Abstract
This study explored the experiences of belonging and adversity among entry-level occupational therapy doctorate students.
When transitioning to a new graduate program or job, individuals often ask themselves, “Do I belong here?” (Baumeister & Leary, 1995; Walton & Cohen, 2007). Emerging research indicates that resolving this question is critical, because a strong sense of belonging in higher education is linked to improved academic performance, retention, and psychological health, with both immediate and long-term benefits (Binning et al., 2020; Brady et al., 2020; Walton & Cohen, 2011). Belonging, defined as one’s sense of social connectedness to others, also influences physical health, emotional well-being, self-efficacy, job satisfaction, and career leadership (Brady et al., 2020; Logel et al., 2021; Walton & Cohen, 2011). In occupational therapy education, belonging is vital for success in academic and clinical settings (Tyminski et al., 2023).
Although there are several categorizations of belonging in higher education, we addressed social belonging, or connectedness to peers, and academic belonging, or perceived degree of fit within a field of study (Walton & Cohen, 2007). These constructs are intertwined in the student experience; for example, students may feel a strong sense of social belonging (feeling part of their peer group) but experience low academic belonging (feeling unsure about their degree program). When students experience adversity or challenges, they often feel isolated in their struggles, further diminishing their sense of belonging (Binning et al., 2020).
Although belonging research focuses primarily on undergraduate students, similar patterns emerge among graduate and health care students, whose social and academic belonging are associated with each other and their perceived confidence in clinical performance (Byrom et al., 2022; Scanlan et al., 2023). In health care professions, decreased academic belonging during education can lead to feelings of inadequacy, self-doubt, imposter syndrome, and fear of being exposed as a fraud after graduation (Ogunyemi et al., 2022; Popova et al., 2023). These feelings are especially acute during new roles, such as starting fieldwork or a first job (Moir et al., 2021).
Both students and practitioners experience belonging uncertainty (Walton & Cohen, 2007) and engage in social comparisons, measuring their perceived failures against others’ successes and questioning their place in health care (Moir et al., 2021). Graduate nursing students frequently report imposter syndrome, fear of making errors, and doubts about their clinical abilities throughout their education (Scanlan et al., 2023). Research indicates these issues can persist into clinical practice (Moir et al., 2021). In a study on the clinical challenges faced by new occupational therapists, self-doubt was a key factor affecting decision-making, clinical skills use, and management of work-related responsibilities (Moir et al., 2021). Anecdotal evidence from student surveys and faculty–student mentoring meetings in our entry-level occupational therapy doctorate (OTD) program revealed a low sense of belonging, with students frequently expressing imposter syndrome and uncertainty about their place in the field.
In a recent scoping review on belonging in graduate health programs, Tyminski et al. (2023) noted that although belonging research in occupational therapy is sparse, there is a critical need to create spaces and social contexts in which all students can attain a sense of belonging. One notable low-cost, low-stakes intervention, an ecological belonging intervention, specifically addressed belonging within social contexts and aimed to establish that adversity is a norm in the learning process (Binning et al., 2020). This intervention effectively improved undergraduate student performance, retention, and self-reported health and well-being (Binning et al., 2020; Hammarlund et al., 2022; Walton & Cohen, 2011). Although the issue of belonging also affects graduate students, few instructional practices and programs address social and academic belonging among this population. Hence, targeted interventions to support graduate students’ sense of belonging and help them navigate their educational journeys are needed to promote success.
Our study aimed to address this gap through focus groups to investigate students’ experiences of social and academic belonging and how graduate-level OTD students manage adversity when experiencing these constructs. Insights into these experiences can inform curriculum development to increase belonging, reduce imposter syndrome, and enhance student well-being in occupational therapy programs. Study findings informed the development of a tailored three-session ecological belonging program, Supporting Hardiness and Inclusion for New Endeavors (SHINE), to integrate into an OTD curriculum.
Method
Design
We used a qualitative descriptive methodology with a constructivist paradigm to explore OTD students’ perspectives on social and academic belonging, adversity experienced in the academic program, and imposter syndrome (Sandelowski, 2000). The methodology acknowledged belonging as a subjective phenomenon, captured diverse experiences, and reflected students’ terminology and concepts. The constructivist paradigm emphasized each student’s unique contribution to understanding belongingness. These approaches provided a rich description and understanding of students’ academic experiences to develop SHINE.
Methodological Rigor
We used several strategies throughout the study to enhance rigor. Elements of confirmability and credibility were enhanced by describing research characteristics a priori, maintaining an audit trail, triangulating data across sources, and having iterative discussions to ensure coder and theme reliability. Three occupational therapy faculty members, self-identified women with postprofessional doctorates (Avital S. Isenberg, Erin L. Mathia, and Ketki D. Raina), moderated focus groups and analyzed the data. Of these three faculty members, the principal investigator (Isenberg) and assistant program director (Mathia) have 5 and 6 yr of teaching experience in OTD programs, respectively. They each had direct contact with the students through their teaching, advising, and administrative responsibilities. Both were trained in qualitative methods and mentored by the third faculty member, Raina, an occupational therapy scientist with 18 yr of qualitative research experience. She did not have direct contact with the students on a day-to-day basis. Credibility and dependability were enhanced by using a psychologist specializing in ecological belonging interventions to assist with data analysis.
We further enhanced reflexivity by documenting our assumptions that belonging was insufficiently addressed among OTD students based on department climate surveys and anecdotal observations. We also acknowledged the power differential between faculty and students and mitigated bias by developing a focus group protocol based on research questions and prior studies (Binning et al., 2020; Walton & Cohen, 2011) and regularly discussing potential biases during data collection and analysis.
Participants
The inclusion criterion was students enrolled in an entry-level accredited OTD program. We determined a sample size of 20 students or five to six focus group sessions a priori (Table 1), planning additional interviews if thematic saturation was not reached (Hennink & Kaiser, 2022; Sandelowski, 1995). We used convenience sampling to recruit students from Yr 1 to Yr 3 via emails and class presentations for this optional study. The sample from which we were recruiting had a mean age of 26.2 yr (SD = 2.39), were primarily self-reported White women, and were not first-generation students (Table 2).
Focus Group Protocol
Demographic Characteristics of Students in the OTD Program
Note. Dash indicates data not available. OTD = occupational therapy doctorate.
Setting
We conducted study activities in an urban, public, Research Level 1 university located in the northeastern United States. The student body consists of approximately 30,000 students with an equal distribution of women and men who are primarily White. The entry-level OTD program is 3 yr in length and typically enrolls 60 students. The university institutional review board approved the study, and we obtained verbal informed consent from participants before focus groups (STUDY23020098).
Data Collection
We chose focus groups for data collection because of their alignment with qualitative descriptive methodology and the constructivist paradigm, which fosters group discussion and uncovers new perspectives (Bradbury‐Jones et al., 2009). The protocol, adapted for OTD students (Table 1), was based on literature (Binning et al., 2020; Walton & Cohen, 2011). Although it was structured, it still allowed students to share additional insights, with moderators using probes to enrich discussions and understanding of belonging (Krueger, 2014).
Focus groups were scheduled outside of classes at convenient times between April and October 2023, avoiding noncampus days, weekends, and holidays. Five in-person sessions, lasting 90 to 120 min, were held with student cohorts to explore program experiences, challenges, and strategies. Moderators fostered a safe, confidential environment by sharing their own struggles and emphasizing transparency to reduce power imbalances. Students had access to private spaces to step away if needed and could return or leave without notifying the moderators. Audio and video recordings, field notes, artifacts (e.g., postcards to self, journey maps), and demographic data via Qualtrics surveys were collected (Table 2).
Data Analysis
Moderators debriefed after each focus group to verify recording completeness and field notes. Audio and video recordings were transcribed and checked for accuracy. Data analysis used interview transcripts, field notes, and artifacts (triangulation).
We conducted a qualitative thematic analysis to capture a rich narrative of student perspectives without predetermined frameworks. Four authors (Isenberg, Mathia, Raina, and Susie Chen) analyzed data by first familiarizing themselves with the data through repeated reading and noting initial impressions. They identified meaningful segments of text, labeling them with concise codes that captured key ideas or patterns. The team reviewed the codes and through iterative discussions refined and grouped them into broader themes to reflect the underlying patterns and insights within the data. We reached thematic saturation when no new themes emerged from additional focus groups, confirming sufficient depth to understand belonging in our sample (Sandelowski, 1995). Because the themes and quotes were used for SHINE, we anonymized quotes by removing references to specific persons and events. Moderators held three additional focus groups with students not initially involved (Table 2), presenting themes to ensure they resonated with their experiences and incorporating feedback to refine and finalize the results.
Results
Fifty-one entry-level OTD students (30.7% of the student body) expressed interest via a Qualtrics survey. After 10 were excluded for scheduling conflicts, 41 students (24.7% of the student body) participated: 27 (12, 5, and 10 students from Yr 1, 2, and 3, respectively) in the focus group sessions and 14 (5, 4, and 5 students from Yr 1, 2, and 3, respectively) in the respondent validation sessions (Table 2). Groups of 4 to 6 participants were formed based on availability (five focus groups, three respondent validation groups). The sample consisted of primarily self-reported women, White, not Pell-grant recipients, or first-generation students, with a mean age between 24 and 26 yr (Table 2).
Themes related to social and academic belonging emerged, with struggles varying at three distinct time points: the first term (Yr 1), the start of Level II fieldwork (Yr 2), and the capstone experience (Yr 3). Although specific details shifted over time, social and academic belonging themes prevailed across cohorts.
Social Belonging Themes
During Yr 1, students voiced concerns about making friends, balancing school and personal life, and dealing with stressors that affected their role as students and their sense of social belonging. For example, a student said, One of my biggest fears … was being alone. I didn’t know anyone in the program, and I felt extremely isolated.… I talked it over with a friend and realized that … my social circle doesn’t define my success in life or in this program … everyone here is having the same, very overwhelming, social experience. (Yr 1, Student 1)
During Yr 2, students had concerns about the support they would receive from faculty and fieldwork educators during their fieldwork, as well as uncertainties about the supervisor–student relationship. They worried about social belonging with their mentors and how to navigate the dynamic. Although excited to begin, students found that the support for changes and struggles in fieldwork differed from what they experienced in the classroom. According to a student, My first placement … had an amazing supervisor. During my second placement my supervisor had a different teaching style … and I felt inadequate in my skills. I talked about my disappointment and feelings of inadequacy [with faculty] … and I realized that I could still learn from different teaching styles, even if it wasn’t what I was used to. (Yr 2, Student 1)
Upon the return to the classroom after fieldwork (Yr 3), students struggled with reacclimating to class after Level II fieldwork and transitioning from a fieldwork schedule to a classroom schedule. Despite knowing about the 3 yr of coursework from the start, they found it challenging to continue as students while their peers in master’s programs graduated and started working, affecting their sense of social belonging. A student shared, After completing both fieldwork placements, I was a little frustrated about going back to the classroom and needing to finish my capstone. Some of the people I had worked with were graduating and able to start working, and I wondered sometimes why I hadn’t chosen that track. However, I realized that at the end of the day, the capstone experience would make me a stronger [occupational therapist]. So even though going back to the classroom was a little challenging in the beginning, I knew that I was moving past my role of being a student and developing my identity as a practitioner. It was a time for me to reflect on my goals and interests before jumping into a job. (Yr 3, Student 1)
Academic Belonging Themes
During Yr 1, students struggled with academic belonging and questioned whether occupational therapy and graduate school were the right path for them. A student explained, There were a lot of times during the first year … that I wondered whether I deserved to be at [school name] OT [occupational therapy].… When I got into [school name] OT, I was really shocked.… Even through the first few terms, I still heard those voices and doubts of those around me, including my own self-doubt.… I needed to stop comparing myself to those around me and to be proud of myself. I know it’s normal to feel that imposter syndrome in a new situation … but I had to train myself to remember that [school name] OT chose me. As long as I’m passionate about my learning and being an OT, I’ll be okay. (Yr 1, Student 2)
At the start of Yr 2, students expressed both worry and excitement about beginning Level II fieldwork placements, which affected their sense of academic belonging. A student shared, I was a little nervous before we started fieldwork in the second year … you realize you have to actually apply what you’ve been learning with real patients. I remember thinking that I might mess up or not be taken seriously.… There were definitely challenging moments and moments of uncertainty, and even frustration, but in the end, I came out of fieldwork with all of these new clinical skills I didn’t know I had before. My fieldwork experiences really pushed me to gain independence and confidence as a clinician, and to learn to be comfortable with being uncomfortable. (Yr 2, Student 2)
As graduation approached, students were excited but anxious about starting as entry-level therapists. They voiced concerns and self-doubt about passing the national board certification exam and their competence as clinicians in entry-level practice. Despite feeling a stronger sense of social and academic belonging, they still worried about being an imposter and belonging in the workplace. As a student described, Going into my final year, I didn’t really feel like an expert in anything. I started to get nervous thinking about the fact that graduation was close and that I would soon have my own caseload. By that point, I wouldn’t have done a manual muscle test in over a year—would I even remember how? I shared these doubts with an [occupational therapist] who was a recent graduate … they said they remembered feeling the same uncertainty, but that it was like riding a bike, you get in front of a patient after a year and just know what to do… . They told me to remember that I have an extensive skill set that I can use to help people and … that this feeling was just a normal part of the process. (Yr 3, Student 2)
Fluctuating Times of Struggle and Success
The ebb and flow of students’ experiences with struggle and success throughout the program were captured in their journey maps created during the focus groups. These maps used drawings, colors, and words to vividly illustrate moments of worry, doubt, achievement, connection, and disconnection (Figure 1). Students reflected on these shifts and identified connections between periods of worry and connection with personal, social, and academic factors.
Exemplar journey maps depicting success and challenges across the occupational therapy doctoral program.
SHINE Development
Focus group findings revealed that many students perceived their struggles as unique, believing others “have it together” while attributing their challenges to personal factors (e.g., first-generation college status, less rigorous undergraduate background, past academic struggles). Ecological belonging interventions may help reframe this mindset, teaching students that adversity is normal, expected, and ultimately beneficial. These interventions may shift students’ perceptions of adversity from being unique and permanent to being universal and temporary (Walton & Cohen, 2011).
To contextualize this for OTD students, we used study results to develop SHINE, based on an effective ecological belonging intervention (Binning et al., 2020). SHINE includes three 45- to 50-min sessions timed to key OTD program challenges: the start of Term I, before Level II fieldwork, and before the doctoral capstone. Each session addresses adversity and belonging themes associated with the transition point and features an introduction, self-reflective writing, testimonials (anonymized student quotes), small- and large-group discussions, and an actionable takeaway (Table 3). SHINE sessions are scheduled outside of class time with students notified of session times before the term. In future studies, we will explore the efficacy of SHINE in promoting student belonging.
SHINE Session Protocol
Discussion
This study revealed that OTD students experience a persistent lack of belonging not just at the start of their program but throughout their education and into their careers. Although prior studies have described similar findings at the start of college (Binning et al., 2020; Byrom et al., 2022), this study reveals the continuance and fluctuations of belonging experiences throughout graduate education and possibly into early career. Students face evolving challenges, including struggles, self-doubt, and imposter syndrome, which contribute to a sense of lacking belonging. Aside from improving academic success, addressing these experiences during graduate school may have positive implications for the students as they enter the workforce as confident practitioners (Tyminski et al., 2023).
Although our study focused on OTD students, similar experiences have been reported among health care graduate students and professionals. Ogunyemi et al. (2022) reported that 57% of medical students, residents, and physicians experienced imposter syndrome. Similar to themes expressed by our students as they began Level II fieldwork, persistent fears of making mistakes and self-doubt hindered professional and clinical growth among students in nursing and occupational therapy (Moir et al., 2021). Graduate nursing students avoided class and clinical participation because of fears of being exposed as frauds (Scanlan et al., 2023), whereas first-generation college students were uncomfortable sharing professional opinions because of decreased belonging (McCarthy et al., 2023). Participants expressed similar feelings at the start of the program and entry-level practice. Like our participants who questioned whether a career in occupational therapy was right for them, nursing students who felt a lack of belonging questioned whether to continue to pursue nursing as a career (Scanlan et al., 2023). Faculty should help students overcome adversity to stay committed to their occupational therapy careers.
Students and practitioners used strategies such as seeking faculty support, building relationships with clinical supervisors, and engaging in self-reflection, social or leisure activities, physical self-care, or faith-based practices to cope with decreased social and academic belonging and to build resilience (McCarthy et al., 2023; Moir et al., 2021; Popova et al., 2023; Scanlan et al., 2023). We found that OTD students used similar coping methods, such as calling family or friends, going for a run, or watching TV. Although informal coping strategies were common, formal evidence-based programs were lacking (Tyminski et al., 2023), thus limiting effective changes.
The SHINE program addresses the unique social and academic belonging challenges of OTD students through self-reflection, peer sharing, and resilience-building activities. Unlike previous single-timepoint programs (Binning et al., 2020; Hammarlund et al., 2022; Ogunyemi et al., 2022; Walton & Cohen, 2011), SHINE spans key transition points for OTD students, normalizing struggles and fostering perseverance. This three-part approach may be a novel solution to support OTD students’ belonging and resilience.
Focus groups revealed a surprising sense of catharsis as students felt validated learning that their peers shared similar struggles with belonging despite outward success. This aligns with research showing students often feel isolated in their challenges, even when they seem to thrive (Walton & Cohen, 2011). The focus groups fostered connection, resilience, and coping strategies, underscoring the value of ecological belonging programs to support all students.
Occupational therapy educators strive to develop students’ clinical skills and confidence. Equipping them to overcome adversity, self-doubt, and imposter syndrome may be equally important. Programs such as SHINE can foster academic and social belonging, normalize struggles, and empower students to become resilient, confident practitioners ready to provide quality care.
This study had several limitations. Participants were from a single OTD program at a large urban research university, so the findings may not be transferable to other programs and universities. Literature and student feedback informed focus group timing and themes but may vary across programs. Research at other institutions could deepen the understanding of student belonging in OTD programs, and future studies will assess the program’s impact on imposter syndrome, social belonging, and resilience.
Implications for Occupational Therapy Education
The study findings have the following implications for occupational therapy education: ▪ Entry-level OTD students experience self-doubt during the program. Even though the circumstances may fluctuate, the self-doubt persists. ▪ Educators should address the academic and social belonging of students in the classroom, fieldwork, and during capstone to facilitate positive student learning outcomes. ▪ Educators should create and implement programs to normalize adversity and struggles to facilitate a sense of belonging among students.
Conclusion
This study examined OTD students’ social and academic belonging and introduced SHINE, a program to normalize struggle and mitigate negative student experiences. Educators are encouraged to develop and implement innovative, low-cost programs such as SHINE to support students during their education to foster resilience and confidence among future practitioners.