_________ Michael L. Clarkson-Hendrix, PhD, MSW, Assistant Professor of Social Work, Department of Sociocultural and Justice Sciences, College at Fredonia, State University of New York, Fredonia, NY. Lynn A. Warner, PhD, Professor and Dean of the School of Social Welfare, University at Albany, State University of New York, Albany, NY. Copyright © 2020 Authors, Vol. 20 No. 2 (Summer 2020), 283-299, DOI: 10.18060/23377 This work is licensed under a Creative Commons Attribution 4.0 International License. A Mixed Methods Examination of MSW Student Satisfaction With Integrated Behavioral Health Field Placements Michael L. Clarkson-Hendrix Lynn A. Warner Abstract: Social workers must be prepared to work effectively within systems that attempt to maximize coordination where integrated behavioral health care is provided. Current students are the profession’s pipeline to the behavioral health workforce. If social work students are dissatisfied with the training they receive in integrated health care settings, they may be deterred from interprofessional collaborative practice. This study examined MSW students’ satisfaction with integrated behavioral health field placement experiences. Thirty-three students completed an online survey that asked about factors associated with field placement satisfaction, and nine of these students participated in two focus groups to explore other aspects of the field setting that influenced satisfaction. Survey results revealed that as role ambiguity increased, student satisfaction decreased. Focus group findings uncovered that the profession’s influence within the field setting and the presence of support by professionals from other disciplines promoted students’ satisfaction. These results suggest that educators should help students develop skills in tolerating role ambiguity and asking for role clarification as part of supervision when placements are in these settings. MSW faculty and field education directors may want to collaborate with integrated behavioral health providers to assess organizational climate and identify ways to foster inclusive interprofessional collaborative practices and a culture of cross- profession respect. Keywords: Student satisfaction, integrated behavioral health, field placements; IPE Behavioral health conditions are prevalent in the United States, yet most people experiencing mental health and substance use problems do not receive the treatment they need (Park-Lee et al., 2017; Substance Abuse and Mental Health Services Administration, 2017). Since the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, significant transformations in the financing, structure, and delivery of health care have been underway to address this gap. For example, reimbursement models are moving from fee- for-service to value-based approaches that reward providers for delivering comprehensive services, including preventative interventions (Asarnow et al., 2015; Rishel et al., 2016). Health care is increasingly being provided in patient-centered medical homes that coordinate health and behavioral services and address individual gaps in care (Horevitz & Manoleas, 2013; Runyan, 2011). There is growing evidence that the integration of behavioral health screenings and interventions into primary health care settings has yielded positive outcomes. For example, an integrated brief, problem-focused behavioral health intervention in military primary care settings resulted in significant mental health symptom reduction that was maintained at two years post-intervention (Ray-Sannerud et al., 2012). Additionally, screening and brief trauma treatment in rural primary care offices resulted in https://creativecommons.org/licenses/by/4.0/ Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 284 significant reductions in posttraumatic stress symptoms and physical health complaints (Osofsky et al., 2017). Given these substantial transformations in the delivery of behavioral health care and acceptance that effective interprofessional education is linked to successful interprofessional collaborative practice (World Health Organization, 2010), social workers must be prepared to work effectively within systems that attempt to maximize coordination, and in settings where integrated behavioral health care is provided (Bilodeau et al., 2010; Lundgren & Krull, 2014). Professional staff, including social workers, need to be able to provide brief, outcome-driven, and team-based care (Collins et al., 2010; Horevitz & Manoleas, 2013) in an interprofessional and team-based environment (Horevitz & Manoleas, 2013; Rishel et al., 2016). Various national foundation and federal government agency efforts aim to prepare future social work professionals for practice in an integrated care environment. For example, the Conrad N. Hilton Foundation (2019) is supporting initiatives that include training more providers on Screening, Brief Intervention and Referral to Treatment (SBIRT) approaches. A strategic priority of the Health Resources and Services Administration (2019) is to develop interprofessional practice competencies of the health care workforce, including social workers, by expanding training and technical assistance opportunities for students and providers and offering scholarships as well. Finally, schools of social work are creating specializations and concentrations in integrated behavioral health to prepare students for practice, which includes didactic and simulation-based instruction. There is growing evidence about the impact of these educational initiatives, especially as they relate to social work students’ improvements in knowledge, attitudes, and confidence to practice in integrated care settings (Collin et al., 2019; Habib et al., 2019; Rishel et al., 2016) and skills (Acquavita et al., 2019). There is also evidence of gaps in students’, faculty’s, and fieldwork instructors’ knowledge, attitudes, and skills in implementing evidence-based practices adherent to model fidelity in integrated care settings (Vinjamuri et al., 2019). However, there is a dearth of information about social work students’ experiences in integrated behavioral health field placements. We define integrated behavioral health field placements as those where students are expected to conduct behavioral health assessments, interventions, or referrals in interprofessional contexts. Field education is designated as the signature pedagogy of social work education (Council on Social Work Education [CSWE], 2015; Wayne et al., 2010), and field placements are where professional norms and commitment are most directly established. Consequently, a better understanding of factors associated with students’ positive experiences in integrated behavioral health placements is warranted. To contribute to the growing body of research on preparing social workers for effective practice in the evolving health care system, the current study examined MSW students’ satisfaction with integrated behavioral health field site experiences. ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 285 Students Experiences With Integrated Behavioral Health Field Placements In higher education, student satisfaction is expected to be positively associated with the quality of instructional methods and is a proxy for how well a learning environment supports academic success (Cleak & Smith, 2012; Elliott & Healy, 2001; Garrison et al., 2010; Lo, 2010). According to the few published studies reporting on social work students’ satisfaction with their field experience, the following factors are positively associated with satisfaction: perceptions of self-efficacy (Kanno & Koeske, 2010), perceptions of the quality of supervision (Kanno & Koeske, 2010; Wang & Chui, 2016), provision of supervision by a person employed by the agency as opposed to an outside supervisor (Cleak & Smith, 2012), and students’ achievement motivation, preparedness for field, and supportiveness of other students (Wang & Chui, 2016). Students’ reported levels of burnout and strain were negatively associated with field placement satisfaction (Kanno & Koeske, 2010). Research on experiences of students whose placements have been in integrated behavioral health care settings is scant. According to an evaluation of an integrated behavioral health care training program for the Canadian primary care workforce, there were significant increases in knowledge among family medicine, nursing, and social work students after completion of classroom and practicum training components (Bilodeau et al., 2010). In addition, a survey sent to social work, medicine, and nursing students at the onset of an interprofessional education program found that although students held generally positive attitudes towards interprofessional collaboration, medicine students were less positive towards interprofessional collaboration when compared to social work and nursing students (Park et al., 2013). Moreover, a survey of social work, nursing, medicine, and other allied health sciences students found that, compared to students with no or negative past experiences of interprofessional collaboration in integrated behavioral health care settings, those with positive ones also reported feeling more comfortable relying on other professionals within their health care teams (Lee & Shipe, 2014). Furthermore, narrative data provided by MSW students who completed an integrated behavioral health training program revealed three areas of impact: by the end of their training, participants were able to describe key integrated practice concepts, apply the concepts in practice, and articulate the importance of interprofessional relationships to their professional development (Rishel et al., 2016). Study Purpose With current students as the profession’s pipeline to the health care workforce, more data on social work students’ experiences in integrated behavioral health placements are needed. The Bureau of Labor Statistics (2018) projects that the number of employment opportunities in health care social work is expected to grow by 17 percent (30,600 jobs) between 2018 and 2028. The vast majority of these opportunities will likely be in integrated behavioral health care settings that require competency in interprofessional collaborative practice. If students are not satisfied with the training they receive in integrated behavioral health settings, they may be deterred from interprofessional collaborative practice, undermining the positive patient health outcomes envisioned within a transformed health care system. Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 286 To examine MSW students’ satisfaction with integrated behavioral health field site experiences, this study examined data collected as part of a larger evaluation of a social work training initiative. Quantitative data were used to examine correlates of social work students’ overall satisfaction with their experiences in integrated behavioral health field placements, and qualitative data were used to explore students’ perceptions of what impeded or promoted their field placement satisfaction. Method Data were collected as part of the evaluation of a project funded by the Health Resources and Services Administration’s (HRSA’s) Mental and Behavioral Health Education and Training Grants Program. The training initiative aimed to increase the capacity of the social work profession within its region to serve the mental and behavioral health needs of veterans, military personnel and their families, and medically underserved rural communities. Data on a range of factors assumed to be associated with students’ preparedness and commitment to social work behavioral health practice were collected, including attitudes about interprofessional practice (Bronstein, 2002; Luecht et al., 1990) and levels of professional well-being (Danna & Griffin, 1999; Jones et al., 2010; Stamm, 2010). Partner schools in the multi-institutional consortium developed field placements in collaboration with health care agencies that served the military community (inclusive of active duty, veterans, and their families) in urban and rural areas or residents of underserved rural communities in a large northeastern state, and provided learning opportunities for integrated behavioral health care delivery. Several of the seven schools of social work involved in the consortium were part of multi-disciplinary colleges where classes included social work students and students in other graduate programs, including Human Development, Clinical Mental Health Counseling, Public Administration, and Marriage and Family Therapy. Interprofessional training experiences for students in the consortium varied across the schools but typically included working in teams that included a combination of physicians, psychiatrists, nurses, and physical therapists. Over the course of the multi-year project, three cohorts of students were recruited for second-year placements through a selective application process. The selection process and related materials were developed collectively by the consortium members, but each program implemented the selection process locally. For example, a standard set of essay and interview questions, as well as an applicant rating form were developed, and participating schools made additions for their school-specific purposes. The opportunity was publicized to all MSW students entering their advanced concentration field placement. Interested students submitted an application that included a brief essay about their interest in the practice area, a transcript, a current resume, and contact information for professional and/or educational references. Applications were reviewed and rated by teams at each school. Teams included a combination of faculty, field unit staff, field instructors experienced with mental and behavioral health services to veterans and services in rural underserved areas and, after the project’s first year, current trainees. The most highly rated applicants were then invited to an interview with members of the review teams. Selected students received a stipend of $5,000 per semester for two semesters. ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 287 To reinforce knowledge of clinical practice with medically underserved communities, the students completed four online educational units. Three educational units were the same across the three cohorts and covered interprofessional practice principles and concepts, an overview of trauma-informed care, and military cultural competence. For the first two cohorts, the fourth educational unit focused on cultural competence with medically underserved communities, and for the last cohort the unit was an overview of depression, delirium, and dementia in older adults. Educational units were presented in two stages. First, students reviewed online asynchronous content (e.g., videos, prerecorded webinars, practice guides) and prepared responses to questions to stimulate participation in the second stage. Then, students engaged in faculty-led synchronous discussions that provided opportunities for students to reflect on the connection between classroom, online, and field- based learning. Procedures A mixed methods approach was used. Quantitative survey data were augmented with qualitative data. Quantitative data were collected with an online survey that included items about student satisfaction with the field experience, the extent of collaboration occurring at the placement, perceptions of interprofessional education, role stress, professional quality of life, and demographics. All students were invited to complete the online survey two to three weeks prior to the end of their placements each academic year. Students were informed that completion of the survey was voluntary and that, if they agreed to participate, they could skip any questions or exit the survey at any time without penalty. Voluntary consent was assumed if students completed the survey via the link provided in the email. To ensure confidentiality of responses, the survey did not collect student names. Focus groups were conducted with the narrow purpose of exploring preliminary results from the quantitative survey. Students were asked specific questions to help illuminate aspects of role stress and to provide specific examples of positive and negative interprofessional experiences. In contrast to the survey, which was conducted with each program cohort, focus groups were conducted only with the last cohort. Students were verbally invited at the end of the two synchronous sessions occurring in the final weeks of the training program to participate in a focus group. Focus group duration was determined by student availability, with one group lasting for fifteen minutes and the other one lasting thirty minutes. Because the online sessions had focused on many of the same themes that were asked about in the focus groups, students in the focus groups were encouraged to summarize salient points from those online sessions. This approach, combined with the fact that groups were comprised of small numbers of students who had spent the year interacting with each other in the online environments, yielded efficient responses to the questions. There were no incentives for participating in the focus groups. Focus groups were audio-recorded with Blackboard Collaborate software, and the first author transcribed the recordings for analysis. This project was exempt from Institutional Review Board approval as it was limited to investigating the training program’s instructional strategies. Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 288 Participants Thirty-three out of forty-one students completed the survey (response rate of 81%). The majority of respondents, similar to the cohorts of students who participated in the program, were female (81.8%) and White (90.9%). Slightly more than half (51.5%) were between the ages of 22-25, and slightly less than half (45.5%) had no prior paid human service experience before enrolling in their MSW program. Both focus groups were comprised entirely of women, with four in one group and five in the other. Measures Student satisfaction with field. Students were asked to indicate how satisfied they were with their field placement using a five-point response scale ranging from 1 (never satisfied) to 5 (always satisfied). Preliminary analysis revealed a skewed distribution (none of the students selected 1 or 2 for the item and less than 5 students selected 3). Consequently, responses were recoded into a dichotomous variable, with “almost always satisfied” and “always satisfied” coded 0, and “satisfied half the time” coded 1. These values were interpreted as “extremely satisfied” and “satisfied,” respectively. The values were ordered in this way so that results could be interpreted in terms of factors that were associated with not being satisfied and that could be targeted to improve student satisfaction. Professional quality of life. Professional quality of life was measured using the 30- item Professional Quality of Life Scale (ProQOL; Stamm, 2010), which was designed to capture the workers’ feelings as they relate specifically to their tasks as a professional helper. Although students’ placements are pre-professional experiences, students’ feelings in relation to their work as helpers are expected to be associated with their level of satisfaction with the field placement. The ProQOL is comprised of three subscales: Compassion Satisfaction (10 items) refers to positive feelings related to helping others; Burnout (10 items) speaks to exhaustion, frustration, anger, and depression; and Secondary Traumatic Stress (10 items) is a negative feeling driven by fear and work-related trauma. Responses for ProQOL items ranged from 1 (never) to 6 (very often). Higher scores on the Compassion Satisfaction subscale indicate frequent positive feelings in relation to helping others while higher scores in the Burnout and Secondary Traumatic Stress subscales indicate frequent negative feelings. Initial analysis indicated low internal consistency for the burnout subscale, but after removing seven items from it, internal consistency reliability for each subscale was sufficient to excellent (Compassion Satisfaction α=.89, Burnout α=.88, Secondary Traumatic Stress α=.92). Role stress. Role ambiguity and role overload scales were used to assess role stress. Management literature (Danna & Griffin, 1999) and prior research (Jones et al., 2010) identified a relationship between role stress and job satisfaction. Since task similarities exist between a social worker’s job and a student’s field experience, role stress would also likely be related to student satisfaction. Role stress measures were adapted from Jones, Norman, and Wier (2010). This was done by substituting “At my field placement” for “At my work” in the item stems. Role ambiguity was measured with five items, such as “At my field placement, I feel certain of how I will be evaluated,” “At my field placement, I ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 289 know exactly what is expected of me,” and “At my field placement, there are clear, planned goals and objectives for my learning." Responses were based on a seven-point scale ranging from 1 (strongly disagree) to 7 (strongly agree) and reverse-coded so higher rather than lower scores indicated elevated levels of ambiguity. Internal consistency reliability for the role ambiguity subscale was excellent (α=.87). Role overload was measured with three items. These items were “At my field placement, I am given enough time to do what is expected of me,” “At my field placement, it often seems like I have too much work for one person to do,” and “At my field placement, the performance standards for my field placement are too high.” Responses ranged from 1 (strongly agree) to 7 (strongly disagree). The response to the initial item was reverse-coded. Internal consistency reliability for this subscale was sufficient (α=.80). Extent of interprofessional collaboration. Perceptions of the occurrence of interprofessional collaboration were measured using the Index of Interdisciplinary Collaboration (Bronstein, 2002). Students knew they were recruited for a specialized initiative focused on developing interprofessional competencies. If the quality and extent of interprofessional collaboration was limited, we expected overall student satisfaction with their field placement experience to be affected. The Index of Interdisciplinary Collaboration consists of 42 items containing five subscales: Interdependence, Newly Created Professional Activities, Flexibility, Collective Ownership of Goals, and Reflection on Process. Responses ranged from 1 (strongly disagree) to 5 (strongly agree). Interdependence, Collective Ownership of Goals, and Reflection on Process demonstrated adequate internal consistency reliability (α=.75, α=.87, and α=.83). To achieve this level of reliability for the Interdependence and Collective Ownership of Goals subscales, it was necessary to remove six of the thirteen items and four of the eight items, respectively. Two subscales, Newly Created Professional Activities (6 items) and Flexibility (5 items), were insufficient in their internal consistency reliability. Therefore, single items from these subscales were used in analyses. Newly Created Professional Activities was measured by the item, “Organizational protocols reflect the existence of cooperation between professionals from different disciplines.” Flexibility was measured by the item, “I am not willing to sacrifice a degree of autonomy to support cooperative problem-solving.” Since responses to these individual items were skewed, the variables were recoded: responses to Newly Created Professional Activities were either 0 (strongly agree) or 1 (neither agree nor disagree, agree), which were interpreted as “extremely present” and “present,” respectively. Responses to the Flexibility item were either 0 (neither agree nor disagree, agree, strongly agree) or 1 (disagree, strongly disagree), and interpreted as “inflexible” and “flexible,” respectively. Perceptions of interprofessional education. Perceptions of interprofessional education were measured using a subset of fifteen items from the 18-item Interdisciplinary Education Perception Scale (Luecht et al., 1990). The training initiative was focused on preparing students for practice in interprofessional settings. Therefore, students’ positive or negative perceptions of professions within their field setting would likely have impacted their student satisfaction. The Interdisciplinary Education Perception Scale measures students’ affective perceptions of their own profession and other allied health disciplines in interdisciplinary settings (Luecht et al., 1990). The subset of items was chosen based on Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 290 their applicability to students’ experiences and were adapted to refer to “social workers” rather than “individuals in my profession.” Items assessed perceptions of social workers’ competence and autonomy, the need for cooperation amongst professionals, whether cooperation occurred, and if the student understood the value of other professions. Responses ranged from 1 (strongly disagree) to 4 (strongly agree). By removing three items, adequate internal consistency reliability was achieved (α=.84). Data Analysis Quantitative. Measures of centrality (i.e., mean, standard deviation) and dispersion (i.e., range) were assessed for continuous variables. For categorical variables, the percentage of observations in each category was examined to determine their relative distribution. Due to the small sample size, several steps were taken to improve power to detect significant relationships between the predictor variables and student satisfaction. These included improving the precision of the measures, as described above, and limiting the analysis to bivariate rather than multivariate logistic regressions. Qualitative. Thematic analysis was used to explore meaningful patterns in the focus group data that could assist in further understanding what promoted or impeded student satisfaction with their integrated behavioral health field experience. Themes were identified on the semantic rather than latent level in alignment with the purpose of the study, which was to identify themes from the perspective of participants rather than explore the construction of these perceptions. Results Quantitative Frequency distributions in Table 1 showed the majority of students were extremely satisfied with their field placement experience (78%) and the rest were satisfied (22%). For professional quality of life, on average students indicated positive feelings of compassion satisfaction (M=5.25 on a 6-point scale). By the end of their field placements, burnout (M=1.94 on a 6-point scale) and traumatic stress (M=1.86 on a 6-point scale) were low. Mean scores for role ambiguity (M=2.69 on a 7-point scale) and role overload (M=2.10 on a 7-point scale) were low. For perceptions of interprofessional collaboration, averages were moderate to moderately high for the Interdependence (M=3.79 on a 5-point scale), Reflection on Process (M=3.48 on a 5-point scale) and Collective Ownership of Goals (M=3.72 on a 5-point scale) subscales. The majority (75%) of students indicated newly created professional activities were present at their field placements. Just under two-thirds (63%) of students agreed flexibility was occurring in their field placement. Finally, concerning culminating perceptions from the Interprofessional Education Perceptions scale, on average, they were moderately high (M=2.99 on a 4-point scale). ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 291 Table 1. Descriptive Statistics Variables n n (%) Dependent Variable Student Satisfaction with Field: Satisfied (Ref.: Extremely Satisfied) 23 5 (22.8%) Predictor Variables, Categorical Flexibility: Flexible (Ref.: Inflexible) 27 17 (63.0%) Newly Created Professional Activities: Present (Ref.: Extremely Present) 28 21 (75.0%) Predictor Variables, Continuous n M (SD) Range Burnout 23 1.94 (0.87) 1.00-4.67 Collective Ownership of Goals 24 3.72 (0.74) 2.00-5.00 Compassion Satisfaction 22 5.25 (0.60) 3.90-6.00 Interdependence 27 3.79 (0.50) 2.57-5.00 Interprofessional Education Perceptions 30 2.99 (0.37) 2.08-3.67 Reflection on Process 23 3.48 (0.58) 2.20-4.40 Role Ambiguity 24 2.69 (0.97) 1.00-4.60 Role Overload 23 2.10 (0.85) 1.00-4.67 Secondary Traumatic Stress 21 1.86 (0.74) 1.20-4.70 Bivariate results. Results from bivariate logistic regression analyses are presented in Table 2. Only role ambiguity was significantly associated with students’ field experience satisfaction (OR=1.52, p<.05). As role ambiguity increased, student satisfaction decreased. Compassion satisfaction, burnout, secondary traumatic stress, role overload, various aspects of interprofessional collaboration, and perceptions of interprofessional education were not associated with students’ overall satisfaction with their field experience. Table 2. Bivariate Logistic Regression Results for Student Satisfaction With Their Field Experience Predictor Variables Student Satisfaction with Field: Satisfied (Reference Category: Extremely Satisfied) B SE p R2 OR 95% CI for OR Burnout 0.49 0.28 0.08 0.21 1.63 [0.94, 2.84] Collective Ownership of Goals -0.27 0.19 0.16 0.10 0.76 [0.52, 1.11] Compassion Satisfaction -0.31 0.16 0.05 0.34 0.73 [0.54, 0.99] Flexibility -2.34 1.24 0.06 0.19 0.10 [0.01, 1.08] Interdependence -0.21 0.16 0.20 0.08 0.81 [0.59, 1.11] Interdisciplinary Education Perceptions -0.09 0.11 0.38 0.03 0.91 [0.74, 1.12] Newly Created Professional Activities -1.67 1.18 0.16 0.08 0.19 [0.02, 1.90] Reflection on Process -0.15 0.10 0.16 0.09 0.86 [0.70, 1.06] Role Ambiguity 0.42 0.19 0.03 0.42 1.52 [1.05, 2.21] Role Overload 0.06 0.21 0.77 0.004 1.07 [0.70, 1.61] Secondary Traumatic Stress -0.01 0.07 0.90 <0.001 0.99 [0.86, 1.14] Note. OR = odds ratio; CI = confidence interval Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 292 Qualitative Two themes characterized aspects of students’ field experiences that either promoted or impeded their satisfaction. These features were profession’s influence and professional support. Profession’s influence. In a number of instances, students identified professional authority in group interactions connected with satisfaction with their field experience. When professionals from other disciplines (e.g., nursing, psychiatry, medicine) were perceived as valuing social workers’ contributions to the group, students were satisfied with their experience. At the same time, lack of respect toward social workers diminished satisfaction with their placement. For example, one student stated: “I feel like if you have good interprofessional collaboration, you have people who listen to you and value your opinion…. I feel like that's really important to this quality of life …(and) desire to continue in the field.” In contrast, another participant discussed that in her field experience social workers were disproportionally allotted undesirable tasks in comparison to professionals from other disciplines. She linked the allotment of these tasks to less satisfaction with her field experience. She stated: I think it can help with…field placement satisfaction or whatever, but I think it can go the other way, too, only because you are now working with all these people and maybe it’s only specific to my placement, but you get, oh this gets dumped on the social worker, that gets dumped on the social worker, so having all of these other people (like), “Oh can you cover this?” “Can you cover that?” Another focus group participant alluded to the relative status of the psychiatric profession. In her case, the psychiatrist fostered a positive team climate within the unit, and the participant had a positive perception of their field experience. This participant confided to the group: Everybody kind of leans on everybody. Well the psychiatrist trumps us all, but she doesn’t really play a power role in a sense. You really rely on everybody, and there’s a lot of good communication and everybody's part of what’s going to happen next so in a power role, in a sense, she really relies on everybody. There’s a lot of communication and everybody is part of what is going to happen. These examples illustrate that expressions and perceptions of professional hierarchy may influence students’ satisfaction. Perceptions of being treated in an egalitarian way by professionals in other disciplines and experiencing positive interprofessional leadership by a psychiatrist were connected with satisfaction. On the other hand, satisfaction was impeded when social workers were tasked with more mundane responsibilities such observing or escorting clients or cleaning up after them. Professional support. Several students described experiencing support from professionals from other disciplines at their field placement. In instances where they received assistance from professionals in addition to their social work field instructor, they ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 293 felt more satisfied. In contrast, when the student felt isolated in relation to others, they felt less satisfied with their field experience. One student reported a fulfilling experience, which was connected to being able to access professionals around her. The available support of an interprofessional team made her feel good about her field experience. She stated: It has made things a lot less stressful for me because I feel like I always have someone I can go to and someone kind of on the journey with me with the clients and really we are working together, and I'm not out there alone so I feel that really makes it a great experience for me. Another student in the focus group in a similar behavioral health field placement talked about the relief she felt working in a setting where she had the support of her field instructor and other professionals. The ability of professionals from different disciplines to provide help to her put her at ease. She stated: It’s very affirming cause I don’t like to be out in this work or anything like that because I’m always worried about what’s going to happen to the people that I see if I’m not there and for me having collaboration (with other professionals in my field placement), I knew that if I had to be sick or one of my kids was sick, or I couldn’t be there for any reason that there was someone who could step right up and take over. In contrast, upon hearing of the instances of professional support, another student shared there was not as much support from the professionals in her field placement, and she was not as satisfied as the other students with her experience. She described her challenge as follows: If I have a client that I'm having an issue with I can always go and talk to them (nurses and doctors in the office), but, a lot of the time we are both so busy that we are not able to schedule meetings, or there’s nothing formally put in place. It’s more that I would have to basically be more of a go getter and go talk to them about the client if there’s a concern that I have or an issue, or if I need clarification on something. But, other than that, we are like, I'm in my part of the office, and they are in their part of the office, and the only real collaboration is just through the referral process. For these students, the intensity of support from field instructors and professionals from other disciplines affected students’ culminating satisfaction with their field experience. Access to multiple professionals promoted positive feelings about their field placement, as did knowing that a team member was available to meet clients’ needs if the student needed to be away from their placement. In contrast, isolation from interprofessional team members within the field setting impeded satisfaction. Discussion The main purpose of this study was to understand MSW students’ experiences and satisfaction in integrated behavioral health field placement settings. Understanding these Clarkson-Hendrix & Warner/MIXED METHODS EXAMINATION 294 factors may be important in sustaining a robust pipeline of social workers who are competent to practice in the evolving health care delivery landscape. At the end of their placement, the majority of participants were extremely satisfied with their field placement experience. Bearing in mind that researchers have utilized differing measures for student satisfaction with their field experience, this level of satisfaction is higher than that reported by other studies of MSW students’ field experiences (Cleak & Smith, 2012; Fortune et al., 2001; Kanno & Koeske, 2010; Wang & Chui, 2016), possibly because of the selective nature of the program and participants’ receipt of stipends. Results of quantitative analyses showed that role ambiguity was inversely associated with student satisfaction with their overall field experience. To our knowledge, there is no research on role ambiguity in the context of social work students’ field experiences. However, the current study’s finding is consistent with those from a range of studies of job satisfaction among health and human service workers (e.g., Chung & Chun, 2015; Gillet et al., 2016; Jones et al., 2010; Paoline et al., 2015; Smith et al., 2011). Qualitative data revealed that professional influence and professional support were intertwined with student field placement satisfaction. Students who perceived that the social work profession’s role was not respected relative to other professions at the setting tended to feel less fulfilled with their experience. In contrast, participants who sensed their profession’s input was valued by practitioners from other professions tended to be more satisfied with their experience. Limitations Several limitations to this study are noted. First, data were collected from a homogenous and distinct group of students. They were interested in the populations served by the training program prior to their involvement and the program provided them a stipend. Consequently, replication with diverse students in interprofessional placements that are not part of a special, paid initiative is warranted. Regarding the quantitative findings, a skewed distribution in the outcome variable and the small sample size precluded conducting multivariate analyses. In addition, the implementation of multiple bivariate logistic regressions inflated the chance of type I error. Concerning the qualitative findings, the themes may have overemphasized aspects of collaboration in identifying what promoted or impeded student satisfaction because a focus of the initiative overall was preparation for interprofessional practice. Implications This exploratory study provides insights into MSW students’ experiences and satisfaction in integrated behavioral health field placements. Results suggest that social work educators may want to help students develop self-regulatory skills to tolerate role ambiguity and communication skills in role clarification as an ongoing part of supervision when placements are in integrated settings. These skills align with CSWE’s (2015) competency-based education framework, in particular, Competency 1, Demonstrating Ethical and Professional Behavior. First, tolerating role ambiguity assists in managing stress reactions related to role uncertainty in a way that preserves a student’s capacity for ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 295 effective judgment, behavior or communications. Second, role clarification assists students in understanding what is expected of them as well as what is expected of other professionals in the setting and facilitates effective communication about unique, intersecting and allied scopes of practice. Proficiency in these skills could also promote an appreciation of the importance of interprofessional teamwork in interventions as part of social work practice (Competency 8). Similarly, field instructors in integrated behavioral health settings may benefit from coaching on how to monitor students’ experience of role ambiguity and how to develop student strategies to manage role ambiguity. In light of a prior study that found social work students perceived themselves as having lower professional prestige than nursing, pharmacy, and medical students (West et al., 2017), there are concerns that students may internalize negative attitudes about the profession unless social work educators strategically manage professional socialization. MSW faculty and field education directors may want to collaborate with integrated behavioral health providers to assess organizational climate and identify ways to foster inclusive interprofessional collaborative practices and a culture of cross-profession respect. Substantial investments are being made to prepare social work students for interprofessional practice, including curriculum and field placements where interprofessional knowledge and competencies are developed. This study identified role clarity, profession’s influence, and professional support as salient aspects of social work students’ satisfaction with interprofessional field placements. To ensure the social work profession’s position in the evolving health care delivery landscape, training and education may need to directly address students’ attitudes and appreciation for their unique professional expertise. Simultaneously, capacity-building in the host field agencies may require advocacy and data regarding the impact of social work on health outcomes. As the value of social work increases in health and behavioral health care agencies, MSW students’ experiences in interprofessional placements may be more satisfying and foster their commitment to pursue a career in this arena. References Acquavita, S. P., Anne Van Loon, R., Smith, R., Brehm, B., Diers, T., Kim, K., & Baker, A. (2019). The SBIRT interprofessional curriculum and field model. 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Framework for action on interprofessional education & collaborative practice. http://www.who.int/hrh/nursing_midwifery/en/ https://doi.org/10.18060/2953 https://doi.org/10.1037/a0027029 https://doi.org/10.18060/18765 https://doi.org/10.1037/a0023454 https://doi.org/10.2466/01.07.21.PR0.109.4.243-251 https://www.hrsa.gov/about/strategic-plan/goal-2.html https://doi.org/10.18060/22333 https://doi.org/10.1093/swr/svw010 https://doi.org/10.5175/JSWE.2010.200900043 https://doi.org/10.18060/19809 http://www.who.int/hrh/nursing_midwifery/en/ ADVANCES IN SOCIAL WORK, Summer 2020, 20(2) 299 Author note: Address correspondence to Michael Clarkson-Hendrix, Department of Sociocultural and Justice Sciences, State University of New York at Fredonia, 280 Central Ave, Fredonia, NY, 14063. Email: michael.clarkson-hendrix@fredonia.edu Acknowledgements: The authors thank the partner members of the consortium at the University at Albany, SUNY (Katharine Briar-Lawson, Estella Williamson [currently at Seattle University]), University at Buffalo, SUNY (Nancy Smyth, Diane Elze, Laura Lewis), Binghamton University, SUNY (Laura Bronstein, Paul Gould [currently at Simmons University], Nazareth College-College at Brockport, SUNY (Virginia David, Debra Fromm-Faria), Roberts Wesleyan College (David Skiff [currently at Liberty University], Laura Ribbing), Syracuse University (Carrie Jefferson Smith, Kristin Esposito). mailto:michael.clarkson-hendrix@fredonia.edu