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Title: Cost-benefit analysis of level II fieldwork for bachelor's-level and basic master's-level students in occupational therapy /
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Title: Cost-benefit analysis of level II fieldwork for bachelor's-level and basic master's-level students in occupational therapy /
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Language: English
Creator: Shalik, Linda Dean, 1948-
Copyright Date: 1986
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Full Text








The author wishes to acknowledge the assistance of those persons

who took an active interest in her academic development as well as in

the implementation and documentation of this research.

Dr. Harold Shalik gave the initial encouragement needed to

enter graduate school. Later, he provided ongoing emotional and

intellectual support throughout the graduate program.

As the major professor, Dr. Michael Y. Nunnery assumed the

mentor role. He provided the appropriate degree of structure and

steady support which enabled the author to move through both the

didactic and research phases of the doctoral program without major

setbacks. His direct, communicative style coupled with his

accessibility permitted prompt problem resolution. Finally, Dr.

Nunnery's expert knowledge of the research process and the proper

presentation of research for academia proved invaluable in the

writing of the dissertation.

Dr. James W. Hensel provided early sponsorship and guidance in

entering graduate school at the University of Florida. As a member

of the doctoral committee, his wise suggestions in the planning

stages of the research were extremely helpful in obtaining the

professional support needed to make the research meaningful. His

later comments were found to be constructive in adding depth and

clarity to the reporting of the research.

Dr. C. Arthur Sandeen gave early encouragement for the

continuation of graduate studies at the doctoral level. In the

planning stages of the doctoral research, he was willing to ask the

hard questions and thus helped guide the study to its theory-based


Ms. Jane Slaymaker, MA, OTR, FAOTA provided much encouragement

in the undertaking of the research topic and served as an advocate

for the study on a national level. Her feedback and comments from

the unique perspective as a professional occupational therapist were

highly valued by the researcher.

Finally, the author wishes to acknowledge the program directors,

fieldwork coordinators, students, and clinical supervisors associated

with the 12 occupational therapy education programs who endorsed and

participated in this study. Particular thanks go to Maggie Adams

(Ohio State University), Carroline Amari (University of Alabama at

Birmingham), Claire Callan (Western Michigan University), Sandy Cash

(Virginia Commonwealth University), Janet Decker (University of

Wisconsin at Madison), Ruth Hansen (Eastern Michigan University),

Doris Hill (University of Southern California), Marlys Mitchell

(University of North Carolina), Caroline Polliard (Texas Women's

University), Vivien Radonsky (Medical University of South Carolina),

Kay Sieg (University of Florida), and Jean Still (San Jose State



ACKNOWLEDGEMENTS . . . . . . . . . . . .

ABSTRACT . . . . . . . . . .


: INTRODUCTION . . . . ..

Background and Justification
Statement of Purpose .
Assu Dtions . . . . .
Definition of Terms
Organization of the Remainder of

the Study


Origin and Application of Cost-Benefit Analysis
Theoretical Base and Concets . . . .
Cost-Benefit Analysis in Educaticn ...
Cost-Benefit Analysis in Health Care ..
Costs and Benefits in Clinical Education Programs
Cost-Benefit Studies in Allied Health ..
Comments on the Literature Review . . . .


Related Background, Setting, and Population . .
Identification of Costs and Benefits . . .
Recruitment of Subjects . . . . .
Method of Data Collection . ....
Instruments for Data Collection . . . .
Data Collection . . . . . . .
Data Analysis . . . . . . .
Processing the Data . . . . . .
Statistical Analysis . . . . . .


Site Questionnaire Responses Relative to Charges
and Salaries . . . . . .
Descriptive Analysis . . . . . . . .
Multiple Regression Analysis . . . . . .
Testing of Assumptions . . . . . . .
Testing the Null Hypotheses . . . . .


Summary . . . . . . . . . .
Conclusions . . . . . . . . .
Limitations . . . . . . . . .
Suggestions for Further Research . . . .

REFERENCES . . . . . . .


A PILOT STUDY . . . . . . . . .








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. . . 101

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. . . 112

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Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy



Linda Dean Shalik

May, 1986

Chairman: Michael Y. Nunnery
Major Department: Educational Leadership

The costs associated with clinical education in the health

professions have been scrutinized by educational and hospital

administrators in recent years. In some cases, the assumption has

been that these programs incur a cost to the hospital. Studies to

this date, although limited in scope, have not supported this cost

assumption. Applying the concepts of cost-benefit analysis to

clinical education in one health care field, occupational therapy, the

following basic questions were addressed:

1. Is there a cost or benefit accrued by clinical fieldwork

sites as a result of occupational therapy Level II bachelor's-level

student placement, basic master's-level student placement, and

bachelor's-level and basic master's-level student placements


2. When other selected relevant variables are held constant,

to what extent are there differences in basic master's-level and

bachelor's-level placement, week of the fieldwork experience, type

of fieldwork, number of fieldwork experiences, and age of student?

Study participants included 181 pairs of bachelor's-level or

basic master's-level occupational therapy students and their

respective clinical supervisors from 12 occupational therapy

educational programs in the United States. Costs and benefits were

measured in terms of time investment by students and supervisors

in fieldwork and clinic-related duties. Data were obtained from

weekly time logs kept by the student/supervisor pairs.

Results of the study revealed an overall institutional benefit

from the fieldwork placement regardless of the degree level of the

student. A strong curvilinear relationship (p < .0001) was found

between week of fieldwork and the value of the fieldwork, with all

types of fieldwork incurring a benefit to the institutions after the

sixth week. However, significant differences (- < .05) were found

in the degree of benefit between different types of fieldwork. No

differences in the value of the benefit were found between degree

levels of students, nor was age related to the overall benefit.

The average benefit from a fieldwork placement ranged from $4700

to $4850 depending upon whether it was a 12-week or 13-week



Background and Justification

The rising cost of health care has been a continuing national

issue in recent years. Health expenditures constituted 4.6% of the

gross national product in 1950 and were expected to increase to 10.5%

in 1985 (Arnett, Cowell, Davidoff, & Freeland, 1985). National

response to these rising costs has been a movement toward cost

containment measures such as prospective payment systems and

disease category related group payment programs (Arnett et al.,

1985; Curtin & Zurlage, 1984; Dowling, 1979).

The pressure toward cost containment has brought about increased

scrutiny of some costs that, while not directly a part of patient

care, have traditionally been included in the charges passed on to

consumers or third party payers. Not surprisingly, these groups

have become much less willing to shoulder additional costs beyond

those associated with direct patient services (Chung, Spelbring, &

Boissoneau, 1980). Financing of student education programs that

take place on hospital sites is one example of these additional

costs. Hospital administrators have viewed these programs as

incurring an overall cost to the institution and, in some cases,

have assigned a certain amount per patient for estimated "costs"

of clinical education (Busby, Leming, & Olson, 1972).

Some question exists, however, on the part of educators as to

whether students really do incur costs to the clinical sites.

There is contention that students actually pay for their presence

(and perhaps bring in additional revenue) through the increased

number of patient charges they generate (Chung et al., 1980;

Freymann & Springer, 1973). That is, students may constitute a

source of inexpensive labor that serves to increase productivity

(and revenue) in hospital departments where they train. While both

sides' opinions have been clearly stated, studies of the question

have been limited to singular hospitals, educational institutions,

or localized geographic areas (Chung et al., 1980; Halonen,

Fitzgerald, E Simmon, 1976; Hammersberg, 1982; Keim & Carney, 1975;

Leiken, Stern, & Baines, 1983; Pobojewski, 1978; Porter & Kincaid,


Coincident to the above trends in health care and clinical

education finance has been the movement in many allied health

professions to upgrade educational requirements from the bachelor's

degree to a required master's degree for entry into the professions.

Speech pathologists, for example, are currently required to possess

a master's degree for independent practice (Council on Professional

Standards in Speech-Language and Audiology, 1981) and such a

requirement is being extended to physical therapists (MacKinnon,

1984). The occupational therapy profession is currently considering

such a change (American Occupational Therapy Association [AOTA],

1984b), with a recommendation made to upgrade the current basic

master's-level program by adding advanced professional training

(Rogers, 1980a, 1980b). Issues of quality are central to these

decisions, but questions of costs and benefits should also be


Clearly, the didactic on-campus training of a master's-level

student will incur greater costs than will the education of a

bachelor's-level student both in foregone income to the student

and in direct costs resulting from the increased number of classes.

However, in light of the earlier mentioned concern about the costs

of clinical education, educational leaders should also consider

possible differences in the costs and benefits between bachelor's-

level and master's-level students.

The occupational therapy profession presents the appropriate

conditions for a study of the question relative to costs and

benefits of clinical fieldwork placement as well as the differentiation

between bachelor's-level and basic master's-level students.

Occupational therapy programs produce both of these entry level

students and both groups are assigned to final fieldwork placement,

the Level II fieldwork experience, at the conclusion of the academic

preparation. Moreover, occupational therapy educational and

professional leaders are currently at the decision-making stage in

determining future entry requirements. It is fitting that the

differences in costs or benefits to the clinical setting of these

two levels of students be compared in order to add an important

financial consideration to the decision-making process.

Cost-benefit analysis, an important technique derived from

welfare economic theory and the theory of consumer's surplus

(Dasgupta & Pearce, 1972), has been increasingly applied to various

questions in the health care field (Warner & Hutton, 1980). In

his explanation of the application of cost-benefit analysis to

health care, Klarman (1974) stated

cost-benefit analysis aims to do in the public sector
what the better known supply-demand analysis does in
the competitive, private sector of the economy. When
market failure occurs--whether through the absence of
a market or through the existing market's behaving in
undesirable ways--public intervention comes under
consideration. Cost-benefit analysis is helpful in
determining the nature and scope of such intervention.
(p. 326)

Cost containment has become a major consideration both in health

care and educational planning. National leaders have come to realize

that there are not unlimited dollars with which to buy educational

and health care services. Priorities must be set and choices must

be made.

This research was intended to provide basic knowledge to assist

the educational leaders in one health care provider field, occupational

therapy, in their planning of both fieldwork placement and professional

entry-level educational requirements. In preparing for this research

it was believed that results indicating overall financial benefits

to clinical sites as the result of student placement would help

justify continued free placement of students in fieldwork sites with

any charges passed on to consumers for educational costs to be

questioned. On the other hand, results that would indicate an

overall financial cost to clinical facilities would refute previous

research and suggest the need for further research.

Further, the results of comparisons between the cost-benefit

analyses of bachelor's-level and basic master's-level students is

valuable in supplying partial evidence as to whether basic

master's-level education contributes to increased productivity

early in the clinical career. Knowledge such as this is important

in helping to evaluate the efficacy of increasing educational

requirements for entry into the profession.

In summary, there were two basic justifications to this study.

First, it was to serve to increase the knowledge base regarding

clinical education in a field that is struggling to make decisions

regarding its future requirements for professional entry and the

impact throughout the health care system that these decisions will

make. Secondly, the study was designed to demonstrate the utility,

as well as the limitations, of the use of quantitative methods for

research in a human services profession.

Statement of Purpose

The primary purpose of the study was to determine whether the

placement of Level II occupational therapy fieldwork students in

clinical facilities brings about a net cost or benefit to the

facilities. The secondary purpose was to determine what other

factors are related to the costs or benefits of fieldwork placement.

More specifically, there were two basic questions to be

answered by this study.

1. Is there a cost or benefit accrued by clinical fieldwork

sites as a result of occupational therapy Level II bachelor's-level

student placement, basic master's-level student placement, and

bachelor's and basic master's-level student placements combined?

2. When other selected relevant variables are held constant, to

what extent are there differences in (a) basic master's and bachelor's-

level placement, (b) week of the fieldwork experience, (c) type of

fieldwork, (d) number of fieldwork experiences, and (3) age of


In order to answer the above questions, it was necessary to (a)

determine and classify those activities that can be identified as

either costs or benefits relative to student placement, (b) establish

methods for measuring the above costs and benefits, (c) apply cost-

benefit analysis techniques to these data to determine net cost or

benefit of student placement in the fieldwork sites, and (d) determine

additional factors that might be related to costs and benefits in



The study was confined to Level II fieldwork students of

participating bachelor's-level or basic master's-level'programs in

occupational therapy. While there were students in other levels of

clinical fieldwork experience, often on-site concurrently with Level

II students, these other students were not included in the research.

Data collection for the study took place during the summer

fieldwork period between May and September, 1985. Included were

276 bachelor's-level and 108 basic master's-level student/supervisor

pairs, or dyads. Usable data were obtained from 181 of these

student/supervisor pairs, 131 bachelor's-level and 50 basic

master's-level. Students in the study attended 5 of the 8 basic

master's-level programs and 7 of the 50 bachelor's-level occupational

therapy programs accredited by the American Occupational Therapy

Association. Registered occupational therapy supervisors were

employed by approximately 300 varied clinical fieldwork sites

scattered throughout the United States. Inclusion of an educational

program in the study was based on the willingness of the occupational

therapy program director and fieldwork coordinator to participate.

Further, participation of individual students and supervisors was


Data were obtained through self-reported time logs, kept

separately by each student and each supervisor. Additional

information concerning average supervisors' salaries and charges

per treatment unit was gathered through a questionnaire sent

directly to clinical coordinators.

The study was concerned solely with the direct economic costs

and benefits to the facility resulting from the presence of fieldwork

students and the implementation of the clinical education programs.

In other words, costs and benefits were defined specifically from

an institutional point of view. Lifetime benefits that are normally

calculated in cost-benefit analyses were not included since costs

and benefits were perceived to extend only marginally beyond the

"life" of the student affiliation period (Keim & Carney, 1975).

Likewise, discounting of costs or benefits was not warranted since

they were incurred in a period of less than a year (Klarman, 1974).

Finally, the cost-benefit analysis included only those costs or

benefits which were tangible, i.e., those factors that were readily

measurable and could be assigned a dollar value.


For the purposes of this research, the following procedural

assumptions were made:

1. Personnel time constitutes the major portion of costs and

benefits in the study.

2. Per unit treatment charges constitute the basic unit of


3. Per unit treatment charges constitute the basic unit of

benefit for patient treatment while the minimum hourly wage and

therapist hourly salary represent appropriate valuation of aide-type

duties and administrative duties respectively.

4. A treatment unit is a 15-minute increment of time for which

charges are made.

5. Similar charges are made per unit of patient treatment

regardless of who performs the treatment.

6. The value of time from supervisor to supervisor is similar.

7. Benefits are predicated on the assumption that independent

patient treatment and other tasks performed by the student will

release the therapist and ancillary staff for other duties.

8. Costs and benefits of student placement are limited to the

clinical site; external effects are considered to be minimal.

9. Educational background and training of occupational therapy

students are similar.

10. Since the Level II fieldwork experience is prescribed

through the Essentials and Guidelines of an Accredited Educational

Program for the Occupational Therapist (Commission on Education of

the American Occupational Therapy Association, 1985), all fieldwork

programs are similar.

Definition of Terms

Bachelor's-level program is an educational training program for

occupational therapy in which the first two years of academic training

are devoted to liberal arts and science courses and the final two

years to professional training in occupational therapy. The bachelor

of science degree is awarded at the successful completion of the


Basic master's-level program is an educational training program

for occupational therapy in which a student already possesses a bachelor

degree in another field and is awarded a master's degree upon the

completion of the necessary science and occupational therapy

professional level courses. This training is differentiated from the

traditional master's degree in that it does not represent the advanced

training which is usually built on bachelor's-level education.

Benefit-cost ratio is the present value of benefits divided by

the present value of costs.

Clinical coordinator is a clinician who acts as the liaison between

an academic program and the clinical education site.

Clinical education program consists of supervised work in a

clinical setting designed to provide practical experience and to

complement academic preparation.

Consumer surplus theory is an economic theory based on the concept

that the excess of consumers' willingness to pay for a good or service

over and above its market value is a measure of the net welfare gain

from a project.

Cost-benefit analysis is a measurement technique in which the

total costs of a program or project are compared to the total benefits

that may be expected.

Direct costs and benefits are increased or

values associated with a project.

Disease category related group is a method

care in which a fee for a specific diagnosis or

determined in advance and is paid regardless of

External effects (spillovers) are costs or

or indirectly affect others outside the project

Fieldwork supervisor is a therapist who is

decreased outputs or

of payment for health

group of diagnoses is

actual cost.

benefits that directly

at hand.

responsible for providing

ongoing direct supervision of an occupational therapy student at the

clinical site. This person is usually employed by the clinical

facility rather than the educational institution.

Fieldwork site (clinical site) is a location where direct

occupational therapy services are offered to health care consumers.

Foregone income is income that is lost, or not earned, while a

person is engaged in an educational program.

Indirect costs or benefits reflect the economic effects of a

project on the economy or society as a whole.

Intangible costs and benefits are factors for which there are no

real market values.

Internal effects are costs or benefits that affect directly or

indirectly the subjects under study.

Internal rate of return is a form of cost-benefit analysis in which

a rate of discounting is determined that equates the initial cost with

the total discounted future benefits.

Level II fieldwork is an internship or practical experience that

usually occurs at or near the conclusion of an occupational therapy

educational program. It represents the stage at which student

competency is expected to meet that of an entry-level therapist.

Net present value method is a means of reducing streams of costs

and benefits to a single number and in which costs and benefits that

are predicted to occur in the future are discounted.

Occupational therapy is the art and science of directing

participation in selected purposeful activities to restore, reinforce,

and enhance performance developmentally, physically, and mentally in

order to adapt to, correct, or diminish pathology.

Prospective payment system is a method of payment for health

care services in which a fixed amount of payment is predetermined

and in which payment is made regardless of cost.

Tangible costs and benefits are factors that are readily assigned

a market value.

Third party payers are agencies or parties other than the consumer

that are responsible for payment for health care services.

Welfare economics is a branch of economics which is normative and

assumes the assessment of the desirability of various economic states

to determine which is "better."

Organization of the Remainder of the Study

Chapter II is devoted to a review of the literature relevant to

the study. Chapter III describes the methods utilized to answer the

basic questions of the research. Chapter IV contains the results of

the study and their interpretations. The final chapter contains the

summary, conclusions, limitations of the study, and suggestions for

further research.


The review of the related literature includes an overview of

the origin and application of cost-benefit analysis in the field of

economics with further exploration of its application to the

educational and health care fields. More specifically, the first

section includes the definition, history, and traditional

applications of cost-benefit analysis in the public sector. The

theory and constructs commonly associated with cost-benefit

analysis are presented in the second section. Next, there is a

brief description of the development and application of cost-benefit

analysis to the field of education with particular emphasis given

to its application to higher education and vocational programs.

In the fourth part, the introduction and use of cost-benefit analysis

in the health care sector is reviewed. The final two sections

contain studies that initiated the use of time logs to evaluate

time spent in clinical education programs and include studies that

more formally utilized cost-benefit analysis procedures in conjunction

with clinical education and allied health education.

Origin and Application of Cost-Benefit Analysis

In their well known and frequently cited article, Prest and

Turvey (1965) defined cost-benefit analysis as

a practical way of assessing the desirability of projects,
where it is important to take a long view (in the sense
of looking at repercussions in the further, as well as
nearer, future) and a wide view (in the sense of allowing
for side-effects of many kinds on many persons, industries,
regions, etc.), i.e., it implies the enumeration and
evaluation of all the relevant costs and benefits.
(p. 683)

This definition was simplified by Sassone and Schaffer (1978) when

they indicated that cost-benefit analysis is "an attempt to ascertain

the net benefit (total benefit less total cost) of a policy or

project" (p. 11).

Some confusion exists in the literature as to the differentiation

between cost-benefit analysis and cost effectiveness. Niskanen (1967)

separated the two approaches by indicating that cost effective

analysis is "directed at problems in which the output cannot be

evaluated in market prices, but where the inputs can" while cost-

benefit analysis "should resemble the analysis of a profit-maximizing

business firm" (p. 18). In other words, if the costs and benefits

can be expressed in some real market values, then cost-benefit analysis

is the appropriate tool. But, when there is no market value for the

outputs, then cost-effective analysis is appropriate. While these

definitions are fairly clear-cut, in practice the two terms are often

used interchangeably. In the study reported herein, both inputs and

outputs were conveniently assigned market values and thus it was

classified as a cost-benefit analysis.

While cost-benefit analysis has been most often associated with

the evaluation of long-range public works projects, a number of

authorities (Dasgupta & Pearce, 1972; Rothenberg, 1975; Sassone &

Schaffer, 1978) have indicated that cost-benefit analysis is really

a generic term that encompasses a number of evaluative procedures

designed to assess the costs or benefits associated with different

project choices. Sassone and Schaffer (1978) further stated, "the

variety of programs addressed and the ingenuity which must be

exercised in estimating costs and benefits make it particularly

difficult, if not impossible, to design an all-purpose procedure"

(p. 3).

Although cost-benefit analysis has been most popular during

this century, the idea of measuring net costs or benefits of a

public expenditure project was first suggested by a Frenchman,

J. Dupuit, in his paper, "On the Measurement of Utility of Public

Works," which was translated in 1844. It gained in popularity in

the United States when it was applied at the federal level to projects

designed for the improvement of navigation. The River and Harbor Act

of 1902, for example, had built into it the requirement that costs

and benefits to commerce of various programs must be taken into

account (Prest & Turvey, 1965).

Further, the United States Flood Control Act of 1936 indicated

that a project may be pronounced "feasible if the benefits to

whomsoever they may accrue, are in excess of the estimated costs"

(Dasgupta & Pearce, 1972, p. 12). As projects in the public sector

continued to increase in number and expense, the demand for

accountability brought about a keen interest in cost-benefit analysis

as a way of ensuring the greatest value for the tax dollar.

Theoretical Base and Concepts

Cost-benefit analysis is usually associated with normative or

welfare economics. The use of normative economics introduces value

judgments or norms into the decision-making process. According to

Sassone and Schaffer (1978), the purpose is to assess the relative

desirability of different economic states or conditions.

Abstractly, at least, the method follows a two-step
paradigm: first, the stipulation of one or several
criteria by which to judge states and, second, analyses
of the states according to the criteria. Since the
decision to implement a public project leads to a change
from one economic state to another, and since our desire
is certainly to determine which state is "better" (a
value judgment) CBA falls directly into the province
of normative economics. (p. 6).

Prest and Turvey (1965) identified four principles that are

followed in carrying out a cost-benefit analysis.

1. It must be determined which costs and which benefits are to

be included.

2. It must be determined how the costs and benefits are to be


3. An appropriate discount rate is to be assigned.

4. Relevant constraints must be identified.

In determining costs and benefits, both internal and external effects

may be considered. Often there are intangible or incommensurable

factors that may affect the decision. These factors must be considered

and either ruled out or incorporated into the cost-benefit comparison.

The values assigned to the costs and benefits may be determined

by market prices, although this practice is sometimes criticized on

the basis that market prices do not always accurately reflect social

value. On the other hand, Sassone and Schaffer (1978) stated,

"often, the credibility of the analysis (hence, its value as a

decision aid) is better served by using market prices as the basis

for calculations, but carefully noting the direction and likely

magnitude of their bias" (p. 50). With this in mind, costs and

benefits in the study reported herein were assigned equivalent

market values.

Usually, the costs and benefits of a project are distributed

over the lifetime of the project, perhaps over several years. In

order to compare and make choices between various alternatives, the

time stream of costs and benefits must be converted to a single number.

This is accomplished by discounting, a method used to take account of

the fact that a dollar earned tomorrow is less valuable than a dollar

earned today (Bowen, 1963). Much controversy exists over the

appropriate rate of discounting that should be used. However, since

the lifetime of the fieldwork analyzed in the present research was

less than a year in duration, further exploration of the calculation

of discounting was not warranted. Klarman (1974) substantiated this

position when he stated, "when a project or program is short-lived,

with both benefits and costs concentrated in the near future, the

choice of discount rate is of minor or no consequence; indeed, for

a short-lived program discounting may be dispensed with" (p. 329).

In choosing a project, it may be necessary for it to meet certain

criteria, or constraints, before it can be considered a viable

choice. Such constraints may be budgetary, legal, social, political,

or institutional. All of these constraints must be identified so

that alternative projects that do not meet these criteria can be

eliminated early. For example, a budgetary constraint would be

when a dollar limit is set on each alternative project (Prest &

Turvey, 1965).

Although cost-benefit analysis is a widely accepted method of

measuring and comparing competing programs, there are valid criticisms

of its use. Maass (1966) criticized the sole emphasis of the method

on efficiency and commented, "the objective functions of most

government programs are complex; yet benefit cost analysis has

been adapted to only a single objective--economic efficiency" (pp.

208-209). His contention was that other factors, such as redistribution

of income, should be considered as part of the decision-making process

in choosing various programs. In addition, he criticized the fact

that cost-benefit analysis is indifferent to the distribution of

income. He questioned the assumption that a dollar of income from

a program is of equal social value regardless of who receives it.

Wildavsky (1966) noted that it is fairly easy to manipulate the

factors counted as costs or benefits, thus making it possible for

nearly any program to meet the stated criteria. Prest and Turvey

(1965) mentioned the difficulty in coming to cost estimates and the

very difficult job of identifying and valuing benefits. On the other

hand, most sources saw cost-benefit analysis as a valuable tool in

spite of its shortcomings. Wildavsky (1966) saw it as having a

definite place in economic analysis and commented, "the great

advantage of cost-benefit analysis, when pursued with integrity,

is that some implicit judgments are made explicit and subject to

analysis" (p. 297).

Cost-Benefit Analysis in Education

The predominant use of cost-benefit analysis in higher education

has been in the determination of the long-term value of education

from the point of view of both the individual and society. Education

in general and specific vocational or training programs have been

scrutinized through the procedures of cost-benefit analysis.

Researchers became interested in examining the monetary costs

and benefits of education when this new area of inquiry was spearheaded

by T. W. Schultz in 1960 (Alexander, 1976). Schultz (1961) was one of

the earliest economists to focus on the concept of human capital as

a means of explaining rapid growth in the national output of some

countries that could not be explained by increases in physical

capital. Levin and Shank (1970) noted that Japan and various

European countries devastated during World War II demonstrated

remarkable recoveries that were due, in great extent, to "the

economic power of accumulated and accumulating knowledge" (p. 37).

Becker (1970) commented that "few, if any, countries have achieved

a sustained period of economic development without having invested

substantial amounts in their labor force" (p. 63).

Weisbrod (1966) noted that increases in physical capital

accounted for only one-half or less of the United States' growth in

per capital output in this century. He labeled as "intangible

capital" the labor resources made up by people (p. 6). Further,

Weisbrod identified factors that would serve to increase the

productive capacity of the worker. Among these factors are

expenditures on information, labor, mobility, health, education, and

training. In addition to the direct economic gains to the individual,

he determined that the intangible benefits of education to society

included such factors as the intergenerational value (the impact

of educated parents on their children), crime prevention, decreased

welfare costs, and the positive effects of an involved, educated


Houthakker (1959) calculated the mean incomes associated with

various levels of education and age. Although he found that individual

income does increase with educational level, he cautioned against

attributing this difference solely to the difference in educational

level. Parental wealth and individual intelligence must also be

considered as factors in these differences.

Hansen (1963) developed and utilized the internal monetary rate

of return analysis to determine the costs versus benefits of schooling.

He calculated the values for the resource costs as defined by Schultz

(1961). These included such factors as salaries, supplies, interest

and depreciation on capital, opportunity costs incurred by individuals

(income foregone), and incidental costs such as books and travel.

Benefits were determined from lifetime cost-income streams for each

level of schooling. Finally, an internal rate of discount which

set the present value of the cost stream equal to the present value

of the net return stream was estimated.

From the above calculations, which are generally considered as

cost-benefit analysis, Hansen (1963) found a gradual increase in the

rates of return with each subsequent year of schooling up to the

eighth grade, then a gradual decrease in the rates of return to the

completion of college.

More recently, the use of cost-benefit analysis in education was

expanded into the general area of evaluation of vocational and

technical manpower training programs at both the secondary and

postsecondary levels. Barsby (1972) commented,

it becomes apparent then, that evaluation of manpower
programs is a necessary adjunct to their operation.
Proper evaluation gives us a mirror that lets us see
past results, allows us to compare relative success in
achieving stated goals; it enables us to adjust the
composition of existing programs and devise new ones
to increase the efficiency with which the goals are
reached. (p. 6)

The use of cost-benefit analysis in this area has served not

only to determine the overall net present value or rate of return on

a particular program, but to compare these figures among the various

vocational programs. Again, the emphasis has been to compare the

direct and indirect costs of the educational program with the

lifetime benefits derived both privately and socially.

Several studies in vocational education are of interest.

Barsby (1972) cited the study by Corazzini which compared cost-benefit

ratios of students enrolled in similar vocational programs at the

vocational high school level versus the junior college level.

Carroll and Ihnen (1967) compared the benefits of junior colleges to

its graduates as opposed to the benefits enjoyed by high school

graduates. Two studies conducted in Florida (Bobbitt, 1978; Harris,

1972) studied the costs and benefits of two vocational programs,

air conditioning and heating mechanics and practical nursing.

Along these same lines, Philippon (1980) conducted a major

study in which 12 nonuniversity training programs in the allied

health field were evaluated for costs and benefits using measures

of payback periods, net discounted present values, benefit/cost ratios,

and internal rates of return. He found highly varied yields among

these programs with several falling below the criterion of an

acceptable rate of return. He further concluded that much more

attention should be paid to costs and monetary returns of programs

in addition to the "manpower" approach traditionally used.

While cost-benefit analysis has been widely used in education,

Woodhall (1970) noted that there are some educators who are critical

of its application in the field. "Some educationists have argued

that cost-benefit studies are inapplicable to education, because of

the multiplicity of educational objectives, and the importance of

non-economic benefits" (p. 12). On the other hand, she summarized

the view of most expert articles reviewed when she stated, "cost-

benefit analysis cannot be the sole criterion for educational

planning, but . such an analysis should be an important element

in decision making" (p. 7).

Cost-Benefit Analysis in Health Care

A rapid rise in the frequency of use of cost-benefit analysis

in recent years has paralleled national concern for escalating costs

in health care. Tolpin (1980) noted that over half of the increase

in health care expenditures is estimated to be due to increased

prices. The concern over prices has been reflected in a growth in

literature on cost-benefit and cost-effective analyses in medical

journals which surpasses that found in nonmedical journals (Warner &

Hutton, 1980).

According to Prest and Turvey (1965), Sir William Petty was one

of the earliest researchers to apply cost-benefit analysis to the

health field when he attempted to quantify the economic value of

man. Hellinger (1980) linked the growth of cost-benefit analysis in

health care with the increase in government involvement associated

with the beginning of the Medicare and Medicaid programs in the mid-

1960s. Further, he stated, "currently, the federal government is

involved actively in testing and evaluating new medical technologies

in an effort to contain the growth of health care costs" (p. 207).

Dittman and Smith (1979), in addition to Klarman (1974), gave

a clear explanation of the dynamics which have led to the rapidly

increasing costs in health care and the subsequent need for evaluative

tools to help contain costs. They mentioned general market failures

that limit the ability of the marketplace to allocate health care

resources. Because of costs, some markets will fail to survive.

Second, market efficiency depends on both the buyer and seller

knowing and understanding the full costs and benefits that are part

of the transaction. This is not the case in health care where many

consumers lack knowledge relative to the health care opportunities

that are available. Finally, in health care there are many cases in

which social benefits are greater than private benefits. In these

circumstances the system cannot depend on private demand to make

necessary services available.

There are circumstances within the health care system itself

that "insulate providers and consumers of health services from

market incentives" (Dittman & Smith, 1979, p. 46). The role of

third party payers serves to isolate the consumer from direct

financial responsibility for health care. In addition, the cost-based

retrospective payment system provides no incentive for cost containment.

Klarman (1974) noted, "in the case of hospitals, cost reimbursement

for most patients leads to an impairment of financial self-discipline,

since a dollar need only be spent in order to be gotten back" (p.

340). Finally, consumers and policy makers alike have been reticent

to deal with the issue of cost versus quality. Difficult choices

must be made as to how much "health" consumers are willing to finance.

Tolpin (1980) explained,

motivated primarily by pressures to curtail inflationary
increases in health care costs, decision-makers in both
the public and private sectors are being forced to make
value judgments which explicitly recognize resource
constraints and, therefore, imply trade-offs among
efficiency, equity, and quality objectives. (p. 217)

Cost-benefit analysis is viewed as a valuable tool to help make

decisions in these cases of market failure and to help set priorities

within the health care sector.

The definition of cost-benefit analysis in the health care

field is fairly consistent with that described earlier by economists.

Klarman (1974) saw it as a means of comparing costs and benefits of

alternative programs that are in competition for limited funds.

Bootman, Rowland, and Wertheimer (1979) adopted the Prest and

Turvey (1965) definition quoted earlier in this review for their

discussion. And, finally, Hellinger (1980) defined it as a "technique

used by decision-makers to choose among several courses of action"

(p. 204).

The cost-effectiveness/cost-benefit delineation is also present

in the health care literature. There is general agreement that

cost-benefit analysis centers on dollar valuations of both inputs

and outputs while cost-effectiveness analysis uses nonmonetary

indicators of goal achievement (Dittman & Smith, 1979; Weinstein &

Stason, 1977). It is also noted that in cost-effective analysis the

end product is constant while the methods to reach the end.goal vary

and have different costs attached to them. The purpose is to find

the least expensive method to reach the goal (Williams, 1974). While

cost-benefit analysis is often associated with broader projects and

cost-effectiveness is deemed useful in projects that are narrower in

scope, Bootman et al. (1979) cautioned that both techniques can be

applied either to very broad or very narrow problems.

In articles reviewed relative to cost-benefit analysis in the

health care sector, benefits are frequently defined as costs

deferred (Klarman, 1974). In other words, "direct benefits are

defined and measured by the cost of health resources that are freed

by the achievement of a particular health status or health system

goal" (Dittman & Smith, 1979, p. 52). Such benefits would be the

dollar value placed on the time of physicians, nurses, and other

health personnel, with the addition of money spent on drugs, supplies,

and hospital equipment. Further, direct benefits would also include

resources saved from future expenditures that would have been

required for research and new treatment technologies. Williams (1974)

viewed benefits somewhat differently and contended that they should

be measured in terms of health, such as morbidity measures or

mortality measures, or through a valuation of increased life

expectancy. It becomes clear that the valuation of these benefits

can become an extremely complex task.

Bootman et al. (1979), Dittman and Smith (1979), and Klarman (1974)

cited as indirect benefits such factors as averted loss of earnings

due to premature death or disability. Intangible benefits were

described as the "psychic costs of disease," such as pain, suffering,

and grief (Bootman et al., 1979, p. 138). In addition to the above

are the spillovers or external benefits that society enjoys as a

result of the eradication of some health problem.

A number of problems are noted in applying cost-benefit techniques

to the health care sector. These problems can generally be considered

as problems of classification and valuation. Klarman (1974) noted

that it is difficult, in health care in particular, to separate the

activities and services that go into the treatment of one problem or

disease from those services that are used in the treatment of

another problem. This is particularly true in hospitals where

departments offer similar services for a variety of illnesses.

In addition, he cited the difficulty of formulating the expected

outcomes of programs. This arises from the fact that medicine is

not all science but entails a great deal of "art" as well.

Problems in valuation arise when attempts are made at assigning

dollar values to human life and other intangible costs or benefits.

Hellinger (1980) described two approaches to value human life. The

"livelihood savings approach" uses the present value of future

streams of income as the measure of the value of an individual's

life. This point of view is criticized in that maximizing income

is not really the goal of health care. The "willingness to pay

approach" is the amount a person would be willing to pay to reduce

the risk of contracting an illness by a specified amount. The problem

with this approach is that the reliability of answers to such a

question is in doubt. Both approaches, at best, yield crude measures.

Hellinger expressed the opinion that,in spite of the drawbacks, one

or the other of these methods is preferable to no formal analysis

at all.

Costs and Benefits in Clinical Education Programs

The following review of costs and benefits of clinical education

programs is focused on studies in both the medical and allied health

fields where the attempt is to examine how time is spent by fieldwork

students in their respective clinical placements and their impact on

the clinical setting from a costs/benefits point of view. A number

of early studies, particularly those that investigated medical

clerkships, were focused simply on how time was spent by students

during the clerkship. In some cases these studies arose out of

concerns expressed by medical students that they were being utilized

more for "work," with little benefits received as far as their own

educations. Although these studies are somewhat tangential to the

major area of concern of the present research, such studies did set

the methodological groundwork for the cost-benefit studies that


Payson, Gaenslen, and Stargardter (1961) conducted one of the

earliest studies on how time was spent by medical interns. Although

it was a descriptive study limited to a local hospital, it established

the use of a time log in determining how time was spent. The logs

were kept by other students who were trained as observers for the

purpose of the study and who followed the interns around continually

during the data collection period. While the results can only be

considered important for that hospital, it is interesting to note that

a very small amount of the interns' time was devoted to direct contact

with patients.

Later, Gillanders and Heiman (1971) carried out a similar study

of medical interns in which time logs were also kept by student-

observers. The purpose of this study was to compare time spent by

the interns with the requirements set forth in the American Medical

Association's "Essentials of an Approved Internship." The researchers

found the three hospital programs studied conformed broadly to the

requirements of the "Essentials." Along these same lines, Arthurson,

Mander-Jones, and Rocca (1976) used time logs kept by observers and

found that an inordinate amount of time was spent by interns in

clerical duties and little in direct patient interaction.

In 1981, LaPalio again studied time spent by interns but in this

instance self-reported logs were used with comparisons made to

questionnaires that were filled out by faculty members. He found

that students were on duty for long periods of up to 32 hours at a

time with little sleep. Like Arthurson et al. (1976), LaPalio found

interns spending insufficient time with patients. More recently,

LaPalio, Filling, Engel, and Ways (1983) studied clerkship experiences

using three methods of data collection, i.e., daily logs, observations,

and interviews. They found the combination of methods of data

collection helpful in obtaining a wealth of qualitative as well as

quantitative information relative to the clerkship experience.

In his 1972 article on the clinical costs of medical education,

Wing summarized the scant research up to that time. He cited studies

by Carr and Feldstein, Ingbar and Taylor, and McCorkle, all of which

indicated increased costs per patient stay of teaching hospitals when

compared to nonteaching hospitals of similar size and scope. A major

weakness in these studies was made evident when Busby, Leming, and

Olson (1972) reported on their study of teaching hospitals. They

reported other factors, found concomitant with the teaching status

of a hospital, that contributed to raising the per patient costs.

Among these factors were a higher medically indigent patient load;

the operation of larger, more diverse, outpatient clinics; a lower

occupancy rate; greater utilization of diagnostic services; and a

higher nursing staffing expense.

Freymann and Springer (1973) provided the first indepth analysis

of the costs and benefits of a clinical education program at Hartford

Hospital. In this study, the researchers computed all the direct

expenditures for educational programs in medicine, nursing, and

allied health. In addition, indirect costs, such as administrative

costs, depreciation, and public relations were also determined. On

the benefit side, students were asked to keep a log of daily activities

that would indicate the amount of time spent in hospital service

activities, such as direct patient care. Based on these logs, the

researchers calculated a proportion of these student-performed

activities that were considered "hospital essential." Dollar values

were assigned to these essential services based on the replacement

costs of trained professional staff. It was concluded by Freymann

and Springer that,even at this proportional level of services, the

students provided manpower of a value that exceeded the costs of their

educational programs.

The instructional costs of a required third-year primary

clerkship were determined by Pawlson, Schroeder, and Donaldson (1979)

through the use of faculty logs, direct observation, and on-site

interviews. They calculated costs through time spent by both

faculty and nonfaculty members, space and materials, and university

overhead. Costs of space and overhead were found to be marginal,

thus faculty salaries constituted the primary expense. No attempts

were made in the study to compare possible benefits generated by

the students. The researchers determined that the overall costs

per student of the clinical program totaled $11,500 per year, or

$54.20 per day.

Subsequently, a second study by Pawlson, Watkins, and Donaldson

(1980) was also focused on medical student instruction costs. This

time they used measures of physician productivity as the indicator

of student effect on the clinic setting. With baseline data kept

when students were not present, the number of patient visits was

used as the indicator of physician productivity. The authors

explained the procedure used as follows:

Where a significant difference in the number of visits
with and without students present was found, the
difference in mean visit productivity is used as a best
estimate of productivity change. The difference is
multiplied by the cost per visit to give the costs due
to lost patient care productivity. (p. 848)

The results of this study indicated a significant loss in

physician productivity for second, third, and fourth year medical

students. Greater losses were noted when students were participating

in patient care than when they just observed. No loss in productivity

was noted with first year medical students where the student role

was purely an observational one.

Cost-Benefit Studies in Allied Health

Keim and Carney (1975) contributed one of the earliest cost-

benefit studies in allied health. Programs included in the study

were medical technology, occupational therapy, physical therapy,

physician's assistant, radiologic technology, respiratory therapy,

and social work. Concentrating on the clinical placement phases

of these seven allied health programs, the researchers utilized

group interviews with staff and students to determine perceived

time spent in student supervision, administrative duties associated

with the clinical placement, patient treatment, and other staff

duties. All costs and benefits were valued according to full-time

staff equivalencies.

In the occupational therapy program, costs were defined in

terms of personnel time for instruction, administrative duties,

miscellaneous expenses such as the provision of room and board for

some students, and student stipends. Although space and equipment

costs were reviewed, they were found to be insignificant. The

frequency of providing room, board, and stipends was found in three

or less of the 10 sites studied but were averaged and valued as

though occurring in all the sites. Program benefits included revenue

production as a result of increased patient treatment, the provision

of nonprofessional labor, and such intangible benefits as recruiting

advantages, staff incentives, and improved patient care.

Based on the data received from the interviews, the researchers

concluded that costs of the occupational therapy fieldwork program

could be equated to the personnel time of 1.3 registered occupational

therapists (of which .1 was attributed to stipends and room and

board). Conversely, the benefits through increased productivity

brought about by the student/supervisor team was evaluated to be

about 130% of the therapist working alone. The authors concluded

that there was no net cost or benefit to the clinical site.

While this study is important in its early thrust in applying

cost-benefit evaluation techniques to clinical education programs,

the lack of more reliable quantitative data is a major weakness.

Consequently, the conclusions reached are questionable.

A study similar to that of Keim and Carney (1975) was conducted

on physical therapy clinical education programs by Porter and

Kincaid (1977). Again, questionnaires were utilized and information

was requested from physical therapy department heads relative to the

impact of their student programs. While costs and benefits were

defined similarly to those of Keim and Carney, benefits relating to

patient treatment were valued according to the treatment revenue

generated. Comparisons were made between junior and senior level

affiliating students with overall benefits being noted in both groups.

Further, benefits as a result of senior level placement were greater

than those realized with junior level placements.

Pobojewski (1978) compared the costs and benefits of clinical

placement of radiologic technology students placed in a local

hospital from a community college program. Again, costs and

benefits relative to student supervision and patient treatment

were based on estimates given by the department head. It was

perceived by the department head that time spent in student supervision

was highest in the early weeks of the fieldwork and gradually declined

throughout the year-long internship period. Pobojewski reported an

estimated overall benefit of student placement in that facility in

excess of $45,000.

In her study of the clinical placement of six junior college

level allied health programs, Hammersberg (1982) surveyed supervisors

and staff members to obtain estimates of the amount of time spent

in educational activities and the cost of supplies needed for

educational purposes. Student contribution to the daily work load

constituted the benefit side of the equation. All data were obtained

through the supervisors; no student responses were sought.

Hammersberg found greater costs than benefits in all six of the

programs she studied. It is of interest that Hammersberg noted in

her article that many of the fieldwork sites where the college

students were placed were beginning to demand a share of the tuition

revenues for each student they accepted. Such demands are not

surprising in light of the results of her study.

Leiken et al. (1983) utilized a somewhat different approach in

their analysis of the impact of clinical education programs. Rather

than delineating costs and benefits, they analyzed the production

effects of student placement. Inputs were defined as the number of

students and therapists present each day, outputs were determined by

the number of daily patient charges. Data were obtained through a

simple review of the hospital accounting and personnel records

yielding data which were subjected to regression analysis.

Occupational therapy, physical therapy, and radiology technology

programs were studied with students having a positive impact on

productivity in all three areas.

Lapopolo (1984) studied the costs and benefits generated by

physical therapy students in three large and three small hospitals

within the San Francisco area. Time logs were kept by student

supervisors to tabulate time spent in the categories of direct

patient care, indirect patient care, administrative activities,

personal time, student education, combined student/therapist direct

patient care, and combined student/therapist indirect patient care.

Dollar values were assigned based on charges for patient treatment

and therapists' salaries. Lapopolo found that a daily benefit of

approximately $89 was generated per student.

A cost-benefit analysis of occupational therapy fieldwork was

conducted by Chung et al. (1980). The major cost in this study was

attributed to the reduction in the production of agency services or

personnel time. Additional costs, such as the provision of room,

board, and student stipends, were also identified. However, because

not all agencies provided these student perquisites, the researchers

excluded them from the overall model indicating that their inclusion

would "introduce inconsistency in the cost structure between different

agencies and lead to a misleading conclusion" (p. 218). It was

recommended that these costs be treated as additive or marginal

costs in dealing with the individual agency's cost-benefit analysis.

Benefits were identified as revenue-producing activities (patient

treatment), low cost labor for miscellaneous duties, and intangible

benefits such as those described in the Keim and Carney study (1975).

The assignment of a discount rate was ruled out due to the subjectivity

of the procedure.

Data were collected from students and supervisors by means of

a daily log. This log provided information regarding daily

investment by agency staff in instructional duties and daily

investment on the part of the students in patient treatment and

other miscellaneous duties. Instructional hours were valued

according to the national average pay scale for professional

occupational therapists.

Results of the study indicated that students contributed hours

of work equivalent to slightly more than half of a full-time staff

work load and "contributed 83.1% more man-hours than the agency

relinquished of its staff time for the student" (Chung et al., 1980,

p. 224). Since the value of the student labor was discounted based

on their lack of full credentials and experience, the researchers

concluded that the fieldwork sites were approximately "breaking even"

with regard to their educational programs.

While the Chung et al. (1980) study is the most thorough cost-

benefit analysis of clinical fieldwork to date, it did suffer from

some serious problems. Attrition was extremely high. While 100 logs

were sought from students and their supervisors, only 16 usable pairs

were actually obtained. It is probable that daily data collection

over a 13-week period was simply too intrusive into the fieldwork

clinic routine. In addition, the discounting of the value of student

time would seem to give the study a conservative bias when

calculating benefits since institutions will benefit on the scale

of patient treatment revenues no matter who performs the treatment.

Nevertheless, this cost-benefit research formed the basis of the

present study that is reported here with adjustments made in

methodology designed to compensate for the shortcomings mentioned.

Comments on the Literature Review

While cost-benefit analysis is widely accepted as a legitimate

form of program evaluation, there are many problems associated with

its implementation. Value judgments must be made in defining costs

and benefits and assigning their values. The review of the literature

indicates no clearly defined procedures to be followed in its

implementation. Controversy exists relative to its definition, the

determination of costs and benefits, and the assignment of discount

rates, market values, and decision criteria. A great deal of

subjectivity can enter.into the process, yet the procedure does

provide some structure for the analysis of programs in a systematic


The review of the literature has revealed widely variant

applications of cost-benefit analysis. Broad applications of the

method in the field of economics are tremendously different from

the narrow applications in the allied health professions. Review of

the allied health studies reveals extremely primitive applications

in earlier research with marked improvement in the sophistication

of more recent studies.


It is clear that scrutiny of expenditures in health care and

education will continue as governmental agencies emphasize

decreased expenditures for social programs. This emphasis on

accountability and cost containment in public programs almost

assures the continued use and refinement of cost-benefit analysis.

The study presented herein is a further attempt at such application

and refinement.


The purpose of this chapter is to describe the planning and

implementation of the research. It begins with a discussion of the

background and setting of the study. This includes an overview of

the accreditation requirements for an occupational therapy education

program and fieldwork experiences, as well as a description of the

structure and setting of the fieldwork assignment. This is followed

by sections related to the (a) steps taken in the identification of

costs and benefits, (b) recruitment of subjects, (c) method of data

collection, and (d) statistical analysis of the data.

Related Background, Setting, and Population

The Essentials and Guidelines of an Accredited Educational

Program for the Occupational Therapist (American Occupational Therapy

Association [AOTA], 1983) describes the role of entry-level occupational

therapy professional education as preparing the individual to

1. provide occupational therapy services to prevent
deficits and to maintain or improve function in
daily living skills and in underlying components;
e.g., sensorimotor, cognitive, psychosocial.
2. manage occupational therapy service.
3. incorporate values and attitudes congruent with
the professions' standards and ethics. (p. 2)

The "Essentials" further define professional occupational

therapy education as taking place at a college or university

authorized to grant baccalaureate or higher level degrees. Content

requirements for occupational therapy professional education

include coursework in liberal arts and sciences; biological,

behavioral, or health sciences; and occupational therapy theory,

practice, and application.

In conjunction with classroom and laboratory learning experiences,

the essentials require associated, real-life fieldwork experiences.

The Level I fieldwork experience serves to directly complement

classroom experiences by providing "opportunities for directed

observation and participation in selected clinical sites" (p. 3).

Level II fieldwork requires the student to spend six months in

supervised clinical practice which emphasizes "the application of an

academically acquired body of knowledge" (p. 3). During the Level II

fieldwork the student is expected to have experience with a wide

range of client ages and types of illnesses or disabilities and to

approach the performance level of an entry-level therapist (Commission

on Education of the American Occupational Therapy Association, 1985).

Generally, a student is assigned to two three-month Level II

assignments. Most often, one of these fieldwork assignments takes

place in a psychiatric setting while the other emphasizes physical

dysfunction, such as a general medicine or rehabilitation hospital.

Other options for fieldwork placement include pediatric or geriatric

settings or specialty programs such as hand therapy or home health.

In addition, the student may choose a third Level II fieldwork

assignment to obtain additional experience in a particular area of


The Level II fieldwork placements are managed at the university

level by the academic fieldwork coordinator who arranges agreements

between the university and selected fieldwork sites for the provision

of clinical experiences. Depending on the size of the occupational

therapy department at the clinical site, there may be persons

designated to coordinate the clinical education program in addition

to the direct supervisor who is responsible for supervising and

evaluating student performance during the fieldwork experience. Most

often, however, one person fills both of these roles.

The student supervisor rates student performance using a standard

evaluation tool, the Fieldwork Performance Report, which was

developed and is periodically revised by the Commission on Education

of the American Occupational Therapy Association. This rating occurs

at the midpoint and final week of the fieldwork experience (AOTA,

1983). A minimum performance rating is required on each of the two

Level II fieldwork assignments and, after meeting this criterion

(as well as successful completion of academic work), the student is

permitted to "sit" for the national certification examination.

In 1984, within the United States, there were 56 accredited

professional-level occupational therapy programs (AOTA, 1984a).

Of these, two offered only the basic master's-level programs, while

10 offered both baccalaureate and basic master's-level educational

programs, and 44 were solely baccalaureate programs.

Identification of Costs and Benefits

According to Prest and Turvey (1965), a cost-benefit analysis

must first identify those factors that constitute the costs and

benefits of a program and it must determine how these factors are

to be valued. In this research, the direct costs identified with

clinical fieldwork placement included the time spent by the supervisor

and other professional staff in preparation for and supervision

during the student placement. This included time spent in general

one-to-one supervision of the student, meetings, preparation and

administration of the fieldwork, and in formal teaching or instructional

sessions. Benefits were derived from (a) the time spent in direct,

independent, patient care that was administered by the student; and (b)

the time spent by the student performing work that released the

supervisor or staff for other duties. This included time spent in

individual and joint patient treatment sessions, administrative work

of the clinic, meetings, and in clerical or aide duties.

As has previously been noted, based on studies by Keim and Carney

(1975) and Chung et al. (1980), the most significant costs and benefits

were expected to be generated in personnel time. Costs such as space

and overhead were viewed as minor and were not included. Because of

inconsistency from site to site in the provision of room, board, and

stipends for students, the inclusion of these factors in the overall

cost-benefit calculation was viewed as inappropriate.

Time spent in supervision or instruction was valued according

to the average charge per 15 minute unit of occupational therapy

treatment in the participating clinical facilities. This was

justified by the point of view that time spent by the therapist

in direct supervision of the student and associated activities

would be available for patient treatment (and its corresponding

income to the institution) if the student were not present.

Time spent by the student in direct patient treatment was also

assigned a value based on the average per unit treatment charges.

While it is not presumed that the student functions at the same level

of effectiveness as the supervisor, from the institutional point of

view, charges for time spent in patient treatment within the

occupational therapy department are the same no matter who performs

the treatment. However, in the case of group patient treatment, the

student was credited only with the treatment of one patient per

15-minute increment, thus taking into consideration the student's

lack of experience and assuming a certain amount of inefficiency on

the student's part.

Student time spent on other professional duties, such as treatment

planning and writing progress notes was valued at the rate per hour

for a salaried therapist. This rate was justified by the fact that

the student brings a certain amount of professional expertise to

the fieldwork site as a result of the occupational therapy educational

process at the academic institutions. The therapist functions of

planning treatment programs, writing progress notes, and representing

occupational therapy at meetings, require this expertise and therefore

warrant valuation at a professional rate. On the other hand, time

spent in aide or clerical duties was valued at the minimum hourly

wage since the replacement cost of providing these services would

be at this level. While the values placed on student contributions

were somewhat greater than those given by Chung et al. (1980), they

were not inconsistent with values assigned by other researchers

that were reviewed (Lapopolo, 1984; Leiken et al., 1983; Pobojewski,

1978; Porter & Kincaid, 1977).

Recruitment of Subjects

The recruitment of subjects for this research took place on

two levels. Initially, educational program directors and their

fieldwork coordinators were contacted to obtain their cooperation

and endorsement of the study. Once endorsement was granted, contact

was made with individual students and their supervisors to enlist

their involvement.

First, a pilot study was conducted to determine the level of

interest of occupational therapy educational program directors in

participating in the research. This was conducted by mail using a

cover letter and questionnaire format (see Appendix A). Approximately

half of all the educational program directors were contacted.

Included in this group were all basic master's-level program

directors as well as bachelor's-level program directors that were

judged by the researcher to be likely candidates for participation

in the study. Based on responses to the questionnaires, it was

determined that the level of interest warranted proceeding with the

study on a national scale.

In further preparation for the study, the researcher attended

the Annual Conference of the American Occupational Therapy

Association which was held in Atlanta, Georgia, during April of 1985.

Formal presentations were made to the meetings of academic fieldwork

coordinators and clinical supervisors relative to the planning of

the research and its implementation. Members in attendance at these

meetings, which represented all academic occupational therapy programs

in the United States, were invited to participate. In addition, the

student representative assembly was also formally addressed to encourage

participation of the individual student members.

As a result of the recruitment efforts, representatives of 16

educational programs expressed willingness to participate. Of these,

the necessary information (e.g., student names, fieldwork locations,

and names of fieldwork contact persons) was provided by 12 programs

prior to the beginning of the summer fieldwork period and thus

constituted the final group of educational programs included in the


Participating basic master's degree granting programs were

Texas Women's University, The University of North Carolina, The

University of Southern California, Virginia Commonwealth University,

and Western Michigan University. Bachelor's degree granting programs

included Eastern Michigan University, Medical College of South Carolina,

The Ohio State University, San Jose State University, The University

of Alabama at Birmingham, The University of Florida, and The University

of Wisconsin at Madison. A total of 384 students from these 12

programs were sent to Level II fieldwork assignments between May and

September of 1985. There were approximately 2,000 students engaged

in Level II fieldwork during this period from the accredited programs

in the United States; the 384 students in the study represented

approximately 20% of the total population of students assigned to


Fieldwork coordinators from participating educational programs

were asked to endorse the study and to join in an introductory

letter requesting participation from their students and fieldwork

supervisors (see Appendix B). They provided lists of students who

were assigned Level II fieldwork during the summer affiliation period.

Names and addresses of the fieldwork sites as well as the contact

person or student supervisor at the site were also provided.

All fieldwork students and their supervisors from the above

programs were contacted to participate in the study. This initial

contact consisted of the introductory letters (described above) plus

the first two time logs and instructions for their completion. While

students and supervisors were urged to complete the logs and return

them, participation was completely voluntary. All students and

supervisors who provided one or more pairs of time logs were included

in the study.

With each student and corresponding supervisor making up a

dyad, responses from a total of 264 student/supervisor dyads were

returned. Of these, 230 paired responses were received; that is,

both the student and supervisor completed time logs from at least

one week of the affiliation period and returned them. Four of the

230 paired responses were eliminated from the data set due to

grossly overestimated time expenditures (totaling well over the

usual 40-hour work week). For purposes of statistical analysis,

additional observations were deleted yielding a total of 181 pairs

of time logs. (See the Data Collection section for a description

of the steps involved and rationale for paring the data set from

226 to 181 observations.)

Method of Data Collection

Instruments for Data Collection

Two time logs and instructions for their completion were prepared

by the researcher. These logs were developed using models from the

previous cost-benefit study by Chung et al. (1980). They were used

to collect data from the student and supervisor relative to time

spent in patient treatment and student supervision respectively.

The fieldwork supervisor log included categories of time expenditures

in general supervision, meetings, preparation and administration of

the student program, and formal instructional sessions. The student

time log had entries for time spent in independent and joint patient

treatment, administrative work, meetings, and clerical or aide duties.

The logs were utilized on a trial basis by occupational therapy

students and their supervisors residing in the vicinity of Gainesville,

Florida, to assure understandability and usefulness. The logs were

also shown to representatives from the participating educational

programs. Clarification and adjustments were made in response to

specific criticisms and suggestions made by these individuals.

Examples of the student and supervisor time logs and their

instructions may be found in Appendix C.

A site questionnaire was developed and sent to the clinical

coordinators of participating fieldwork sites with the provision that

it could be returned without identification (or anonymously). The

primary purpose of the site questionnaire was to determine annual

salaries of participating student supervisors and the hourly patient

treatment charges in the fieldwork sites in order that the average

of these values could be used to calculate net present value. In

addition, as can be noted by a review of the site questionnaire in

Appendix D, additional data were sought to determine the frequency

in which stipends and room and board were provided to students and

the possible added institutional costs associated with providing

these student perquisites.

Data Collection

Each student/supervisor pair was asked to complete the time log

for three one-week periods throughout the fieldwork placement. Weeks

of data collection were assigned as follows:

1. Student/supervisor dyads were randomly assigned a number

from one to four.

2. This number indicated which week, of the first four weeks

of the fieldwork period, the first time log was to be completed.

3. Once the first logging week was established, the final two

logging weeks were assigned the fourth and eighth week after the

first log. For example, when the number 2 was assigned a student/

supervisor pair, then logs for that pair were requested for the

second, sixth, and tenth weeks of the fieldwork period.

By assigning data collection according to this method, it was

believed that the requirements of the research were met by

adequately sampling time expenditures throughout the fieldwork

period. At the same time, intrusion into the daily routine of

supervising therapists and their students was kept at a minimum.

Requests for data were sent in two separate mailings. In the

first mailing the letter requesting participation in the study plus

the first two sets of time logs with instructions were sent. The

second mailing included a cover letter with the final time log and

site questionnaire. Two different cover letters were written for

the second mailing with content directed to those who had or had not

returned the initial time logs. Samples of these final cover letters

are found in Appendix E.

As mentioned earlier, a total of 384 student/supervisor pairs

were contacted and asked to complete the data sheets. Responses

were obtained from 264 of the student/supervisor dyads. Since

calculation of the net present value was dependent on paired

responses showing both benefits and costs, it became necessary to

discard unpaired responses from 34 participants. This yielded a

remaining total of 230 student/supervisor paired responses, or a 60%

return rate. Four of these pairs were unusable due to large gaps in

data or grossly overestimated time expenditures.

The reader will recall that requests were made for three one-week

observations from each student/supervisor dyad. However, there was

variation in the number of responses received from these dyads

with many sending one or two rather than the three requested time

logs. As a result, it became necessary to reduce the number of time

logs used in the statistical analysis so that just one observation

per student/supervisor dyad was used thus avoiding errors stemming

from repeated measures from some, but not all, subjects.

The paired responses from each student/supervisor dyad were

listed together in sequential order (e.g., first observation, second

observation). These responses were then further grouped according

to the educational program with which the student was affiliated so

that all student/supervisor observations from a particular educational

program were listed together. Observations were then sequentially

selected from the first (weeks 1 through 4), second (weeks 5 through 8),

and third (weeks 9 through 13) periods of data collection with only

one observation selected from each student/supervisor dyad. Data

that did not fall into the sequence were deleted. The following

list illustrates this method of sampling.

Student/Supervisor Period of Week of Data
Pair # Observation Collection

A* 1 2
A 2 6
B* 2 8
C 1 1
C 2 5
C* 3 9
D 3 10

indicates observations included in the final sample.

In the preceding example, pair "A" had completed time logs

for the second and sixth weeks of the fieldwork (from the first and

second periods of data collection). The first observation was

selected to retain in the data set. Pair "B" returned only the

second time log and, since this observation falls into the 1-2-3

sequence, it also was retained in the data set. Pair "C" returned

all three logs and, since the third log fits into the sampling

sequence, it was retained for the analysis. Pair "D", however,

returned only the third log. This was out of the sampling sequence

(a log from the first four weeks was required) and, therefore, was

deleted from the data set. This sampling method yielded a final

total of 181 pairs which were then subjected to statistical analysis.

Data Analysis

Processing the Data

Information from the time logs was totaled into cost (time spent

by the supervisor) and benefit (time given by the student for patient

treatment and other duties). The costs were multiplied by the

average hourly charge for treatment in the participating clinical

sites, or

C = T(G+M+P+I)


C = Cost
T = Hourly treatment charge
G = General one-to-one supervision
M = Meetings
P = Preparation and administration
I = Formal instructional sessions

Benefit was determined by multiplying time spent in patient

treatment (both individual and group) by the hourly treatment charge,

time spent in meetings and administrative duties by the average

therapist's hourly salary, and time spent in clerical or aide duties

by the minimum wage. This is more clearly represented by the following


B = T(PI+PJ)+S(A+M)+W(D)


B = Benefit
T = Hourly treatment charge
PI = Individual patient treatment (time)
PJ = Joint or group patient treatment (time)
S = Average hourly salary for an
occupational therapist
A = Administrative work (time)
M = Meetings (time)
W = Minimum wage
D = Clerical or aide duties (time)

The net present value (NPV) for each student/supervisor pair was

determined by subtracting the cost as calculated above from the



A positive value indicated an overall benefit in the student/supervisor

pair, while a negative value NPV indicated an overall cost for that

week of observation.

Statistical Analysis

The reader will recall there were two basic questions which

gave direction to the study. The first was, is there a cost or

benefit accrued by clinical fieldwork sites as a result of occupational

therapy Level II bachelor's-level student placement, basic

master's-level student placement, and bachelor's-level and basic

master's-level placements combined? In order to answer this

question, simple descriptive analysis of the data in the

questionnaires and fieldwork time logs was carried out.

Results from the site questionnaires, returned anonymously,

were used to determine the average salary paid to occupational

therapists who participated in the study (the clinical supervisors)

and the average charge for one hour of treatment in the clinical

sites. This information, in turn, was utilized in calculating the

dollar value of time spent by students and supervisors and,

subsequently, arriving at the net present value of the fieldwork


As mentioned in the previous section, the total cost, consisting

of the dollar value of time spent in direct supervision, teaching,

meetings, and administration was subtracted from the total benefit,

consisting of the dollar value of direct and joint treatment,

administrative duties, meeting attendance, and clerical/aide duties.

This calculation resulted in the net present value, or NPV, for each

student/supervisor pair. Mean weekly NPVs were determined for

bachelor's-level fieldwork, master's-level fieldwork, and overall

fieldwork (both groups combined). A negative mean NPV was indicative

of greater cost than benefit in the fieldwork, while a positive mean

NPV indicated that the fieldwork placement generated a financial

benefit to the clinical sites. These calculations served to answer

the first question posed in the research.

Of concern in the research was the influence of degree level

(bachelor's or basic master's) on the net present value of the

fieldwork placement. It was also suspected that other factors,

in addition to degree level, might also have an influence on the

NPV. Age, for example, might be related to a higher NPV since the

greater life experiences and maturity of the older students might

enable them to function more independently thus bringingg greater

financial benefit to the fieldwork site. Along these same lines,

students on their second or third fieldwork assignments might also

generate greater benefits than those in their first fieldwork

placements. The type of fieldwork placement was also viewed as

having a possible effect on the NPV. It is conceivable, for example,

that certain types of fieldwork placement, more than others, would

encourage (or restrict) independent student activities thereby

affecting the NPV. Finally, the cost or benefit realized might

also be related to the week of fieldwork. As the student becomes more

familiar with the fieldwork site and the assignments involved, it is

realistic to expect increased benefit for the clinical site as a

result of the student's presence.

In order to take into consideration the influence of such

factors, a special analysis of covariance application of multiple

regression analysis was used. This method of analysis enables one

to model an interval dependent variable (in this case, NPV) "in

terms of both interval level and categorical independent variables"

(Agresti & Agresti, 1979, p. 458). Analysis of covariance as a

regression procedure is useful in testing the significance of

differences between group means after controlling for initial mean

differences on covariates or concomitant variables (Kerlinger, 1973;

Kerlinger 4 Pedhazur, 1973). Covariates included in the analysis

were (a) age of student, (b) type of fieldwork experience, (c) number

of fieldwork experiences of the student, and (d) the week of

fieldwork in which data were collected. More specifically, the

multiple regression analysis was utilized to determine the significance

of each of the independent variables in predicting net present value

while simultaneously controlling for the other covariates. This

analysis served to answer the second question that was posed in the

planning of the research.

The following equation represents the full regression model for


Y = a + BlX1 + B2X2 + B3X3 + B4X4 + B5X5 + B6X6 + B7X7 + B8X4 + e


Y = net present value
a = constant
X1 = age of student
X2 = dummy variable for degree level
(1, if bachelor's; 0, if master's)
X3 = number of fieldwork experiences student
has had
X4 = week of fieldwork
X5, X6, and X7 = dummy variables for type of fieldwork (physical
dysfunction, psychiatry, pediatrics, and
X8 = quadratic variable for week of fieldwork
E = error
Bl . B8 = coefficients for the independent variables and
the quadratic variable

As preliminary procedures to the regression analysis, certain

tests were implemented to check for violations of the assumptions

of normality, homoscedasticity, and linearity. In addition, testing

for interaction between the variables is a procedure required in

analysis of covariance. This testing involved the construction of

a number of residual scatter plots prior to the multiple regression

procedures. In addition to the examination of scatter plots, a

quadratic variable was added to the regression equation above and

the regression analysis since a curvilinear relationship between week

of fieldwork and the dependent variable was highly suspected.

Following are the operational null hypotheses related to question

2 that were tested at the .05 level. Hypotheses 1 through 3 test for

the significance of the covariates age, degree level, and number

of fieldwork experiences in predicting NPV. Hypothesis 4 tests for

the presence of the curvilinear relationship between week and NPV,

while hypothesis 5 tests the significance of increase in the

coefficient of determination when the different types of fieldwork

(dummy variables X5, X6, and X7) are added to the regression analysis.

1. Controlling for the covariates degree level, number of

fieldwork experiences, type of fieldwork, and week of fieldwork,

age of student is not a predictor of net present value.

2. Controlling for the covariates age, number of fieldwork

experiences, type of fieldwork, and week of fieldwork, there is no

difference in the mean net present values between bachelor's-level

and basic master's-level students. (HO:B2=0)

3. Controlling for the covariates age, degree level, type of

fieldwork, and week of fieldwork, there is no difference in the net

present values between the number of fieldwork experiences.


4. Controlling for the covariates age, degree level, number

of fieldwork experiences, and type of fieldwork, there is no

curvilinear relationship between week of fieldwork and the NPV.


5. Controlling for the covariates age, degree level, number

of fieldwork experiences, and week of fieldwork, there is no

difference in the net present values for students in different

types of fieldwork placements. (HO:R2FM-R2RM=0)

A rejection of null hypothesis 5 would indicate further

hypothesis testing as follows:

5a. Controlling for the covariates, there is no significant

difference between the adjusted means for physical dysfunction

fieldwork placements and pediatric placements. (HO:B5=0)

5b. Controlling for the covariates, there is no difference

between the adjusted means for physical dysfunction placements and

psychiatric placements. (HO:B6=0)

5c. Controlling for the covariates, there is no difference

between the adjusted means for physical dysfunction placements and

geriatric placements. (HO:B7=0)

The data were analyzed through the use of an IBM 3033N computer

located at the Northeast Regional Data Center, utilizing the


Terminal Computer Package (TCP) operating system (Northeast

Regional Data Center, 1982). Statistical analysis was carried

out using the SAS statistical analysis package (Helwig, 1983;

SAS Institute, 1985). Appendix F shows the computer program cards

as they were set up for the data analysis.


In the present chapter, the results of the descriptive and

multiple regression analyses are presented. A summary of responses

to the site questionnaire is given in the first section because the

calculation of the net present value (NPV) was dependent upon

information received from this source. This is followed by an

overview of the participant responses, which includes a description

of the distribution of participants within the educational programs

that cooperated with the study. Next, the results of the calculations

of overall weekly mean net present values as well as the weekly

mean NPVs for bachelor's-level and basic master's-level placements

is presented in order to address the first question of the study.

In addition, tables showing mean weekly net present value (the

dependent variable) on each of the independent variables (age of

student, degree level, type of fieldwork, number of fieldwork

experiences, and week of fieldwork) are included.

The third part of the chapter focuses on the second question

of the study and presents the results of the multiple regression

analysis. This includes the tests for violations of assumptions

of the regression analysis, the polynomial variable, and the

significance of each of the independent variables in their prediction

of the NPV (Kerlinger & Pedhazur, 1973).

Site Questionnaire Responses
Relative to Charges and Salaries

Site questionnaires were returned from 167 clinical fieldwork

locations. Of these sites, 149 provided information relative to the

yearly salary of supervising occupational therapists, and 95 provided

estimates of the hourly occupational therapy treatment charges. A

number of the site respondents were unable to provide information

relative to hourly treatment charges since costs for occupational

therapy were included in an overall per diem charge for the hospital

treatment. This appeared to occur most frequently in responses from

psychiatric facilities.

In order to be used in the computation of NPV, the values for

salary and treatment charges were averaged with the annual salary

prorated to an hourly figure. For the sites participating in the

study, the average hourly treatment charge was found to be $61.35

and the average hourly therapist salary was $11.38. These results

were then inserted into the formulas used to calculate the NPV for

each student/supervisor pair. Results of the calculations for the

cost, benefit, and NPV of the individual student/supervisor pairs

are listed in Appendix G.

Descriptive Analysis

Of the 181 student/supervisor pairs dyadss) included in the

statistical analysis, 130 were from pairs with bachelor's-level

students and 51 were from pairs with basic master's-level students.

Table 1 depicts the number of student/supervisor pairs that

responded from each participating educational program compared to

the total pairs per program. Number of pairs per program ranged

from a low of 4 from the University of North Carolina to a high

of 28 from The Ohio State University.

Means and standard deviations were calculated on the overall

NPV across all levels of the independent variables, as well as the

NPV for each condition of the independent variables. Results of these

calculations are presented in Tables 2-6.

The first question put forth in this research was, is there a

cost or benefit accrued by clinical fieldwork sites as a result of

occupational therapy Level II bachelor's-level placement, basic

master's-level placement, bachelor's and basic master's-level student

placements combined?

The results of the analysis clearly indicate that the clinical

sites derive a financial benefit from Level II fieldwork placement

of both bachelor's and basic master's-level students in their

facilities. Table 2 shows an average weekly benefit of Level II

fieldwork of the combined bachelor's and basic master's-level

fieldwork amounting to approximately $397. When the weekly NPVs

shown in Table 4 are added together, the average benefit for a

13-week fieldwork placement is approximately $4850, or $4700 for a

12-week placement.

Table 1

Number of Student/Supervisor Pairs from Each Educational

Program Degree Pairs Pairs in
(B or M) Participating Program
(N=181) (N=384)

Eastern Michigan University B 23 49

Medical University of
South Carolina B 9 20

Ohio State University B 28 58

San Jose State University B 19 42

Texas Women's University M 20 40

University of Alabama B 8 26

University of Florida B 20 28

University of North Carolina M 4 10

University of Southern
California M 7 16

University of Wisconsin-
Madison B 23 51

Virginia Commonwealth
University M 10 21

Western Michigan University M 10 23

Table 2

Overall Weekly

Mean NPV (expressed in dollars)

N Mean Standard Minimum Maximum Standard Error
Deviation Value Value of the Mean

180 397.02 639.56 -1413.00 2069.00 47.66

Table 3

Weekly Mean NPV (expressed in dollars) by Degree

Degree Mean Standard Minimum Maximum Standard Error
Deviation Value Value of the Mean

n=129 389.07 648.42 -1413.00 2069.00 57.09

n=51 417.12 622.41 -694.00 1679.00 87.15


Table 4

Overall Weekly Mean NPV (expressed in dollars) by Week of

Week Mean Standard Minimum Maximum Standard Error
Deviation Value Value of the Mean

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Week 9

Week 10

Week 11

Week 12

Week 13


































































Table 5

Weekly Mean NPV (expressed in dollars) by Number of
Fieldwork Experiences

Experience Mean Standard Minimum Maximum Standard Error
Deviation Value Value of the Mean

n=116 381.85 629.24 -986.00 2069.00 58.42

n=57 440.23 651.27 -1413.00 1934.00 86.26

n=3 88.00 196.85 -138.00 222.00 113.60

Note. There were four responses with no designation for number of
fieldwork experiences.

Table 6

Mean NPV (expressed in dollars) by Type of Fieldwork

Type Mean Standard Minimum Maximum Standard Error
Deviation Value Value of the Mean

n=77 520.47 734.50 -1413.00 2069.00 83.70

n=8 63.63 388.99 -694.00 659.00 137.50

n=91 315.57 547.60 -986.00 1347.00 57.40

n=4 540.25 688.14 -475.00 1014.00 344.00

Table 3 shows average weekly NPV broken down into bachelor's

and basic master's-level fieldwork. These results indicate a

positive value NPV (or benefit) at both educational levels.

Average weekly benefit of bachelor's-level placement came to

$389.07, while the average weekly benefit of master's-level

placement was $417.12.

Tables 4, 5, and 6 further illustrate the relationship between

the NPV and the different levels of the independent variables

week of fieldwork, number of fieldwork experiences, and type of

fieldwork. Table 4 demonstrates that early in the fieldwork

experience, the fieldwork assignments were costly to the clinical

sites as indicated by the negative NPVs for weeks 1 and 2; in the

succeeding weeks the NPVs became positive, reaching a high of

$858.06 in week 9. The last week (or exit week) of the 12-week

fieldwork assignments ended with an average NPV of $731.25 from

eight student/supervisor pairs. The median of this group of

observations was $642. The mean NPV in the last week in a 13-week

fieldwork experience was $144.67, with a median of $282 in the

three pairs included in this group. The difference in these two

exit weeks may simply be due to the low n in the 13-week group

(only three pairs) causing skewing of the data. On the other hand,

there may be some real differences existing between the final week

of the 12-week versus the 13-week fieldwork placements. Further

research with greater numbers of subjects in both groups would be

required to determine the nature and extent of possible differences

between the two groups.

Tables 5 and 6 indicate that different NPVs were found

depending on the number of fieldwork experiences the student

had and the type of fieldwork experience encountered. For

example, students in their first fieldwork experience had an

average NPV of $381.85 per week, while students in their second

fieldwork experience had a weekly average NPV of $440.23.

Students in their third fieldwork experience had an average NPV

of $88; it must be noted that two of the three observations in

this group occurred in the first two weeks of the fieldwork,

yielding a low (and somewhat misleading) NPV. In addition, students

in physical dysfunction clinical sites had an average NPV of

$520.47, while results from students in pediatric clinical sites

demonstrated the lowest weekly NPV for the different types of

fieldwork with an average of $63.63.

The final variable of interest in the study was student age.

As mentioned previously, it was of interest because of the possible

influence on the NPV brought about by the increased life experiences

and maturity of the older students. Student respondents ranged in

age from 22 to 45 years of age. The mean student age was 25 years,

the mode was 22, and the median age was 23.

Multiple Regression Analysis

The second question to be answered by this research was,

when other selected relevant variables are held constant, to what

extent are there differences in the NPV in (a) bachelor's and basic

master's-level placement, (b) week of fieldwork experience, (c) type

of fieldwork, (d) number of fieldwork experiences, and (e) age of


In order to answer this question a special analysis of

covariance application of multiple regression analysis was used

and five basic null hypotheses were projected. The results of

the regression analysis are reported in this section. They are

preceded by the results of the testing for violations of

assumptions which must be evaluated when using this statistical


Testing of Assumptions

The scatter plots that were constructed showed no major

violations of the assumptions of normality, homoscedasticity, or

linearity. No interaction was found between the covariates.

However, results of previous research by Chung et al. (1980)

indicated the presence of a curvilinear relationship between week

and the net present value. On the basis of earlier findings, the

quadratic model was used for the statistical analysis in spite of

a normal-appearing scatter plot. (Results indicated that this

approach was justified since the coefficient on the quadratic

variable listed in Table 7 was found to be significant at the

p < .05 level.)

The scatter plots were also used to determine the presence of

outliers. One outlier was found and eliminated from the data set

based on the fact that its residual was well beyond four standard

deviations from the regression line (Younger, 1979).

Testing the Null Hypotheses

Using the SAS computer subprogram REG, the data were analyzed

to determine the significance of each of the independent variables

in predicting the net present value. The probability of a Type I

error was preset at .05. Total number of subjects in this

analysis was 173 after 7 observations were excluded by the

computer because of missing data and the one outlier mentioned

earlier was eliminated from the data set. Table 7 lists the

results of the computer analysis.

Of the independent variables that were built into the model,

the variables number of fieldwork experiences, type of fieldwork,

and week of fieldwork were found to be statistically significant

in the prediction of net present value. On the other hand, the

age of the student and degree level were found not to be significant

in predicting NPV.

More specifically, the variable "age of student" was found to

be unrelated to the net present value (p < .7553). In other words,

whether the student was older or younger had no particular

relationship to whether the fieldwork placement was a cost or

benefit to the clinical site. The lack of significance of this

variable supports the retention of null hypothesis 1.

Moreover, the results indicate that the degree level of the

student, either bachelor's or master's, bore no relationship to

the resulting NPV. While the descriptive data showed a slightly

higher NPV for master's-level students, the statistical analysis

Table 70

Results of the

Multiple Regression Analysis

Source Df Sum of Mean R-Square
Squares Square

Regression 8 23150884 2893861 .335

Error 164 45949790 280182

Total 172 69100674

Parameter Estimate Standard Error p Value

Intercept -859.10 333.70 .0109

Age 2.78 8.92 .7553

Degree -74.42 101.62 .4650

Fieldwork experience 194.64 87.61 .0277*

Week 290.89 52.61 .0001*

Week 2 (polynomial) -15.20 3.90 .0001*

X5 (Ped-PD) -605.91 219.79 .0065*

X6 (Psy-PD) -166.07 84.34 .0506

X7 (Ger-PD) -144.40 277.02 .6029

Note. *p < .05
PD physical dysfunction fieldwork
Ped pediatric fieldwork
Psy psychiatric fieldwork
Ger geriatric fieldwork

reveals no significant difference between the two groups (p <

.4650). These results indicate that null hypothesis 2, which

states that when controlling for the other variables there is no

difference in the mean net present values between bachelor's and

basic master's-level students, should be retained.

The results indicate a significant, direct relationship

between the number of fieldwork experiences and the net present

value (p < .0277). That is, students who are on their second or

third fieldwork assignments bring greater financial benefits to

the fieldwork sites than are students who are on their first

fieldwork assignments. The parameter estimate for number of

fieldwork experiences in Table 7 shows that when the other

variables are controlled, students in their second fieldwork

assignments can be expected to generate approximately $194 more

in weekly benefits to the clinical sites than those in their first

fieldwork assignments. The significance of the variable "number

of fieldwork experiences" serves to reject null hypothesis 3 which

states that when controlling for the covariates age, degree level,

type of fieldwork, and week of fieldwork, there is no difference

in the net present values between the number of fieldwork experiences.

The week of fieldwork was found to be a strong predictor of

NPV with significance found at the .001 level. A curvilinear

relationship exists between this variable and the NPV, as indicated

by the significant coefficient on the polynomial variable Week 2.

The nature of the general relationship between week and NPV is

clearly depicted in Figure 1, where a hypothetical case is taken

in which the age is set at 22, the fieldwork placement is in a

physical dysfunction setting, with bachelor's-level students in

their first fieldwork assignment.

As illustrated in Figure 1, the NPVs begin to take on

positive values at approximately the third week of the fieldwork,

indicating that when other variables are controlled, the fieldwork

placement begins to bring about a dollar benefit by the fourth week.

The NPVs tend to increase for the next several weeks, then they

level off and decline. The decrease in benefit in the 12th and 13th

weeks of the fieldwork may be related to the conclusion of the

fieldwork itself, when supervisors are required to increase their

time investment in student evaluation procedures and students are

disengaging from patient treatment activities.

While the shape of the curve would be expected to remain

unchanged, students on their second or third fieldwork experiences

would be expected to bring about a benefit earlier in the fieldwork

placement and, as is explained in reference to null hypothesis 5,

students in pediatric fieldwork placements would be expected to

show a benefit later in the fieldwork placement. The results of the

above analysis support the rejection of null hypothesis 4 which

states that when controlling for the covariates age, degree level,

number of fieldwork experiences, and week of fieldwork, there is

no curvilinear relationship between week of fieldwork and the NPV.

0 a










-400 *


------1-- 2-- 3-- 4--5--6--7--8--9-- 10--11--12--13

Relationship of Week to NPV when other variables are held

Note. Age=22, physical dysfunction fieldwork, bachelor's level
students, first fieldwork experience.


Figure 1.

Finally, the analysis reveals that there is a relationship

between the type of fieldwork experience and the resultant benefit

to the clinical site. The significance of the qualitative variable,

"type of fieldwork," was evaluated using an F test on the relative

increase in the coefficient of multiple determination (increase in

R2) between the full model with the four levels of "type of fieldwork"

variable included and the reduced model without the "type of fieldwork"

variable. A significant increase in the R2 indicates significance in

the type of fieldwork as a predictor of the NPV. Table 8 lists the

results of this analysis.

Table 8

Test of Significance: Type of Fieldwork

Model R2 F Df

Full .3350
(With type of fieldwork

Reduced .2962
(Without type of fieldwork)

Difference .0388 3.19* 3, 164

*E < .05

The significant increase in R' as a result of the inclusion of

type of fieldwork in the regression model serves to reject null

hypothesis 5 and requires examining more closely differences between

the types of fieldwork (null hypotheses 5a, 5b, 5c; parameters

X5, X6, and X7 shown in Table 7). The comparison of physical

dysfunction fieldwork placements with each of the other types of

placements (pediatric, psychiatric, and geriatric) resulted in a

significant difference only between physical dysfunction and pediatric

placements. An average difference in NPV of approximately $606 per

week of fieldwork was found between physical dysfunction and pediatric

fieldwork assignments with physical dysfunction providing the greater

benefit. It is also interesting to note, however, that while no

significant difference was found between physical dysfunction

assignments and psychiatric assignments, the criterion for significance

was missed by a very small amount (p < .0506). With reference to null

hypotheses 5a, 5b, and 5c, these results support the retention of

hypotheses 5b and 5c and the rejection of 5a.



The primary purpose of the study was to determine whether the

placement of Level II occupational therapy fieldwork students in

clinical facilities brings about a net cost or benefit to the

facilities. The secondary purpose was to determine what other

factors are related to the costs or benefits of fieldwork placement.

More specifically, there were two basic questions to be

answered by this study.

1. Is there a cost or benefit accrued by the clinical fieldwork

sites as a result of occupational therapy Level II bachelor's-level

placement, basic master's-level placement, and bachelor's-level and

basic master's-level student placements combined?

2. When other selected relevant variables are held constant,

to what extent are there differences in the NPV in (a) bachelor's

and basic master's-level placement, (b) week of fieldwork experience,

(c) type of fieldwork, (d) number of fieldwork experiences, and (e)

age of student?

In relation to the second question, five basic null hypotheses were


Subjects for the study were recruited from 12 occupational

therapy education programs in the United States. Seven of these

programs were bachelor's-level, five were basic master's-level.

Participants were the students from these programs assigned to

Level II fieldwork during the summer of 1985, and their respective

clinical supervisors in the fieldwork sites.

A means of measuring costs and benefits was developed through

the use of time logs which were designed to measure time investment

in preparation, planning, and direct student supervision on the

part of the student supervisor (costs), and in direct patient

treatment and performance of clinic duties on the part of the

students (benefits). These logs were developed using earlier logs

from previous research as models. In addition, a site questionnaire

was also developed to provide needed information to attach dollar

values to the various aspects of costs and benefits of clinical


Information concerning the time expenditures of the students

and supervisors was obtained by sampling different weeks of the

fieldwork placements. Each student/supervisor pair was asked to

complete logs for up to three different weeks of the fieldwork

period. It was necessary to receive at least one complete pair of

logs (both student and supervisor logs returned with data collected

for at least one week) for the data to be used in the final analysis.

A total of 181 student/supervisor pairs met this criterion and were

included in the analysis. Two basic forms of analysis were used.

First, descriptive analysis was used in question one, and a covariate

form of multiple regression analysis was used to answer question


From the descriptive statistics calculated on the raw data,

it was found that the average weekly NPV for bachelor's-level

students was $389.07; for basic master's-level students it was

$417.12; and for bachelor's and basic master's-level students

combined it was $397.02. Since all are positive values, the response

to question one is that the placement of students in the Level II

fieldwork resulted in a clear benefit to the clinical sites. The

sum of the overall mean weekly NPV's for the entire fieldwork period

indicated a benefit ranging from $4700 to $4850, depending on the

length of the fieldwork experience.

From the covariance form of the regression analysis the following

null hypotheses relative to the second basic question were retained:

Controlling for the covariates degree level, number of fieldwork

experiences, type of fieldwork, and week of fieldwork, age of student

is not a predictor of net present value.

Controlling for the covariates age, number of fieldwork

experiences, type of fieldwork and week of fieldwork, there is no

difference in the mean net present values between bachelor's-level

and master's-level students.

Controlling for the covariates, there is no difference between

the adjusted means for physical dysfunction placements and psychiatric


Controlling for the covariates, there is no difference between

the adjusted means for physical dysfunction placements and geriatric


Furthermore, the following null hypotheses relative to the

second basic question were rejected at the p < .05 level.

Controlling for the covariates age, degree level, type of

fieldwork, and week of fieldwork, there is no difference in the

net present values between the number of fieldwork experiences.

Controlling for the covariates age, degree level, number of

fieldwork experiences, and type of fieldwork, there is no curvilinear

relationship between week of fieldwork and the NPV.

Controlling for the covariates age, degree level, number of

fieldwork experiences, and week of fieldwork, there is no difference

in the net present values for students in different types of

fieldwork placements.

Controlling for the covariates, there is no significant difference

between the adjusted means for physical dysfunction fieldwork

placements and pediatric placements.

Said another way, from the statistical analysis it was learned

that there was no significant difference in the benefits generated

by bachelor's and basic master's-level students, even though the

descriptive data indicated a slightly higher benefit for the basic

master's-level students. In addition, age apparently had no influence

on the resultant net present value during the student fieldwork


The analysis also revealed that type of fieldwork, the number

of fieldwork experiences, and week of fieldwork were all directly

and significantly related to the dependent variable, the net present

value. More specifically, it was found that there was a positive

NPV to the clinical site after the third week of the fieldwork

placement and that benefits continued to increase in magnitude until

the final two to three weeks of the fieldwork placement. A slight

decrease in the benefit was noted after the llth week, which is

probably the result of specific activities that occur during the

final weeks of fieldwork.

Further, it was determined that the particular type of fieldwork

was related to the amount of benefit that was generated. The

fieldwork placement in a physical dysfunction setting yielded greater

benefits to the institution than that in the pediatric setting.

Results from the other two types of fieldwork settings included

(psychiatry and geriatrics) showed similar benefits to those of

physical dysfunction. Finally, it was learned that the second and

third fieldwork experiences of students generated greater benefits for

the institution than the first fieldwork experiences.


Based on the questions and hypotheses that gave direction to the

study, and the results, the following conclusions may be drawn:

1. A reasonably extended fieldwork experience does not constitute

a cost to the institution, rather it is a benefit.

The sixth or seventh week appears pivotal in that at this point

the presence of the student becomes a clear financial benefit to

the site, regardless of student related variables. This benefit

may accrue slightly earlier in the case of physical dysfunction

settings. However, a fieldwork experience of less than five weeks

will probably constitute a cost to the fieldwork site in terms of

the value of personnel time.

2. There is no relationship between age of student and the

value of the benefit of the fieldwork placement.

Again, maturity and possible increased life experiences apparently

are no particular advantage in this situation and have no significant

effect on the overall net present value.

3. There is no difference in the value of the benefit between

bachelor's and basic master's-level students.

The performance of both of these groups in the fieldwork setting

is statistically the same. It appears that the additional experiences

of basic master's-level students offer no real advantage, perhaps

due to the fact that this experience is often unrelated to the

practice of occupational therapy. It is important to mention that,

while this information may be helpful in evaluating the relative value

of bachelor's-level and basic master's-level education, to draw

conclusions based on these results alone would be erroneous and should

be avoided.

4. There is a positive relationship between the number of

fieldwork experiences and the value of the benefit.

That is, students in their first fieldwork experiences had

positive mean NPVs. However, students with two or three fieldwork

experiences generated greater NPVs for their facilities than

students on their first fieldwork assignments.

5. There is a strong curvilinear relationship between the

week of fieldwork and the net present value.

Level II student placement in the fieldwork site generally

incurs a cost to the institution for the first two to three weeks,

but soon these costs are recovered and a benefit is generated by

approximately the sixth week. Benefits continue to increase for the

next three to four weeks, then level and decline in magnitude at

the conclusion of the fieldwork experience.

6. There are differences among the types of fieldwork settings

relative to the value of the benefit of student placement.

Student fieldwork placement in physical dysfunction settings

brought about a significantly greater benefit than those in pediatric

settings. While no significant difference was found in the NPVs

between physical dysfunction and psychiatric placements, it should be

noted that the actual p value was .0506, narrowly missing the rejection

of the null hypothesis of the comparison of these two types of


Although not directly related to the questions/hypotheses that

gave direction to the study, as a result of this investigation it

seems appropriate to conclude that, while generally utilized for more

global assessments of programs, cost-benefit analysis is also quite

useful and appropriate in evaluating programs on a much smaller scale.

It appears to be particularly helpful in establishing some

quantifiable measures in a field in which evaluation is usually

carried out in more affective, qualitative ways.


The external validity of the study was weakened by the

nonrandomization of its participants and further by the fact that

participation was voluntary. Attrition of subjects was also a

threat to external validity in that it raised the possibility of

biased responses. However, if one accepts the assumption that

occupational therapy programs are similar due to the constraints and

requirements placed on them by the national accrediting agency, then

with the reasonable rate of return from participants associated with

the programs included, it could be argued that the study had a high

degree of external validity.

The use of questionnaires and logs that relied on self-reporting

methods also introduced further threats to both internal and external

validity. Participant misunderstanding of questions asked was a

risk, with little opportunity to clarify or check the answers that

were given.

A third and major limitation of the study relates to the fact

that the cost-benefit analysis was confined to costs based on

personnel time. The decision to design the study in this manner

was based on the notion, supported by previous research, that the

impact of space and overhead costs were nil and the inclusion of

factors such as student stipends and payments for room and board in

the overall model would introduce error because of their occasional,

rather than across-the-board occurrence. This was further complicated

by the anonymous nature of the site questionnaire which was used to

obtain supervisor salary information and site treatment charges as

well as room, board, and stipend information. As a result, it was

not even possible to use the room, board, and salary data in calculating

the cost-benefit equation for a specific student/supervisor pair.

Rather, this information was collected simply to determine the

number of sites in the study that provided these student perquisites

and the average dollar value of these factors in order to note possible

influence on the average weekly NPVs.

Based on the information from the site questionnaire, it was

found that 67 (or 40%) of the 167 sites responding provided room

and/or board for students. This amounted to an estimated cost of

$36 per week for the sites providing room/board. Only 10 sites (6%)

reported paying students a stipend during the fieldwork, costing

these sites an average of $75 per week. Finally, an additional 10

sites indicated that they provided both room/board and stipends, valued

at an average cost of $58 per week for these 10 sites.

In spite of the exclusion of the above factors from the cost-

benefit equation, it is believed that because of the relatively

small magnitude of these factors, the overall conclusion of the

investigation would remain the same. The practical effect of

providing room, board, or stipends would be to delay the time in which

a benefit would be realized by the clinical site or to decrease the

overall magnitude of the benefit to the clinical site.

A final limitation of the study is that cost-benefit analysis

represents but one type of economic analysis. It is limited in that

it requires a dollar value assignment to factors identified as

costs or benefits. As such, many important qualitative variables

escape valuation and are excluded from the cost-benefit equation.

Suggestions for Further Research

Based on the results of the study and the review of the

literature, the following suggestions for further research are


1. Further research is suggested for the study of additional

costs of fieldwork that occur in the form of student stipends and the

provision of room, board, and other student assistance measures.

Research which would include these factors at the individual

institutional level would serve to determine more definitively the

effects they may have on the net present value of the fieldwork

placement. This could be accomplished through a cost-benefit analysis

and comparison of groups that do, and do not, provide these additional

student perquisites.

2. Replication of this study would also be useful in determining

the consistency of these results over time and with new sets of


3. A study that would examine more closely the effect of type

of fieldwork on the net present value is also indicated. Research

in which subjects are more equally distributed in a variety of

fieldwork settings would give more conclusive information relative

to the impact of this factor.

4. As previously stated, this research failed to show a

difference in the benefits between bachelor's-level and basic

master's-level students. This is consistent with the occupational

therapy professional view that both programs produce entry-level

personnel. However, with considerations being made of upgrading

professional entry requirements, it is necessary that occupational

therapy educational and professional leaders identify what is to be

gained, from an institutional and societal point of view, by

increasing such requirements. Some justification will need to be

made in light of the increased costs associated with master's-level

education and the higher salaries that will likely be demanded.

Research centering on qualitative differences between bachelor's-level

and master's-level personnel may be productive. Further quantitative

research in the areas of productivity analysis or a longitudinal

comparison of retention rates of these two groups in the profession

may also yield useful information. It is important to consider the

research reported here as a starting point for further inquiry.


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Sample Cover Letter

Route 2, Box 35E12
Archer, FL 32618

March 11, 1985

Elizabeth J. Yerxa, Ed.D., OTR
Chair, Department of Occupational Therapy
University of Southern California
12933 Erickson Avenue
Downey, CA 90242

Dear Dr. Yerxa:

May I have the cooperation of your program for the research study,
"The cost/benefit for the entry level bachelor's and master's
occupational therapy programs in Level II fieldwork placements"?

In 1983, Eastern Michigan conducted a similar study with their
students at the bachelor's level. The results were interesting, and
they concluded that a larger study comparing the bachelor's and
master's programs should be undertaken by another researcher. Thus
the purpose of this study and my requesting your cooperation. As you
realize, our profession has a problem developing larger n's in many of
their studies, one of the weaknesses of the Eastern Michigan research.
It is essential for meaningful results that a number of O.T. schools
cooperate in this study.

What is involved? I will work directly with your Fieldwork
Supervisorss. The students in your master's program on fieldwork
placement this summer will be asked to keep a simple log for a week
at the beginning, middle, and end of a single affiliation. The log
will take approximately 10 minutes per day. The supervising clinician
will be asked to complete a similar log, under the same arrangement.
The completed logs will be returned to me. I will supply the forms
for the logs. Essentially, that is it!

If you consider this study worthwhile and feel you can cooperate,
will you kindly return the enclosed questionnaire. I will be at the
annual conference from April 13th to 19th. Monday, April 15th,
appears to be the best day for me to make direct contact with those
of you who will be participating.

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