therapy

2

Occupation (including Practice Placement 3)

Occupational Therapy Process

Utilising Evidence for Occupational Therapy

Practice Placement 4

3

Option Module

Contemporary Issues for Occupational

Therapy

Final Placement

Meeting the Challenges for Occupational Therapy Practice

Occupational Therapy Final Project

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2014/15 Timeline BSc Occupational Therapy

Wk Terms Date 1st year BSc 2014 intake

2nd year BSc 2013 intake

3rd year BSc 2012 intake

0 22/09 Induction

1 1 29/09 University University University

2 1 06/10 University University University

3 1 13/10 University University University

4 1 20/10 University University University

5 1 27/10 University University University

6 1 3/11 University Placement University

7 1 10/11 Inter-professional Learning week

Placement University P

8 1 17/11 University Placement University P

9 1 24/11 University Placement University P

10 1 01/12 University Placement University P

11 1 08/12 University Placement University P

Xmas 15/12 Holiday Holiday Holiday

Xmas 22/12 Holiday Holiday Holiday

Xmas 29/12 Holiday Holiday Holiday

12 2 5/1 University University Placement

13 2 12/1 Placement University Placement

14 2 19/1 Placement University Placement

15 2 26/1 Placement University Placement

16 2 02/2 Placement University Placement

17 2 09/2 University Placement University

18 2 16/2 University Placement University

19 2 23/2 University Placement University

20 2 02/3 University Placement University

21 2 09/3 University Placement University

22 2 16/3 University Placement University

Spring 23/3 Holiday Holiday Holiday

Spring 30/3 Holiday Holiday Holiday

Spring 6/4 Holiday Holiday Holiday

23 3 13/4 University Placement University

24 3 20/4 University Placement University

25 3 27/4 University Placement University

26 3 04/5 Placement University University

27 3 11/5 Placement University University

28 3 18/5 Placement Assessment Assessment

29 3 25/5 Placement Assessment Assessment

1st week of the summer holiday

Placement

*P = Placement one day per week for five weeks. NB: dates for Years 2 and 3 will vary due to the University calendar.

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UNDERPINNING ACADEMIC MODULES First Year Placements The student will participate in two practice placements; one of four weeks and one of six weeks each to be undertaken in contrasting settings. The emphasis will be on consolidating skills and knowledge gained in the academic modules, developing interpersonal skills relating to the practice setting and gaining an understanding of the pathology of the conditions encountered. The following modules will be studied during the first year. Occupational Therapy Professional Practice The module aims to enable you to:

Consider the skills of a competent communicator in an occupational therapy setting.

Set the context for professional behaviour in practice.

Develop presentation skills including giving and receiving feedback and self-evaluation.

Explore the principles of key skills in preparation for practice, necessary to formulate appropriate intervention.

Building Evidence for Occupational Therapy The module aims to enable you to:

Embrace the current demands of learning in higher education and encourage them to identify and plan their own learning and development.

Contextualise the position of research within occupational therapy and occupational therapy practice and introduce the key methodologies and the other sources of information utilised by occupational therapists.

Encourage the development of self in terms of becoming a reflective practitioner.

Principles of Occupational Therapy The module aims to enable you to:

Recognise and explain the core philosophies and theoretical principles of occupational therapy.

Occupational Being (Incorporates Practice Placement 1) The module aims to enable you to:

Understand different theories that account for the forces influencing the development and occupational performance of an individual from birth through to senescence and death.

Recognise life-stage characteristics in relation to occupational functioning and how it is experienced by the individual and perceived by members of their society.

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Discuss the effects of pathological processes and symptomatology as manifested along the life-span continuum and understand and recognise secondary problems that could impact on occupational performance.

Develop an understanding of regional and systematic anatomy and relate this to how optimum occupational performance is achieved.

Develop an appreciation of the relationship between the individual and the environment and how this inter-relationship influences occupational performance.

In relation to Practice Placement 1, the module aims to enable you to:

Incorporate theoretical and practical learning from the academic setting to the placement setting.

Describe and explain judgements made by the placement educator.

Identify common issues for the clients seen within the placement setting.

Plan and manage the acquisition of new knowledge and skills.

Knowledge and comprehension of a condition and how this affects the occupational performance of an individual that the student encounters on this placement will form the academic assessment.

Promoting Independent Lives (Incorporates Practice Placement 2) The module aims to enable you to:

Explore the occupational therapy process.

Consider ways to collect relevant information and develop appropriate SMART goals.

Set in context the factors limiting independent living and the effect on the individual.

Consider the concepts of illness, disease and disability.

Explore the use of basic assistive equipment and technology in the home context.

In relation to Practice Placement 2, the module aims to enable you to:

Apply knowledge and translate theoretical (i.e. person, environment, occupation) and practical learning from the academic setting to the placement setting.

Apply the theory and concepts introduced in the academic teaching to the context of practice.

Use SMART goals in setting of treatment goals for individuals encountered on placement.

Demonstrate the application of the occupational therapy process under the supervision of the placement educator.

Second Year Placements The student will participate in two practice placements; one of six weeks and one of 10 weeks each, to be undertaken in contrasting settings. The emphasis will be on consolidating skills and knowledge gained in the academic modules.

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The following modules will be studied during the second year. Utilising Evidence for Occupational Therapy To enable you to:

Develop the question construction, searching and critical evaluation skills necessary to locate and utilise evidence relevant to Occupational Therapy practice or Occupational Science.

Develop a sound knowledge and understanding of different research methodologies.

Make use of evidence to inform professional decision-making. Occupation (Incorporates Practice Placement 3) The module aims to enable you to:

To promote the critical analysis occupations within a wide variety of individual and community contexts.

Encourage students to apply a balanced, logical and supported argument in a range of occupational contexts.

In relation to Practice Placement 2, the module aims to enable you to:

Consider the application of occupation, applying theory to clinical settings.

Apply a balanced, logical and supported argument for the use of the occupation within the practice placement setting.

Occupational Therapy Process The module aims to enable you to:

Consider the selection and application of appropriate assessment tools/ methods for specific clients.

Study the formulation of goals appropriate to the client and the setting.

Use clinical reasoning in order to construct plans of intervention.

Formulate options on the use of a range of evaluation tools. Practice Placement 4 and Clinical Reasoning The module aims to enable you to:

Facilitate the translation of theoretical and practical learning from the academic setting to the practice placement.

Develop skills to make independent judgements which reflect the clinical reasoning process.

Promote practice within the legal and ethical boundaries of the occupational therapy profession.

Practice as an autonomous professional, exercising your own professional judgement under the direction of a placement supervisor.

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Third Year Placements Practice Placement 5 is the final pre-qualifying placement and is aimed for this to take place in a role-emerging environment or a traditional setting with service development as focus. The following modules will be studied during the third year: Final Placement The module aims to enable you to:

Apply knowledge and incorporate theoretical and practical learning from the academic setting to the practice placement.

Synthesise, appraise and evaluate evidence to make independent judgements.

Consider practice within the legal and ethical boundaries of their profession.

Promote the planning, management and evaluation of the acquisition of new knowledge and skills.

Contemporary Issues for Occupational Therapy The module aims to enable you to:

To analyse the economic, social, political and cultural environment within which health and social care policies are formulated and implemented.

To demonstrate a comprehensive and detailed awareness of major contemporary health and social care policy initiatives.

To appraise the roles of a variety of players in the policy community of health and social care.

To analyse and evaluate how the relevant contemporary policies and debates influence and impact upon practice of Occupational Therapists in both health, social care and voluntary settings.

Meeting the challenge for Occupational Therapy Practice The module aims to enable you to:

Analyse and evaluate the personal skills required for a graduate occupational therapist.

Encourage intellectual flexibility and openness to new ideas.

Synthesise complex concepts to enable students to operate ethically in complex situations.

Occupational Therapy Final Project The module aims to enable you to:

Consolidate and draw together previous learning.

Promote the development of the necessary skills to compile the evidence base into a formal proposal and scientific poster.

Encourage and support the development of initiative, insight, creativity and entrepreneurial thinking.

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Option Modules – you will have a choice of one of the following option modules. Usually three different options will be offered to you, subject to staff availability within the academic year. World Focused Occupational Therapy Occupational Therapy Issues in Mental Health Inclusive Environmental Design Occupational Therapy Practice in Neurology Occupational Therapy in Paediatric Practice Health Care Law for Occupational Therapists

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APPENDIX 3 STAGES OF STUDY All University programmes are designed around levels of study. The aims of these are to enable the student to progress through the programme with increasing responsibility towards autonomous and independent learning. These levels of study may also assist the Practice Educator to appreciate the level the student should be operating at whilst on placement. Stage 1 Outcomes Knowledge and Understanding

Identify and explain the different research methods used in the discipline and apply them in simple contexts.

Recognise the role of ethics in the study of the discipline.

Describe and explain key elements of the core foundation knowledge of the discipline.

Cognitive and Intellectual Skills

Systematically gather record and describe data/evidence from a range of sources.

Understand and describe/explain the nature of knowledge/concepts.

Recognise and engage in intellectual argument.

Recognise the provisional/changing nature of knowledge. Professional Qualities and Skills

Identify the skills and knowledge base associated with the field of study.

Demonstrate awareness of the abilities and competencies associated with the field of study.

Consider the role of ethics within the field of study. Stage 2 Outcomes Knowledge and Understanding

Critically review, select from and apply alternative research methodologies in more complex situations.

Apply the skills of research design to undertake a small-scale study.

Critically analyse the variety of ideas, contexts and frameworks associated with the discipline.

Explore legal and ethical issues relevant to the discipline.

Demonstrate a detailed knowledge of the discipline.

Analyse the application of disciplinary knowledge in limited but challenging contexts.

Cognitive and Intellectual Skills

Analyse, apply and interpret evidence/information from a variety of sources.

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Apply, question and relate appropriate knowledge/concepts to a range of activities.

Employ a balanced, logical argument to a range of presenting issues.

Demonstrate intellectual flexibility and adaptability.

Demonstrate openness to new ideas. Professional Qualities and Skills

Take individual responsibility for developing the skills and knowledge base associated with the field of study.

Work effectively within the range of environments associated with the field of study/profession.

Analyse the impact of ethical and legal issues relating to the field of study/ profession.

Stage 3 Outcomes Knowledge and Understanding

Plan, undertake and evaluate a self-initiated inquiry or research project.

Synthesise, appraise and evaluate new knowledge and contemporary developments and issues in the discipline.

Analyse and evaluate the impact of ethical and legal issues relevant to the discipline.

Demonstrate a comprehensive and detailed knowledge of the discipline.

Synthesise and critically appraise different aspects of disciplinary knowledge in complex contexts.

Cognitive and Intellectual Skills

Synthesise, appraise and evaluate evidence/information from relevant/ appropriate sources.

Evaluate appropriate knowledge/concepts as an aid to problem-solving.

Challenge orthodoxy using balanced, logical and supported argument.

Compare ideas and make appropriate judgements. Professional Qualities and Skills

Review and evaluate personal skills and attributes to prepare for career applications.

Critically assess personal competencies and skills and prepare an Action Plan for enhancement.

Work within the ethical and legal framework of the chosen field of study/ profession.

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PRACTICE PLACEMENT 1 ASSESSMENT FORM BSc (Hons) Occupational Therapy

Practice Placement 1 Assessment Form

Name of Student Name of Practice Placement Educator Address of Practice Placement Speciality Dates of Practice Placement to Number of Hours Completed Reasons for Absence

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the HCPC Standards of Proficiency for Occupational Therapists (2013). Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes. PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .......................................................................................................................................................... …….................................................................................................................................................... ......................................................................................................................................................... .......................................................................................................................................................... .......................................................................................................................................................... ................................................................................................................................................................ ....................................................................................................................................................

APPENDIX 4

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Student’s Comments: ....................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... Signature of Practice Placement Educator Date:……………………………………………………………………………………………………… Signature of Student Date:……………………………………………………………………………………………………… Signature of Academic Practice Placement Organiser Date:………………………………………………………………………………………………………

LEARNING OUTCOMES Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists. For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale. In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments provided may indicate strengths which the student has and areas of development which may need to be addressed in subsequent placements. You can use the electronic version of the forms to expand the comments boxes to add detail.

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Learning outcome 1

Unable to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Able to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Comments:

Learning outcome 2

Unable to describe the role of the OT in the placement area.

Able to describe the role of the OT in the placement area.

Comments:

Learning outcome 3

Unable to demonstrate the need to practice safely and effectively within their scope of practice.

Able to demonstrate the need to practice safely and effectively within their scope of practice.

Comments:

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Learning outcome 4

Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Learning outcome 5

Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Learning outcome 6

Unable to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Comments:

Learning outcome 7

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Unable to demonstrate the ability to gather appropriate information

Able to demonstrate the ability to gather appropriate information

Comments:

Learning outcome 8

Unable to describe appropriate assessment techniques

Able to describe appropriate assessment techniques

Comments:

Learning outcome 9

Unable to define the underpinning theories and reasoning which impact on treatment decisions.

Able to define the underpinning theories and reasoning which impact on treatment decisions.

Comments:

Learning outcome 10

Unable to describe appropriate Able to describe

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interventions that they have seen during their placements.

appropriate interventions that they have seen during their placements.

Comments:

Learning outcome 11

Unable to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

Able to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines. maintain records appropriately.

Comments:

Learning outcome 12

Unable to explain how planned activity may be modified to ensure effectiveness.

Able to explain how planned activity may be modified to ensure effectiveness.

Comments:

Learning outcome 13

Unable to demonstrate the ability to reflect on and review practice.

Able to demonstrate the ability to reflect on

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and review practice.

Comments:

Learning outcome 14

Unable to define the key concepts of the bodies of knowledge which are relevant to the profession practice area.

Able to define the key concepts of the bodies of knowledge which are relevant to the profession practice area.

Comments:

Learning outcome 15

Unable to describe the need to establish and maintain a safe practice environment.

Able to describe the need to establish and maintain a safe practice environment.

This Comments:

Learning outcome 16

Unable to understand the importance of participation in supervision and

Able to understand the importance of

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mentoring. participation in supervision and mentoring

Comments:

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PRACTICE PLACEMENT 2 ASSESSMENT FORM BSc (Hons) Occupational Therapy

Practice Placement 2 Assessment Form

Name of Student Name of Practice Placement Educator Address of Practice Placement Speciality Dates of Practice Placement to Number of Hours Completed Reasons for Absence

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the HCPC Standards of Proficiency for Occupational Therapists (2013). Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes. PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................................................................................................................... ............................................................................................................................................................... .................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................

APPENDIX 5

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Student’s Comments: ....................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... Signature of Practice Placement Educator Date:……………………………………………………………………………………………………… Signature of Student Date:……………………………………………………………………………………………………… Signature of Academic Practice Placement Organiser Date:………………………………………………………………………………………………………

LEARNING OUTCOMES Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists. For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale. In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments provided may indicate strengths which the student has and areas of development which may need to be addressed in subsequent placements. You can use the electronic version of the forms to expand the comments boxes to add detail.

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Learning outcome 1

Unable to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Able to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Comments:

Learning outcome 2

Unable to describe the role of the OT in the placement area.

Able to describe the role of the OT in the placement area.

Comments:

Learning outcome 3

Unable to demonstrate the need to practice safely and effectively within their scope of practice.

Able to demonstrate the need to practice safely and effectively within their scope of practice.

Comments:

Learning outcome 4

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Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Learning outcome 5

Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Learning outcome 6

Unable to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Comments:

Learning outcome7

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Unable to demonstrate the ability to gather appropriate information.

Able to demonstrate the ability to gather appropriate information.

Comments:

Learning outcome 8

Unable to demonstrate the ability to select and use appropriate assessment techniques.

Able to demonstrate the ability to select and use appropriate assessment techniques.

Comments:

Learning outcome 9

Unable to describe the use of reasoning and problem-solving skills to determine appropriate actions.

Able to describe the use of reasoning and problem-solving skills to determine appropriate actions.

Comments:

Learning outcome 10

Unable to demonstrate Able to demonstrate

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appropriate interventions under the supervision of their educator.

appropriate interventions under the supervision of their educator.

Comments:

Learning outcome 11

Unable to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

Able to demonstrate the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines. maintain records appropriately.

Comments:

Learning outcome 12

Unable to discuss ways in which planned activity can be modified to ensure effectiveness.

Able to discuss ways in which planned activity can be modified to ensure effectiveness.

Comments:

Learning outcome 13

Unable to demonstrate the ability to reflect on and review

Able to demonstrate the ability to reflect on

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practice. and review practice.

Comments:

Learning outcome 14

Unable to identify and discuss the key concepts of the bodies of knowledge which are relevant to placement setting.

Able to identify and discuss the key concepts of the bodies of knowledge which are relevant to placement setting.

Comments:

Learning outcome 15

Unable to demonstrate the need to establish and maintain a safe practice environment.

Able to demonstrate the need to establish and maintain a safe practice environment.

Comments:

Learning outcome 16

Unable to understand the importance of participation in supervision and mentoring.

Able to understand the importance of participation in

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supervision and mentoring

Comments:

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APPENDIX 6

PRACTICE PLACEMENT 3 ASSESSMENT FORM BSc (Hons) Occupational Therapy

Practice Placement 3 Assessment Form Name of Student Name of Practice Placement Educator Address of Practice Placement Speciality Dates of Practice Placement to Number of Hours Completed Reasons for Absence

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the HCPC Standards of Proficiency for Occupational Therapists (2013). Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes. PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................... ........................................................................................................................................................... ................................................................................................................................................................. ................................................................................................................................................................. .................................................................................................................................................................. ................................................................................................................................................................... ...............................................................................................................................................................

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Student’s Comments: ....................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... Signature of Practice Placement Educator Date:……………………………………………………………………………………………………… Signature of Student Date:……………………………………………………………………………………………………… Signature of Academic Practice Placement Organiser Date:………………………………………………………………………………………………………

LEARNING OUTCOMES Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists. For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale. In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments provided may indicate strengths which the student has and areas of development which may need to be addressed in subsequent placements. You can use the electronic version of the forms to expand the comments boxes to add detail.

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Learning outcome 1

Unable to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Able to demonstrate the ability to practice within the legal and ethical boundaries of the profession.

Comments:

Learning outcome 2

Unable to analyse the role of the OT in the clinical area.

Able to analyse the role of the OT in the clinical area.

Comments:

Learning outcome 3

Unable to demonstrate the need to practice safely and effectively within the scope of the practice environment.

Able to demonstrate the need to practice safely and effectively within the scope of the practice environment.

Comments:

Learning outcome 4

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Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Learning outcome 5

Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Learning outcome 6

Unable to demonstrate the ability to gather appropriate information.

Able to demonstrate the ability to gather appropriate information.

Comments:

Learning outcome 7

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Unable to demonstrate and analyse appropriate assessment techniques.

Able to demonstrate and analyse appropriate assessment techniques.

Comments:

Learning outcome 8

Unable to apply the underpinning theories and reasoning which impact on treatment decisions.

Able to apply the underpinning theories and reasoning which impact on treatment decisions.

Comments:

Learning outcome 9

Unable to formulate and Demonstrate appropriate interventions under the supervision of the educator.

Able to formulate and Demonstrate appropriate interventions under the supervision of the educator.

Comments:

Learning outcome 10

Unable to demonstrate the Able to demonstrate

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ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines.

the ability to keep accurate comprehensive and comprehensible records in accordance with legislation and guidelines. maintain records appropriately.

Comments:

Learning outcome 11

Unable to demonstrate the need to establish and maintain a safe practice environment.

Able to demonstrate the need to establish and maintain a safe practice environment.

Comments:

Learning outcome 12

Unable to Discuss ways in which planned activity can be modified to ensure effectiveness.

Able to discuss ways in which planned activity can be modified to ensure effectiveness.

Comments:

Learning outcome 13

Unable to demonstrate the ability to reflect on and review

Able to demonstrate the ability to reflect on

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practice. and review practice.

Comments:

Learning outcome 14

Unable to identify and discuss the key concepts of the bodies of knowledge which are relevant to placement setting.

Able to identify and discuss the key concepts of the bodies of knowledge which are relevant to placement setting.

Comments:

Learning outcome 15

Unable to demonstrate the need to establish and maintain a safe practice environment.

Able to demonstrate the need to establish and maintain a safe practice environment.

Comments:

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Learning outcome 16

Unable to understand the importance of participation in supervision and mentoring.

Able to understand the importance of participation in supervision and mentoring

Comments:

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PRACTICE PLACEMENT 4 ASSESSMENT FORM BSc (Hons) Occupational Therapy

Practice Placement 4 Assessment Form

Name of Student Name of Practice Placement Educator Address of Practice Placement Speciality Dates of Practice Placement to Number of Hours Completed Reasons for Absence

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the HCPC Standards of Proficiency for Occupational Therapists (2013). Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes. PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... ....................................................................................................................................................

APPENDIX 7

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Student’s Comments: ....................................................................................................................... ............................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... .................................................................................................................................................... Signature of Practice Placement Educator Date:……………………………………………………………………………………………………… Signature of Student Date:……………………………………………………………………………………………………… Signature of Academic Practice Placement Organiser Date:………………………………………………………………………………………………………

LEARNING OUTCOMES Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists. For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale. In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments provided may indicate strengths which the student has and areas of development which may need to be addressed in subsequent placements. You can use the electronic version of the forms to expand the comments boxes to add detail.

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Learning outcome 1

Unable to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Able to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Comments:

Learning outcome 2

Unable to demonstrate effective self management of work load and resources.

Able to demonstrate effective self management of work load and resources.

Comments:

Learning outcome 3

Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Learning outcome 4

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Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Learning outcome 5

Unable to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Comments:

Learning outcome 6

Unable to demonstrate the ability to gather appropriate information.

Able to demonstrate the ability to gather appropriate information.

Comments:

Learning outcome 7

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Unable to demonstrate the ability to select and use appropriate assessment techniques.

Able to demonstrate the ability to select and use appropriate assessment techniques.

Comments:

Learning outcome 8

Unable to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Able to demonstrate the use of reasoning and problem-solving skills to determine appropriate actions.

Comments:

Learning outcome 9

Unable to analyse research and other evidence to inform their own practice.

Able to analyse research and other evidence to inform their own practice.

Comments:

Learning outcome 10

Unable to draw on appropriate Able to draw on

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knowledge and skills in order to make professional Judgements.

appropriate knowledge and skills in order to make professional Judgements.

Comments:

Learning outcome 11

Unable to formulate specific and appropriate management plans including the setting of timescales.

Able to formulate specific and appropriate management plans including the setting of timescales.

Comments:

Learning outcome 12

Unable to demonstrate appropriate interventions or other actions safely and skilfully.

Able to demonstrate appropriate interventions or other actions safely and skilfully.

Comments:

Learning outcome 13

Unable to demonstrate the ability to keep accurate

Able to demonstrate the ability to keep

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comprehensive and comprehensible records in accordance with legislation and guidelines.

accurate comprehensive and comprehensible records in accordance with legislation and guidelines. maintain records appropriately.

Comments:

Learning outcome 14

Unable to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Able to Monitor and review the ongoing effectiveness of planned activity and modify it accordingly.

Comments:

Learning outcome 15

Unable to demonstrate the ability to reflect on and review practice.

Able to demonstrate the ability to reflect on and review practice.

Comments:

Learning outcome 16

Unable to understand the importance of participation in supervision and mentoring.

Able to understand the importance of participation in

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supervision and mentoring

Comments:

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FINAL PLACEMENT ASSESSMENT FORM BSc (Hons) Occupational Therapy

Final Placement Assessment Form

Name of Student Name of Practice Placement Educator Address of Practice Placement Speciality Dates of Practice Placement to Number of Hours Completed Reasons for Absence

A student must be deemed to be professionally suitable in order to pass the practice placement. Educators are referred to the Code of Ethics and Professional Conduct for Occupational Therapists (2010) and the HCPC Standards of Proficiency for Occupational Therapists (2013). Please tick the appropriate box below to indicate whether the student has demonstrated consistent high standards of professional and personal conduct (HCPC 3.1).

PASS REFER

Please tick the appropriate box below to indicate whether the student has successfully met the learning outcomes. PASS REFER

Practice Placement Educator’s Comments/Advice to the Student re. his/her overall performance ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ .................................................................................................................................................................. .................................................................................................................................................................. .................................................................................................................................................................... ............................................................................................................................................................... .................................................................................................................................................................... ............................................................................................................................................................... .................................................................................................................................................................. Student’s Comments: .......................................................................................................................

APPENDIX 8

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.................................................................................................................................................... Signature of Practice Placement Educator Date:……………………………………………………………………………………………………… Signature of Student Date:……………………………………………………………………………………………………… Signature of Academic Practice Placement Organiser Date: ……………………………………………………………………………………………………...

LEARNING OUTCOMES Each of the following learning outcomes are based on the Health and Care Professions Council’s Standards of Proficiency for Occupational Therapists. For each learning outcome below, please mark on the scale the point which you feel reflects the student’s performance. If the student is less able to achieve the learning outcome, mark to the left hand side of the scale, and if the student is more able to achieve the learning outcome, mark to the right hand side of the scale. In the comments box, provide feedback to assist the student in their understanding of the point at which the scale is marked. Comments provided may indicate strengths which the student has and areas of development which may need to be addressed in subsequent placements. You can use the electronic version of the forms to expand the comments boxes to add detail.

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Learning outcome 1

Unable to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Able to demonstrate the ability to practise as an autonomous professional, exercising their own professional judgement under the direction of a placement supervisor.

Comments:

Learning outcome 2

Unable to demonstrate effective self management of work load and resources.

Able to demonstrate effective self management of work load and resources.

Comments:

Learning outcome 3

Unable to demonstrate the ability to work in partnership with other staff, service users and carers.

Able to demonstrate the ability to work in partnership with other staff, service users and carers.

Comments:

Learning outcome 4

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Unable to demonstrate effective and appropriate communication skills including communication and information technologies.

Able to demonstrate effective and appropriate communication skills including communication and information technologies.

Comments:

Learning outcome 5

Unable to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Able to demonstrate knowledge of when it is appropriate to share information to safeguard service users or the wider public.

Comments:

Learning outcome 6

Unable to demonstrate the ability to gather appropriate information.

Able to demonstrate the ability to gather appropriate information.

Comments:

Learning outcome 7

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Unable to demonstrate the ability to select and use appropriate assessment techniques.

Able to demonstrate the ability to select and use appropriate assessment techniques.

Comments:

Learning outcome 8

Unable to use research, reasoning and problem-solving skills to determine appropriate actions.

Able to use research, reasoning and problem-solving skills to determine appropriate actions.

Comments:

Learning outcome 9

Unable to evaluate research and other evidence to inform their own practice.

Able to evaluate research and other evidence to inform their own practice.

Comments:

Learning outcome 10

Unable to draw on appropriate Able to draw on

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knowledge and skills in order to make professional Judgements.

appropriate knowledge and skills in order to make professional Judgements.

Comments:

Learning outcome 11

Unable to formulate specific and appropriate management plans including the setting of timescales.

Able to formulate specific and appropriate management plans including the setting of timescales.

Comments:

Learning outcome 12

Unable to conduct appropriate interventions or other actions safely and skilfully

Able to conduct appropriate interventions or other actions safely and skilfully.

Comments:

Learning outcome 13

Unable to demonstrate the ability to keep accurate comprehensive and

Able to demonstrate the ability to keep

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comprehensible records in accordance with legislation and guidelines.

accurate comprehensive and comprehensible records in accordance with legislation and guidelines. Maintain records appropriately.

Comments:

Learning outcome 14

Unable to monitor and review the on-going effectiveness of planned activity and modify it accordingly.

Able to monitor and review the on-going effectiveness of planned activity and modify it accordingly.

Comments:

Learning outcome 15

Unable to reflect on and review Practice.

Able to reflect on and review practice.

Comments:

Learning outcome 16

Unable to apply the theoretical concepts underpinning occupational therapy.

Able to apply the theoretical concepts underpinning

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occupational therapy.

Comments:

Learning outcome 17

Unable to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Able to know how professional principles are expressed and translated into action through a number of different approaches to practice.

Comments:

Learning outcome 18

Unable to demonstrate the need to establish and maintain a safe practice environment.

Able to demonstrate the need to establish and maintain a safe practice environment.

Comments:

Learning outcome 19

Unable to understand the importance of participation in supervision and mentoring.

Able to understand the importance of participation in supervision and

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mentoring

Comments:

Learning outcome 20

Unable to understand the structure and function of health and social are services in the UK

Able to understand the structure and function of health and social are services in the UK

APPENDIX 9 MANUAL HANDLING TRAINING STANDARDS Competency Statements – Occupational Therapy Provision on the BSc (Hons) Programme

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The competencies are covered in the pre-clinical weeks which are compulsory for students prior to going out on fieldwork placements, and during a lecture delivered in the first year Occupational Therapy Professional Practice module. Competency 1 – Work within an agreed framework to minimise risk to self and client. Performance criteria: A. Evidence compliance with safer patient handling techniques and

organisational and local safe systems of work. (Covered in the Year 1 lecture and practicals in the Occupational Therapy Professional Practice.)

B. Evidence of the ability to select and use appropriate equipment for client needs and safer patient handling. (Covered in Year 1 practicals in the Occupational Therapy Professional Practice.)

C. Evidence of attendance at handover and contribution to care planning and problem solving. (Care planning/problem-solving tasks covered in updates in Year 2/3 during the pre-clinical preparation may or may not occur on placement.)

D. Evidence of implementation of care plans and understanding/reporting of changes in risk assessment using the TILE format. (The importance of understanding/reporting changes in risk assessment is covered in all three years during both the Occupational Therapy Professional Practice and pre-clinical preparation. May or may not occur on placement, some students are involved in completing the HALO risk assessment.)

E. Evidence of taking up opportunities for formal and informal education to discuss manual handling training needs with line manager. (Students should take up any opportunities for education on placement as part of their learning objectives.)

F. Evidence of knowing when to stop and ask for help or guidance, including knowing the risk to self of unsafe manual handling practices. (The importance of seeking help when needed is covered during taught sessions in pre-clinical preparation and is also part of the placement learning objectives.)

G. Evidence of understanding body dynamics and safer handling principles using reflective practice skills. (Covered in the first year lecture in the Occupational Therapy Professional Practice.)

Competency 2 – Comply with departmental and organisational policies and procedures to carry out manual handling activities safely, with minimum threat to musculoskeletal health. Performance criteria: A. Evidence of contributing to the risk assessment process within the local area,

including the ability to understand, evaluate and to follow basic TILE assessment. (Risk assessment using TILE is covered in University teaching in Year 1 Occupational Therapy Professional Practice. Students may or may not be involved on placement.)

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B. Evidence of contributing to departmental decision-making in equipment selection and usage to meet client needs. (Equipment selection is covered in University teaching in the Occupational Therapy Professional Practice. Students may or may not be involved on placement.)

C. Evidence of maintaining self-care in relation to musculoskeletal health. (Information provided in the Year 1 lecture in the Occupational Therapy Professional Practice, good practice monitored on placement where appropriate.)

D. Evidence of ability to act as an advocate for the client’s needs as reflected in the contribution to problem-solving and care planning. (Considered in case studies in pre-clinical preparation. May or may not be seen on placement in relation to manual handling.)

E. Evidence of participation in problem-solving sessions and care planning for safer patient handling. (Considered in case studies in pre-clinical preparation. May or may not be seen on placement in relation to manual handling.)

F. Evidence of recognition of own limitations. (Students asked to monitor their own levels of competency in both the Occupational Therapy Professional Practice and the pre-clinical practicals.)

G. Evidence of supporting co-workers to ensure that policy, procedures and departmental risk assessments are followed. (Considered in case studies in pre-clinical weeks. May or may not be seen on placement in relation to manual handling.)

Competency 3 – Working with others to create and sustain a culture which promotes health in the workplace with respect to musculoskeletal issues. Performance criteria: A. Evidence of collaboration with other staff and clients in implementing policy

and procedures. (Considered in case studies in pre-clinical preparation. May or may not be seen on placement in relation to manual handling.)

Competency 4 – Maintain accurate records and documentation which comply with professional, legal and administrative requirements. Performance criteria: A. Evidence of working with Clinical Supervisor to keep clear, legible,

confidential records of risk assessments within the department. (Will be carried out in some placements arrears where appropriate, HALO risk assessment is regularly used in Teesside.)

B. Evidence of contributing to the maintenance of up-to-date care plans that reflect risk assessments. (Will be carried out in some placements areas where appropriate, HALO risk assessment is regularly used in Teesside.)

C. Evidence of receipt of formal and informal education and problem-solving, including identification of education needs in collaboration with Clinical Supervisor. (Will be carried out in some placements areas where appropriate, HALO risk assessment is regularly used in Teesside.)

Competency 5 – Promote improved standards of quality of care for clients/patients. Performance criteria:

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A. Evidence of working with colleagues to ensure that all staff work within policies and procedures. (The importance of this area is covered in taught sessions using case study material in pre-clinical preparation. May or may not be seen on placement in relation to manual handling.)

B. Evidence of feeding back on the efforts of integration of evidence-based practice for continuous improvement in client care. (The importance of this area is covered in taught sessions using case study material in pre-clinical preparation. May or may not be seen on placement in relation to manual handling).

Competency 6 – Practice and promote Continuing Professional Development (CPD). Performance Criteria:

Evidence of taking responsibility to enhance, update and develop appropriate knowledge and skills. (Covered in taught sessions in Occupational Therapy Professional Practice).

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APPENDIX 10

OCCUPATIONAL THERAPY PLACEMENT RECORD This form is to be used if an educator or student has concerns they are not meeting the

learning outcomes/professional requirements for the placement and will be initiated by the visiting tutor.

Student Name: ……………………………………. Student Number: …………………

Practice Placement 1/2/3/4/final Placement Location: ………………….. Programme: BSc (Hons) Occupational Therapy/PgD/MSc Occupational Therapy (pre-registration) Cohort: ……………………….

Nature of issues arising

Identified areas for professional development

Identified areas for practice skills development

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Identified personal support needs

Action Plan for on-going development

Signed by Practice Placement Educator ………………………………………………. Name …………………………………………………………………………………………. Signed by Student ………………………………………………………………………….. Signed by University Tutor ……………………………………………………………….. Name ………………………………………………………………………………………….

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Obtaining Informed Consent Rationale As part of the assessment and/or portfolio keeping process students are sometimes required to illustrate the relationship between theory and practice by using information relating to specific clients, e.g. care studies, care plans, assessments, projects and reflective pieces. In these circumstances obtaining informed consent is essential. In order to demonstrate compliance with statutory/professional codes of conduct the attached Obtaining Informed Consent Declaration Form must be completed and submitted with the work. Failure to obtain consent and/or submit the completed declaration form will result in automatic referral/failure and could lead to disciplinary action. A slide show relating to Confidentiality and Informed Consent can be accessed via e-learning@tees. It is the student’s responsibility to review this at least annually. Responsibilities The Lecturer supervising a piece of work for which consent is required is responsible for:

Directing the student to the e-learning@tees site where they can access a copy of the Obtaining Informed Consent Declaration Form and Guidance Notes prior to the assessment.

Drawing the student’s attention to the Access to Health Records Act (1990), in particular:

Section 5.3, which states that third parties may only access patients’, records provided that information given by the patient and/or the results of examinations/investigations will not be disclosed.

Section 5.1 which states that the information obtained from the patients’ health records must not be used in a way as to cause the patient serious physical or mental harm, or that the patient may be identified.

Drawing the student’s attention to the Data Protection Act (1998) in particular:

Reviewing the rationale and each point set out in the Obtaining Informed Consent Declaration Form.

Reminding the student that the completed Declaration Form must accompany the assignment when submitted.

APPENDIX 11

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The Student The student is responsible for:

Informing the Practice Mentor/Supervisor of the nature of the assignment/ portfolio and the requirement to complete an Obtaining Informed Consent Declaration Form.

Seeking informed consent from the patient/client and/or patient/client representative and/or carers, and/or colleagues/staff in accordance with points 1–4, as set in the Declaration Form.

Completing and signing the Declaration Form with the Practice Mentor/ Supervisor.

Ensuring the completed Declaration Form is submitted with the assignment by the required date.

Ensuring that a pseudonym is used for client/patients, relatives, carers and staff. The use of the pseudonym should be documented within the assignment and clearly identified on the Informed Consent and Declaration Form.

Ensuring that any documentation submitted as part of the assessment will be rewritten and not photocopied e.g. care plans, assessment forms.

Practice Mentor/Supervisor The Practice Mentor/Supervisor is responsible for: 1. Providing the student with appropriate support and guidance whilst obtaining

informed consent from the patient/client and/or patient/client representative and/or colleagues/staff.

2. Signing the Obtained Informed Consent Declaration Form, if s/he is confident that the criteria have been met.

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Obtaining Informed Consent Declaration Form

Declaration by Student In order to comply with the requirements of the Access to Health Records Act (1990) and the Data Protection Act (1998), I confirm I have discussed the following with the patient/client* and/or the patient’s/client’s* representative, e.g. parent/guardian, next of kin, carers, colleagues/staff and have obtained permission to use personal relevant data: * Delete as appropriate

The nature of the assessment.

The reason I wish to use data relating to the patient/client.

That client/patient, carers, colleagues/staff anonymity and confidentiality in relation to any material gathered or produced in the course of this work will be maintained e.g.:

For all persons mentioned pseudonyms and/or general titles will be used, not individual names;

The patient/client address and any information which could identify their address will be omitted;

General terms will be used to describe occupation/workplace/school/ hobbies etc.;

Time, date and location of admission will be omitted;

Information which may identify the patient/client/relatives/carer and colleagues/staff will be omitted from documentation e.g. care plans, pathways of care, risk assessments etc.

Those who will have access to the work in addition to me e.g. typist, teaching staff, other students, Board of Examiners.

Student Name

Cohort/Year of Entry

Personal Tutor

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INFORMED CONSENT DECLARATION FORM N.B. Patient/Client/Carer/Colleagues/Staff column should be completed by using a Code e.g. Client/Patient A, Client/Patient B in order to provide anonymity and confidentiality. If names are used in the first column a pseudonym must be used and it must be clearly stated that this is a pseudonym. The pseudonyms used must be the same as those referred to in the assignment.

Patient/Client/Carer/ Colleague/Staff

Module Title Academic Support Teacher

Informed Consent Gained

Practice/Mentor Supervisor Name

Practice/Mentor Supervisor Signature

Student Signature

Date

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

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PLACEMENT CONCERN FORM

This form is to be used by School of Health & Social Care staff and students, to record any concerns that they may have regarding a practice placement area. This must be reported no later than 5 days of the concern occurring. Most concerns and queries should normally be raised with a student’s Practice Mentor/educator in the first instance. However, some concerns may be of a sensitive nature and if this is the case the student may feel that they wish to discuss them with the Zoned Academic or visiting tutor. If the issue is not resolved, the above members of staff have not been seen, or the issue is of serious concern, the student should complete and return this form in a sealed envelope to Director of Placements, Room H2.24, Centurial Building, School of Health & Social Care. This form will be treated in the strictest confidence. However, students are reminded that the Director of Placements and nominated individual from the programme team, have a professional responsibility to explore and address the concerns with the placement area, as appropriate. The student may be required to meet with the Director of Placements/ nominated individual from the programme team or their deputy to clarify the situation and discuss any further action which may be taken e.g. enquiries into staff conduct. If the student is required to attend any meetings with representatives from the organisation concerned, and/or disciplinary hearings they will be provided with advice and support from a nominated person in the School of Health & Social Care, Teesside University.

Please complete the following information:-

Name of person completing the form: Surname: Forename (s):

Date of Birth: Student Number:

Role: (e.g. student, senior lecturer)

Programme: Cohort: Pathway: Personal Tutor: Practice Educator

Term-time Address:

Post Code:

Telephone number:

E-mail address:

Placement area concerned: Name: Address:

APPENDIX 12

APPENDIX 12

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Telephone number: E-mail address Mentors Name

The practice period this concern relates to (e.g. Year 2,

Placement 3):

Date/dates concerns arose: Location of concerns Date the concern received from the student Date of safeguarding alert

Placements dates: Started Finished

Duration of Placement

Please document your concern/s and detail all circumstances leading up to the concern. (If the concern is referred to Safeguarding then the student will be required to provide details of

patients and staff names who were involved in the concern)

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Name:

Signature: Date:

Please complete the following information

Have you raised your concerns with anyone prior to completing the form? Yes No

If yes who did you raise this with?

What date did you

Raise the concern?

What was the outcome?

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To be completed by the academic member of staff dealing with the concerns

Actions taken;

Name of person completing this section:

Designation:

Signature:

Date:

23/07/13