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VALUE NEGOTIATION AS THE BASIS
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THE EXAMPLE OF PHYSICAL THERAPY

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Christine Stiller-Sermo

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VALUE NEGOTIATION AS THE BASIS FOR PROFESSIONAL SOCIALIZATION:
THE EXAMPLE OF PHYSICAL THERAPY

By

Christine Stiller-Sermo

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements of
DOCTOR OF PHILOSOPHY
Department of Counseling, Educational Psychology, and Special Education

1 998

ABSTRACT

VALUE NEGOTIATION AS THE BASIS FOR PROFESSIONAL SOCIALIZATION:
THE EXAMPLE OF PHYSICAL THERAPY

By

Christine Stiller-Senno

One of the goals of professional education is to assist students in becoming a
part of the professional community by helping them internalize an ethos that
reflects the culture of the profession. Because a professional ethos is formed
and influenced by social, cultural, and historical events and the individual
identities of the people who enter the profession, it is necessary to understand
these events and individuals to establish a starting point for what it is that
educators wish students to learn through the process of professional
socialization. In spite of the importance of describing the professional ethos as
a basis for professional socialization, many professions have not clearly defined
their ethos. In addition, educators may not realize the importance of
establishing clear expectations for behaviors that reflect the professional ethos
and utilizing specific teaching methods to assist students in becoming
successful members of the professional community. The purposes of the study
are to describe the culture and professional ethos of physical therapy, to identify
current methods used to help students internalize the professional ethos, and to
describe and analyze the experiences of students and their teachers in the
socialization process of physical therapists as an example of professional
socialization.

In Part 1 of this study data obtained through historical documents and
interviews with individuals who have been in the profession for a long period of

time revealed that there are some traits and values that form the core ethos of ,
the profession that have not changed since the inception of the profession and . v
are unlikely to change in the future. There are also factors from both within and
outside the profession that influence the professional ethos resulting in changes
in values and beliefs. This evolution of the professional ethos over time
ulfimately results in the need for new methods of professional socialization.

Based on interviews with faculty, students, and clinicians from two programs
that were identified as making a conscious effort to socialize students into the
profession, Part 2 of this study examined methods of socialization in the
profession of physical therapy. Analysis of the data revealed that faculty,
clinicians, and students were able to identify methods used by educators to
socialize students into the profession, and that students’ perceptions of these
methods are similar to those of their teachers. These methods reflect good
teaching practices applied to professional socialization, as well as changes in
the profession and society throughout the history of physical therapy. Some
evidence suggests that methods employed by educators in these two programs
were effective in facilitating the internalization of the professional ethos.

Based on the relationship between the data from the two parts of this study a
model, “Value Negotiation,“ for understanding the role of educators and
students in the socialization process was developed. The role of educators in
this model is to provide opportunities within academic and clinical environments
that facilitate the internalization of the professional ethos. The more important
role, however, belongs to students as they assume responsibility for their own
professional development by taking advantage of educational opportunities and
becoming active participants in the socialization process.

Copyright by
CHRISTINE STILLER-SERMO
1 998

ACKNOWLEDGEMENTS

I would like to thank the many teachers who have contributed to my
education at Michigan State University and who have provided me with
opportunities for Ieaming and professional development. To the members of
my dissertation committee, Chris Clark, Anna Neumann, Steve Yelon, and
Doug Campbell, I thank you for your support throughout this process. You
helped make my work stronger through your thoughtful critiques and
suggestions and they are greatly appeciated. Of the many educators I have had
the good fortune to meet during my education, none has been more supportive
or positive than my dissertation committee chair, Chris Clark. I thank you for
your time, your thoughtful ways, and your scholarly insight. You have provided
me with an opportunity to experience an exceptional mentor-student
relationship, one that I feel I will be able to use as a model for working with my
own students in the future. For this and for your continued support throughout
this process, I will be forever grateful.

I would also like to express my gratitude to the many colleagues who have
supported me or served as participants in this project. To those who have
served as participants, thank you for sharing your time and experiences with
me. I acknowledge Elizabeth Mostrom for sharing her doctoral experiences
with me, for her input into my pilot study, and for her words of wisdom
throughout this process; Warren May for helping me understand the importance
of professional behavior; Inez Peacock for putting me in touch with Fellows and
Prime Timers; John Krauss for his help in putting my rough drawings into a
more usable format through his computer expertise; Kris Thompson for being
there to share this process with me; and Jane Walter for her support and

V

encouragement in my pursuit of a doctoral degree. You are a true friend and
role model for me.

To the friends and neighbors who have watched me grow and Ieam, thank
you for watching. I thank Gloria Bucciero for a lifetime of friendship; Marcia
Bade and Pam Kristufek for watching over my children and for all your words
of encouragement; and all my other friends and coworkers for always
understanding what a long process it is to obtain a doctoral degree.

Finally, I express my gratitude and love for my family who have supported me
not only in this process, but throughout my entire life. To my parents for always
encouraging me to do my best, for teaching me how to strive for excellence, and
for helping me to become the person I am today; and to my siblings, especially
my sister, Sue, for always being there. Most importantly, I recognize my
husband, Chris, for your love and support, for understanding when I was busy,
and for teaching me the value of enjoying a sunset; and my daughters, Jamie
and Lindsay, for providing me with precious memories and for always

reminding me with your laughter and love that life is a precious gift.

vi

TABLE OF CONTENTS

LIST OF TABLES
LIST OF FIGURES

Chapter 1
The Importance of the Professional Ethos

The Origins of a Professional Ethos - Social, Cultural,
and Historical Influences

The Social Construction of Professional Identity: Where are
We in Understanding Our Professional Ethos?

An Evolving Professional Ethos in a Changing World

Purposes of the Study
(1) Description of the Professional Ethos of Physical Therapy
(2) Pragmatic Approaches to Socialization to Core Values

(3) The Phenomenology of Professional Socialization

Chapter 2

Professional Cultures and Professional Socialization
A Definition of Culture
A Definition of Professional Culture
Development of the Culture of a Profession
Physical Therapy as an Example of Historical Evolution
Understanding Relationships in Professional Cultures
Social, Historical, and Cultural Influences on Professional Cultures
Occupational Therapy

Teaching
vii

xiv

XV

11

12

15

15

17

19

23

24

25

26

28

Nursing

Social, Cultural, and Historical Changes: Their Impact on
Physical Therapy

The Process of Socialization
Organizational Socialization
Three Phases of Organizational Socialization
Learning Social Roles and Norms
The Development of Cultures in Organizations
A MuIti-faceted Perspective on Professional Socialization
Influences on the Process of Professional Socialization
Professional Socialization Through Community Interaction

Shared Meaning in Communities: discourse versus
Discourse

The Role of Society and Prior Experience on Professional
Socialization

Professional Socialization as an Active and
Reciprocal Process

Power Relationships

The Influence of Training Versus Work Settings on
Professional Socialization '

Multiple Socializing Forces
Socialization in Health Care and Other Professions
Professional Socialization During Formal Education
Anticipatory Versus Real World Expectations

Summary of Literature Review

viii

3O

31
32
33
34
35

37

41

41

45

47

49

51

62

Chapter 3
Gathering Evidence for Describing the Process of Professional
Socialization
Overview of the Design
Part 1A - Interviews with Leaders in the Field
Participants
Instrumentation
Part 13 - Focus Group with Prime Timers
Participants
Instrumentation
Part 10 - Historical Documents
Mary MacMillan Lectures
Presidential Addresses
Part 2 - Program Interviews
Participants
Instrumentation

Data Analysis

Chapter 4
Part 1: The Evolution of the Professional Ethos of Physical Therapy:
Passing the Torch from One Generation to the Next

A Brief History

Enduring Traits and Values: Caring, Hard Work and Dedication,
Warmth and Openness, and a Positive Attitude

Changes from Outside the Profession: Types of Patients Served,
Societal Changes, and Subtle Influences of Social Change

ix

7O
7O
71
71
72
72
72
73
73
74
74
74
75

76

79

79

81

89

Changes from Within the Profession: The Appearance of Males,
Increased Delegation, Increased Responsibility and Autonomy,

Changes in Educational Requirements, and an Increased ‘
Emphasis on Scholarly Activity 95

Summary of Historical and Developmental Interviews and
Document Analysis 100
Chapter 5
Part 2: Professional Socialization in Physical Therapy: The Experience
of Two Programs 102
Overview of Program 1 102

What’s Special About Program 1?: Generic Abilities, Specific
Criteria and Expectations, Self-Assessment, and Regular
Feedback 106

Overview of Program 2 109

What’s Special About Program 2?: Reflection through Journals,
Portfolios and Interviews, a Strong Emphasis on Ethics, Longer

Clinical Internships, Regional Coordinators of Clinical Education,

and Mock Clinic 111

What do These Two Programs have in Common?: Shared

Expectations, Opportunities for Practice, Consistent Expectations,
Professional Development Courses, Feedback, Adult Learning,
Evaluation of Effectiveness of Socialization, and Recognition of
Socialization as a Development Process 115

Socialization Methods Common to Most Physical Therapy
Programs: Role Modeling, Course Work, Real Life Examples
Provision of Examples and Nonexamples, and Encouragement

to Join Professional Organizations 121

The Phenomenology of Professional Socialization: The Voices of

Students 124
Recognition of the Need for Socialization 124
Awareness of Problems with Professional Behavior 125

Awareness of Goals, Expectations, and Methods of
Professional Socialization 127

X

Recognition of the Role of the Student in the Socialization
Process 133

Preparing for the Future: Awareness of Changes in the
Profession 134

Recognition of Professional Socialization as a

Developmental Process 135
Summary of Student Perceptions 137
Summary of Part 2 139
Chapter 6
Putting it All Together: The Relationships Between Values, Teaching
and Professional Socialization in a Changing World 142

Contemporary Values: Similarities and Differences with the Past 143

Content as Values: A Reflection of the Core Values 147
Traditional Teaching Methods: A Changed Role for Faculty 151
Content as Values: New Roles for Practitioners as a Reflection
ofthe Changing Ethos 153
Process as Values: Contemporary Teaching Methods for a
Changing Ethos 154
Summary of Chapter 6 156
Chapter 7
Evolution and the Process of Professional Socialization 159

Understanding Professional Cultures as the Basis for

Professional Socialization 161
A Multiperspective View of Culture 161
The Integration Perspective 163
The Differentiation Perspective 163
The Fragmentation Perspective 167

xi

The Process of Professional Evolution
A Model for Professional Evolution
The Physical Therapist of Today

Facilitating the lntemalization of the Professional Ethos in
Professional Education Programs

lntemalization of the Professional Ethos through “Value
Negotiation”

Value Negotiation -- What is it?

The Role of the Educator in Value Negotiation

Creating Meaning in Communities of Practice

The Role of the Student in Value Negotiation

The Process of Value Negotiation: The Big Picture
Phase I : Awareness of Values and Expectations

Stage 1: Awareness of Expectations

Stage 2: Identification and Comparison of Personal and
Professional Values

Summary of Phase I
Phase II: Active Learning
Traditional Teaching Methods: Practice and Feedback

The Role of the Student During Phase II: Value Negotiation
Using Case Grounded Self-Assessment

Formal Self-assessment During Phase II
Increasing Participation in the Professional Community
Summary of Phase II

Phase III - Artistry
xii

169
169

173

176

179
179
182
185
188
189
193

193

196
199

199

203

210

211

Stage I: Approaching Graduation
Reflection

The Result of Successful Completion of Stage 1 of the
Artistry Phase

Stage 2: Post Graduation
Stage 3: The Epitome
Summary of the Study
Implications for Physical Therapy
Implications for Professional Education
Limitations and Suggestions for Future Study
APPENDIX A Fellows Consent Forms
APPENDIX B Fellows Interview Guiding Questions
APPENDIX C Focus Group Consent Form
APPENDIX D Focus Group Interview Guiding Questions
APPENDIX E Programs Consent Form
APPENDIX F Programs Interviews Guiding Questions
APPENDIX G Description of Participants
APPENDIX H Generic Abilities and Behavioral Criteria
LIST OF REFERENCES

xiii

213

215

217

217

221

223

225

226

229

239

242

246

248

251

256

260

Table 1
Table 2
Table 3
Table 4

Table 5

Table 6
Table 7

Table 8

LIST OF TABLES

Overview of Research Design 13
Review of Findings of Studies on Professional Socialization 52
The Evolution of the Profession -- Summary of Results -- Part 1 82
Methods of Socialization - Summary of Results -- Part 2 103

Putting it All Together: The Relationships Between Values,
Teaching, and Professional Socialization in a Changing

World 144
The Role of Educators and Students During Phase I 194
The Role of Educators and Students During Phase II 200
The Role of Educators and Students During Phase III 212

xiv

LIST OF FIGURES

Figure 1 A Model of Professional Socialization as the Product of

Culture and Socialization 18
Figure 2 The Evolution of the Professional Ethos 170
Figure 3 The Process of Value Negotiation 191

Chapter 1

The Importance of the Professional Ethos

One of the goals of professional education is to assist students in becoming
part of a professional community. Tammivaara and Yarborough (1984) have
referred to this process of enculturation into a profession as “attaining a
professional ethos.” Ethos is defined as “the distinguishing character,
sentiment, moral nature, or guiding beliefs of a person, group, or institution”
(Merriam-Webster Dictionary, 1974, p. 247). The ethos of a profession, then, is
comprised of the distinguishing characteristics, sentiments, and beliefs of that
profession that guide the behavior of practitioners. This professional ethos is
most often reflected in Codes of Ethics and Standards of Practice founded in the
norms and mores of the profession, which, in turn, can be viewed as a reflection
of the values, attitudes, and beliefs of the profession (Abbott, 1988). Because of
the importance of the professional ethos to successful practice, I believe it is as
important for faculty in professional education programs to address values and
Professional socialization issues, as it is to teach cognitive and psychomotor
skills. The incorporation of the idea of a professional ethos into the profession’s
cUlture and educational program expands the definition of professional culture
beyond a mere description of what practitioners do to a description of who the
Praetitioners are as a group and what meaning they find in their work.

Like educators in other professional programs, the faculty of physical therapy
pro9rams want their students to emerge from academia as competent
Wessionals - problem solvers who can evaluate patients and devise treatment
plans based on the evaluation, who can interact with people of all cultures, who

3'9 festfonsible for their own Ieaming, who serve as ethically exemplary role

1

models for future students, making contributions to their profession and
communities (Packard, 1986). They want students to internalize the ethos of
the profession as they are enculturated into the world of physical therapy.
According to Tammivaara and Yarborough (1984):

To do this, educational programs must develop a cultural
orientation toward professional behavior, a professional ethos.
This is not something to be offered as a course or even as a series
of courses; this is an attitude, a set of values, which must be
conveyed and practiced by the clinical and academic faculty. It
must be manifest for students in expectations of their behavior, in
the conduct and content of all courses, in the procedures of
faculty/student interaction, in the evaluation of the students, in the
use of space, in clinical education, in the designation of
professional heroes and valuing of the field’s history, and most of
all in the faculty’s and clinical faculty’s commitments to patient
care, the primary task of physical therapy. (p. 25)

The students must move from a world of college life to a professional one.
The cultural values of “student” must be transformed into the “professional
ethos.“ The individual must stop being merely a competent student and must
become a competent professional. This occurs as the student begins the
Process of “internalizing the values, traditions, and obligations of the profession
- 1 - [it] occurs when the student develops a clear and accurate perception of the
role of the profession and of the self as part of that profession” (Saarrnan,
Freitas, Raps, and Riegel, 1992, p. 27). Learning about the professional world
thus involves not only mastering the skills needed to perform the work of the
Wession competently, but also includes Ieaming about the many roles that a
Wessional assumes in terms of ethical behavior, standards of practice, and
aI’lmpriate interactions with a variety of clients, colleagues, and superiors. It
inVOIVes internalizing the values and beliefs shared by others in the profession

30 that collectively held professional values and ideals come to characterize the

very identity of the novice physical therapist.
I : 0'0I01=.P9=\0-Inl tho - . , It rl eno Hi ori .el Infl n s
The questions in this study concern the origins and evolution of the norms,

values, and beliefs of physical therapy, described as “professional ethos” by
Tammivaara and Yarborough (1984), and the processes by which the
professional ethos is transmitted to new members of the physical therapy
profession. I contend that a professional culture is embedded in a cultural,
historical, and social framework. A profession evolves in response to these
larger influences and the changes they produce. In order to survive,
professionals and their national associations must be responsive to historical
events, societal pressures, and changes in cultural values. For example,
current advances in technology are changing the ways children are educated
and the services offered to individuals with disease or disability. The use of
computer technology, in particular, is opening up new avenues of
communication and care. Elementary school children can communicate with
peers all over the world via the Internet and can access information never
before available to them on the World Wide Web. Similarly, individuals with
disabilities can use the lntemet to communicate with others without the stigma
of having a conspicuous disability. As a result of this technology, the world is
becoming a smaller place, creating a need for understanding other cultures and
societies.

In contrast to these positive aspects of living in a technological world,
Kenneth Gergen (1991) describes different consequences of living with
increasing technology. Unlike those who lived in the past. those living in
today’s postmodern world are constantly bombarded with information and

people via television, radio, fax, and e-mail. In addition, the relative ease of

3

global travel offers many more opportunities for face-to-face interaction with
culturally exotic people around the world. Because each of us is constantly
bombarded with information and encounters with cultural strangers, Gergen
claims that today’s citizens experience a sense of social saturation in which
individuals have little time for nurturing relationships either at work or home and
each person develops so many perspectives from all that he or she comes into
contact with that a committed and solid sense of identity is impossible. As a
result, one begins to experience what he terms a multiphrenic condition. “A
multiphrenic condition emerges in which one swims in ever-shifting,
concatenating, and contentious currents of being. One bears the burden of an
increasing array of oughts, or self-doubts, and irrationalities.” (p. 80) In order to
cope with social saturation and the multiphrenic condition, Gergen suggests
that we turn this multiphrenic condition into a positive experience by
considering what we can gain from this postmodern phenomenon. He
describes how this cultural change gives us the ability to consider issues from
different perspectives, to blend the beliefs of yester-year’s romantic and modern
versions of the world with the beliefs of today, and to be more accepting of
others who are unlike us, leading to a greater ability to deal with diversity. This
ability has evolved from several aspects of social saturation - a plurality of
perspectives that comes from multiple interactions with people and places all
over the globe and the moral and ontological relativism of the postmodem
world. Postmodernism, Gergen believes, speaks to the importance of
interdependence between people around the globe in terms of personal, social,
and economic matters, and he offers us a way to accomplish and cope with this
interdependence.

An example of how this plurality of perspectives, a social change, affects

4

professional cultures, at least in the United States, is the move from a “melting
pot“ orientation to one that recognizes the positive value of differences and the
need to embrace cultural diversity. Professional associations and academic
programs are responding by establishing goals aimed at understanding and
respecting people from all walks of life, a change reflected in the evolution of
these professions. This emphasis on diversity is evidenced in courses or units
of courses within professional programs that address the need for students to
'Ieam to interact with individuals from a wide variety of cultures, as well as an
increased effort on the part of academic programs to admit students from a
different cultures and walks of life.

Diversity can also be seen from a historical perspective as each cohort of
students entering professional preparation programs brings with them a unique
identity that results not just from their personal experiences, but also from their
collective experiences related to the historical era during which they were born.
Perhaps the best example of this cohort effect on a societal level is the powerful
influence that the baby boomers have had on every institution and era with
which they have come into contact. From the free spirit days of the 1960s to
their entrance into the American Association of Retired People within the next
few years, this group has had a significant impact on the way we think and
function. The professional arena feels this influence as well. As formerly novice
practitioners become the leaders in the field, their influence becomes greater
and their ability to incorporate their ideas and values into the discipline is

enhanced.

il n 'anrf ionlln':Whr rewin
n ni rPf inIEth?

This study is grounded in the theoretical assumption that the development of
a professional culture, its values and ideals, is a social construction resulting
from the interactions and discourse among practitioners, clients, other
professionals, and the general public. Based on their personal histories,
practitioners, as well as consumers of professional services, bring unique
identities to the practice setting that influence the development of a professional
ethos. In addition, a variety of cultural, historical, and social factors shape the
emergence and development of all professions. In this way changes in society
influence the evolution of a profession and, subsequently, what and how
educators teach students in order to prepare them to practice ethically and
effectively in an ever changing society.

The influence of these larger changes in society on the practice of physical
therapy has been reflected primarily in the technical aspects of the profession.
But in recent years researchers and practitioners in physical therapy have
begun to recognize the importance of acknowledging the contributions of
history to present and future practice, research, and education. To celebrate the

75th anniversary of the profession, for example, the American Physical Therapy

 

time, a history of the profession can be found in one comprehensive source. As
a result of this book, as well as other historical articles and presentations that
chronicle the history of the profession, the evolution of the scientific and
technical aspects of physical therapy has been well documented. Changes in
the types of treatment used, the diagnoses of our patients, practice patterns, and

other demographic variables have been delineated in these various places.

In contrast to this clear picture of what physical therapists have done and
presently do, who they were, are, and may become is not as well documented.
In spite of the fact that the American Physical Therapy Association creates many
documents aimed at the socialization of newcomers into the profession (e.g.,
Code of Ethics, Standards of Practice, Accreditation Standards), little scientific
inquiryhas been carried out to describe more precisely what it is that physical
therapists want to socialize students into. While some authors have made
attempts to define some individual characteristics of physical therapists such as
helping behaviors (Curtis, Davis, Trimble, 81 Papoulidis, 1995) and sensitivity to
gender issues (Raz, Jensen, Walter, & Drake, 1991 ), there is currently no
description of the norms, values, and beliefs-the culture--of physical therapy.
We have no clear picture of who we are and what we represent today. Further,
we have no real idea of whether and how the essence of what it means to be a
physical therapist has changed over the years. If the culture has changed, why
have these changes occurred and what do they mean for professional
socialization? More specifically for the purposes of this study, what does the
development of the professional culture imply for the physical therapist educator
who is trying to help students to internalize a professional ethos?

Because of this lack of a clear description of the culture of physical therapy,
students may be receiving mixed messages from academic and clinical faculty
as to what it is that defines the profession. While to some extent there may
always be ambiguity in the professional world portrayed to students, the ability
of educators and practitioners to share core beliefs and views of how the
professional world operates is important in helping foster students’
understanding of professional culture. Examples of how this lack of agreement

7

between educators and practitioners can confuse students has been reported in
the literature on professional socialization in nursing (Myers, 1982; Cohen and
Jordet, 1979). Similarly, while academic faculty in physical therapy are
presenting an ideal view of patient care based on their past experiences as
practitioners, clinical faculty, who are working in the real world, may have seen
changes in practice (e.g., managed care) that are quickly changing the role of
the physical therapist in practice. Additionally, faculty may be presenting the
world of physical therapy as a black and white world with easy answers to
difficult ethical dilemmas. This world of absolute rights and wrongs does not
exist in today’s world. This loss of absolutes is described by Gergen (1991):

In the traditional community, where relationships were reliable,
continuous, and face-to-face, a firm sense of self was favored.
One’s sense of identity was broadly and continuously supported.
Further, there was strong agreement on patterns of ‘right’ and
’wrong’ behavior. One could simply and unseIf-consciously be
(italics in original), for there was little question of being otherwise. .
. . As one interacts with persons from diverse backgrounds, and is
exposed to various media representations of ‘good persons’, the
range of self-evaluative criteria expands manifold. It is not simply
the local community that dictates the nature of the good, but
virtually any visible community. (pp. 147-148)

Even worse than receiving mixed messages, students often receive no
message at all, with faculty expecting students to internalize the faculty’s
professional ethos by intuition and osmosis. Today, students are affected by
many potential role models. In spite of the best intentions of their faculty to be
'good role models,“ the common indirect and implicit approach to professional
socialization does not serve our students well in the cacophonous marketplace
of ideals and values. As described above by Gergen, there is not the “strong

agreement on patterns of ‘right’ and ‘wrong’ behavior“ (Gergen, 1991, p. 147)
today that there was years ago. As a result, students with no means for

8

identifying and dealing with professional development or ethical issues that
arise as they begin their journey into the professional world will be at a
disadvantage. Personal conversations with practicing physical therapists and
direct experience in dealing with students who are experiencing problems with
the transition from student to professional often reveal that some students have
little idea of who it is they are supposed to be as a physical therapist and how
they are supposed to get there.

P ‘ l th in h n in W rI

Because faculty are responsible for educating future professionals, they
need to be cognizant of the fact that they have an obligation to prepare students
for a changing world-one that the profession must change with to remain
viable. Change is an integral component of the concept of the culture of a
profession. As described earlier by Gergen (1991), change is occurring at a
faster rate due to the rapid growth in technology and our constant interaction
with multitudes of individuals via television, phone networks, e-mail, and
increasing travel. Because professions are subcultures of the larger societal
culture in which they are embedded, rather than isolated entities, these
changes are reflected in professional norms, values, and beliefs of professional
cultures. As a result, the ability to deal with new roles, values, and technology
in an evolving society is an important asset for any professional.

Fox (1957) has coined the term “training for uncertainty” to describe this
phenomenon. Fox claims that there are three sources of uncertainty with which
students in professional training deal (Fox’s subjects were medical students, but
her views can be applied other professions as well). These are “(1) incomplete
or imperfect mastery of available knowledge; (2) limitations in current . . .
knowledge; and (3) difficulty in distinguishing between personal ignorance or

9

ineptitude and the limitations of present . . . knowledge” (pp.208-209). Fox
feels that it is imperative that educators use teaching methods that will help
future professionals deal with these uncertainties. For the medical students she
studied, these methods include acknowledging uncertainty by having students
be active, responsible Ieamers rather than “spoon feeding” them information;
helping students to realize that they will never be able to master everything due
to the limitations of the human brain and the daily new discoveries that are
made in the field; acknowledging the limitations of human senses and
technology in detecting problems; sharing experiences of uncertainty with
fellow students to help them realize that their peers, as well as attending
physicians, also are uncertain at times; and providing real life situations in
which students can learn to cope with this uncertainty and, thus, increase their
confidence and sense of responsibility in their professional role. Fox does not
claim that we can eliminate uncertainty. Rather, educators must help students
cope with and take responsibility for it. Similarly, while it may be unrealistic to
expect that educators can prepare students for a future world that we may not
be able to even imagine, they can, I believe, prepare them for functioning in
today's world and give them tools for dealing with future professional changes.
Floden and Clark (1988) applied the principle of “training for uncertainty‘ to
the teaching profession. They discuss the meaning of uncertainty for teacher
education and identify several variables about which teachers are uncertain,
including " what. . . students know, what effects teaching has had and will have,
the content they should be trying to teach, what instructional authority they have,
and how they can improve their teaching” (p. 504). Like Fox (1957), Floden and
Clark (1988) acknowledge that some uncertainty will always be present since

no one can know everything and there are some things about which no one is

10

certain. Pursuing certainty, in fact, can lead to teaching methods that result in
“factual content that can be taught by rote memorization and tested by requests
for recall . . . a focus on immediate, obvious, specific difficulties, away from
global, Iong-terrn plans and goals . . . (and ) discomfort to students” (p. 513) due
to excessive questioning by the teacher in an effort to be certain about what
students know.

Floden and Clark’s suggestions for decreasing the tension that results from
uncertainty fall into two major categories. First, they suggest that faculty in
teacher education programs teach strategies for reducing uncertainty such as
the ability to create well-established, yet flexible classroom routines, and
knowing when and how to increase their own knowledge and skills. Second,
they feel that teacher education programs need to raise teachers’ awareness of
uncertainties without conveying an “anything goes” perspective, and teaching
them strategies for dealing with the stress that results from living with
uncertainty. Educators can help teachers cope with this stress by teaching them
the art of engaging in professional conversations with colleagues about their
feelings of uncertainty in spite of initial difficulties in revealing some of their
weaknesses, and by helping them to create an atmosphere of certainty in their
classrooms by taking decisive action so that students and parents can be ‘
confident in their abilities as a classroom teacher. Finally, the importance of
inservice education and field research for experienced teachers are nominated
ways to keep these professionals in touch with the reality of uncertainty so that
they do not become overly confident or rigid in their teaching techniques.
W

This study has three purposes: I. To describe the culture and professional
ethos of physical therapy; II. To identify current methods used to help students

11

internalize the professional ethos; and III. to describe and analyze the
experience of students and their teachers in the socialization process of
physical therapists as an example of professional socialization. Table 1
portrays the research design in relation to these three purposes, each of which
is discussed in detail below.

W The fiI’St purpose
of this study is to describe the culture and professional ethos of the profession of
physical therapy, acknowledging that many factors 0.9. social, cultural,
historical, economic, political) must be considered in this description. For
purposes of this study, culture is broadly defined as “that complex whole which
includes knowledge, belief, art, morals, law, custom, and any other capabilities
and habits acquired by man as a member of society“ (Tyler, 1903, cited in
Goodenough, 1981, p. 1). A professional culture can then be further defined as
the knowledge, belief, art, morals, law, custom, and other habits and capabilities
acquired by practitioners as members of a profession.

Although a complete examination of all the social, cultural, and historical
events that have occurred since the inception of the profession is beyond the
scope of this study, there are many events both within and outside of the
profession that have had a direct impact on its professional culture. This first
step of describing the contemporary professional culture-its acceptable norms,
values, and beliefs-4s important in helping to gain an understanding of the
meanings embedded in these norms, values, and beliefs. According to
Goodenough (1981), before we can examine behaviors or come to any
understanding of their meaning, it is important to establish the rules and
standards by which these behaviors are judged. He states that we must be

able to istinguish the relevant from the irrelevant. “(W)e can count all kinds of

12

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13

things; but all of these things are significant units in a complicated game of
living. We cannot count them if we cannot recognize them; and before we can
recognize them, we have to know the standards and rules of the game. To
make predictive statements about actual behavior, we must first know the
culture of which that behavior is an expression” (p. 58). The first part of this
study, describing the evolution of the professional culture of physical therapy,
then, is important for several reasons. First, it will help to establish and define
the beliefs, values, and norms of the culture1 that are evidenced in

professional behavior. Next it will help to identify those beliefs, values, and
norms that may have stayed constant and those that have changed over the life
of the profession so that the core characteristics of the profession can be
identified and the evolution of those that have changed can be described.
Second, examining the past will help put the present in perspective and explain
why it is that the profession is “what it is” today. While the fluid nature of cultures
prevents anyone from ever portraying a concrete picture of exactly what
constitutes any culture over an extended period of time, I feel that tracing the
evolution of the culture and professional ethos of physical therapy will at least
offer a useful snapth of how the profession evolved to where it is today. The
present view of the profession can then be used as a point of contrast with the
past to better appreciate where the profession has come from, as well as
offering a glimpse into the future to see what it is that students need to learn
about the professional ethos and the skills and behaviors that are part of that
ethos. That is, as described by Goodenough, we must define the culture

 

‘Riverside Webster's ll Dictionary. Revised Edition (Berkley Books, 1996)) gives the following definitions of
theseterms: belief-‘somthing,asatenetthatisbelievedzconvfction'(p.64);norm-'amodelorpattem
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14

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including its core, shared standards, and domains of contention, before we can
begin to discuss the ways in which we pass this culture on to the next
generation of professionals.

= . The second

 

purpose of this study is to describe some methods that are used to pass on the
professional ethos to students. Through a case study approach, I have
identified some of the current methods that are used to socialize students into
the culture of physical therapy as an example of professional socialization.
These methods are used by physical therapy educators to facilitate the
internalization of a professional ethos in physical therapy students, as well as to
enhance the students’ ability to recognize and adapt to the societal and
professional changes that will likely occur over the lifetimes of their professional
careers in response to social, cultural, and historical events.
WWW Finally, bUt perhaps
most importantly for faculty and students in professional education programs,
the third purpose is to describe the experiences of students and educators in
the process of professional socialization in these programs. Because physical
therapy is being used as the example of professional socialization, however,
the first two purposes of this study must be addressed in order to help the
reader gain an understanding of the current state of the field in terms of its
culture and educational programs. Those reading this study can then draw
their own conclusions about the similarities and differences between the culture
and education of physical therapists and that of other professions. For those in
fields other than physical therapy, I hope to offer a picture of professional
Socialization that will shed some light on issues such as the ways in which
students feel that faculty help or hinder them in the process of socialization and

15

making the transition from student to professional, how students come to
recognize the core concepts of a professional ethos, and how they Ieam to

apply these core concepts in practice and in their professional behavior.

16

   

Chapter 2

Professional Cultures and Professional Socialization

There are two major concepts that are necessary to understand in order to
Put this study into perspective. These concepts are professional culture and
professional socialization. While culture offers a basis for understanding what it
is that a profession believes in and values, professional socialization provides a
means for understanding the process by which students in professional
education programs Ieam about and become part of that culture. Both the
content (i.e., culture) and the process (is. socialization) are important
components of fostering the internalization of the professional ethos in students.

This section is intended to describe a framework for defining professional
Cultures and tracing their evolution, and for describing the means by which
educators attempt to socialize students into their respective professional
cultures. Figure 1 depicts a model for understanding the relationship between
the professional culture and professional socialization. The two large circles
represent the concepts of culture and socialization in a much broader sense.
That is, culture within the large circle can be thought of as a way of life or the
beliefs, values, and norms of a society in general. Socialization within this
I"'todel is defined as the process by which members of a culture Ieam social
'“'65 (Mehan, 1980; Merton, Reader, and Kendall, 1957). Embedded within
each culture are a multitude of subcultures, including professional cultures
(represented by the oval within the circle of culture). Similariy, one type of
s()cialization, organizational socialization, is embedded within the context of
s<>cialization. Organizational socialization, as a subset of socialization in

general, is defined as the process by which individuals are socialized into an

17

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18

organization. Understanding the concepts of and relationship between
professional cultures and organizational socialization helps put the process by
which students are socialized into professional cultures as organizations into
perspective. In addition to the influence of culture and socialization on the
internalization of the professional ethos, other influences, such as community
interaction, shared meanings, society and prior experience, the active role of
the individual, power relationships, and training and work settings, are also
important. The influence of all these concepts on socialization of students in
professional programs are indicated by the arrows from each of them to the
”socialization into professional cultures as organizations” oval.

In addition to the information regarding professional cultures and
socialization depicted in the model just described, the remainder of this chapter
offers a summary of literature concerning the processes by which students in
professional programs are socialized into their respective professions. The
concepts and ideas included in both the model and the literature are described
in more detail below.

E D [i T I Q !!

Over the years, culture has been defined in various ways. Tyler (1903, cited
in Goodenough, 1981) first defined culture as “that complex whole which
includes knowledge, belief, art, morals, law, custom, and any other capabilities
and habits acquired by man as a member of society” (p. 1). At that time in the
history of the modern world, culture was something that was considered to be
more developed in some societies than in others.

In this view, societies did not have discrete cultures but a greater
or lesser share in the degree of general culture so far created and
developed by mankind as a whole. . . .The object of cultural
anthropology was to try to reconstruct the steps or stages that had
marked the growth of culture. Societies with the simplest

19

 

 

 

 

technologies and the least elaborate political orders presumably
represented the lowest stage of growth; others represented
various intermediate stages; while western European societies,
politically and militarily dominating the rest of the world in the
nineteenth century, represented the most advanced stage.
(Goodenough, 1981, p. 48)

In the early nineteenth century, this ethnocentric and hierarchical conception
of culture began to be replaced, primarily through the work of Franz Boas, with
a more egalitarian view of culture in which each society was seen as having
their own distinct form of culture (Goodenough, 1981 ). Since that time,
anthropologists have combined Tyler’s conception of culture as “the complex
whole” with Boas' view of cultures as distinct, rather than hierarchical. In
addition, the “complex whole” described by Tyler was expanded to include
language. “Language and culture went together as a body of distinctive things
about a community that were transmitted by Ieaming and that gave to each
community its own peculiar linguistic and cultural tradition” (Goodenough,
1981, p. 49).

Two of the most influential scholars involved in determining how cultures are
studied today are Ward Goodenough and Clifford Geertz. While agreeing on
the basic beliefs about culture described by Franz Boas, each sees the ways in
which culture is shared and transmitted to new members in a slightly different
context. Geertz (1973) views culture as a semiotic field or shared symbol
system. The shared meaning that results from the symbol system is how
societies come to also share knowledge, beliefs, norms, etc. Culture, in
Geertz’s view, is public. It is by analyzing the meaning behind behavior (is.

social action) and social discourse in a society that one comes to understand
the culture of others. “Meanings are not ‘in people’s heads;’ symbols and

meanings are shared by social actors-between, not in them: they are public. . .

20

. To study culture is to study shared codes of meaning. . . and interpretation
becomes ‘thick description” that must be deeply embedded in the contextual
richness of social life” (Keesing, 1974, p. 79).

Goodenough (1981) views “cultures . . . as systems of knowledge. . . . [and]
language [as] . . . a subsystem of culture” (Keesing, 1974, p. 77). In contrast to
Geertz, he views culture as “being in the minds and hearts of men.” Without
this private view of the individual as the center of culture, Goodenough (1981)
feels that the study of culture is reduced to simply the study of behavior without
meaning behind it or to a study of a collective unconscious, neither of which is
acceptable to him. Instead, he posits that because culture is learned through
language and the study of the meaning behind behavior, language, and
material artifacts, and because we can only Ieam things as individuals, it is the
relationship between individuals and the societies in which they live that
determines the standards by which people are accepted by others as viable
members of a group.

Based on the work of Geertz and Goodenough, as well as others in the field
of anthropology, key features of cultures have been identified. These include:
(1) the importance of language; (2) the importance of understanding the
meaning behind social discourse, behavior, and material artifacts rather than
simply recording what, how, and when individuals engage in behaviors and
discourse; (3) the adaptability of cultures over time in response to
environmental and other demands; (4) the belief mat culture is learned, not
biological; (5) the belief that culture is shared; (6) the belief that culture is a
complex, interconnected whole, not just random bits and pieces; and (7) the
belief that culture offers rules or standards for knowing, for behavior, for
feelings, and for thoughts so that one is acceptable to his or her culture (Geertz,

21

 

 

 

1973; Goodenough, 1981; Keesing, 1974). The definition of culture reflected in
these common key features serves as the definition used in this study. In
professional cultures, for example, there is shared meaning between members
of the profession which is evidenced in the professional ethos; professional
cultures change over time in response to broader societal changes; and, like
societal cultures, professional cultures are complex, interconnected wholes that
share meaning with individuals from other professional cultures and walks of
life.

EDE'I' [El . IQI!

As stated earlier, a professional culture is the knowledge, belief, morals,
laws, customs, and other habits and capabilities acquired by practitioners as
members of a profession. Based on this definition, the culture of a profession
cannot be defined only by what the profession does. Rather, the identification of
the values, norms, and beliefs that determine how and why the profession
functions the way it does and the meaning behind them are also critical
components. Professional cultures are somewhat fluid, changing over time as
new cultural, social, and historical events occur and various people move into
and out of it, shaping their evolution as they do so. They are composed not only
of what is obvious to the causal observer, but also of many things that may not
be entirely describable, but still exist in minds and hearts of the individuals who
have attained the professional ethos.

Professional cultures are influenced by a multitude of factors, rather than by a
single event or person. They respond to changes within and outside
themselves. They reflect the ability of the practitioners in the field to articulate
what they do and who they are as unique, yet related to what others do, and for
these views to be consistent with beliefs of those outside the field so that what is

22

claimed as distinctive about the profession is accepted by the culture at large. .

Defining a professional culture and some of the factors that influence it,
although important, is only the first step in the process of understanding how it is
that students internalize the professional ethos of their more experienced
colleagues. A second step, described in the following section, is to try to
describe the processes by which professional cultures develop over time.
WW

Understanding the history and evolution of the culture of a profession can be
important in avoiding mistakes that predecessors have made, gaining an
appreciation of who and what has been helpful in the evolution of the
profession, and perhaps most importantly, realizing that what happens today
will shape the future of the profession (Woods, 1995). Multiple variables need
to be considered to gain an understanding of this evolutionary process. For
example, each cohort of members brings new and different views to the culture.
The addition of new members to a professional culture is one of the ways in
which differences in subcultures within a profession develop and the culture
evolves. To the extent that new members become more powerful members of
the group, the culture will adapt to these views. Next, the profession does not
develop its culture in isolation. Rather, it should be viewed as a part of society,
a subculture that evolves as a result of being situated in a larger societal
culture. it is influenced by other social, cultural, and historical changes in the
world. In addition, how one profession views another has an impact on who the
practitioners and the profession become. Just as interactions with family
members, peers, and authority figures influence how people see themselves
and consequently behave, so does the view of others influence how a
profession sees itself. If a more powerful group sees another group as less

23

powerful and incapable of making decisions, the interactions between the two
groups will continue to perpetuate this view. The less powerful group may
continue to behave as they are treated and viewed by those in power.

Ph ' I n m l f Hi ri | l ti n

The development of physical therapy is a case in point. In the early years of
the profession, physicians were a powerful group that viewed physical
therapists, or reconstruction aides as they were called at the time (during and
shortly after World War I), as technicians who needed guidance in order to carry
out their jobs. Although there were some who were offended by this technical
role, a review of the writings of the pioneers in the field revealed that many of
the reconstruction aides shared this sentiment (American Physical Therapy
Association, 1979). Similarly, physicians “urged the use of the term technician
. . . . A well known physician and friend of the Association said: ‘You can't fight
the medical profession. If you wish to stand you must cooperate’ " (American
Physical Therapy Association, 1979, p. 74-75).

It was only as the women who chose physical therapy as a career began to
gain a more independent sense of self as a result of the changing views of
women beginning with the Women’s Rights movement in the sixties, and as
more males began to enter the field, that the profession responded by moving
away from the direction of the American Medical Association and began to seek
autonomy. The view from within changed as a new cohort of working women,
as well as men, who embraced the ideals of independence and equality
between sexes and rejected a more passive role, became the leaders in the
field. It was as recently as 1981 that the American Physical Therapy
Awociation adopted a resolution to actively pursue autonomous practice by
seeking to change state licensure laws to allow practice without physician

24

 

 

referral and to enhance the image of the profession portrayed to consumers
and other health care providers as independent practitioners. This is but one
example of how the views of new members and societal changes helped
change the professional ethos and the practice of a profession.

' i P i n l l r

A description of professional culture, then, goes beyond the dictionary
definition that can be found in state licensure laws that merely describe the
“jobs“ that those in the field perform and the credentials they must have. Rather,
each culture is socially constructed through interactions and discourse among
practitioners, clients, other professionals, and the general public. Each new
practitioner is not a final product that can be fit into the profession much as one
would put the final piece into a jigsaw puzzle to make it complete. Instead, the
culture of the profession is continually being constructed and reconstructed
over time. It is always a work in progress. Many of the foundations are in place,
yet much remains to be built. The construction continues as active, reciprocal,
ongoing relationships develop between the profession itself and other people,
events, and institutions that surround it.

To carry the construction metaphor further, the profession can be viewed as a
complex of buildings with each individual building or person contributing. to the
function of the complex. While the complex does not look complete or function
adequately without each building, neither can the buildings stand alone. Each
segment of the whole is incomplete without considering it in relation to other
segments. One can imagine that those buildings outside the complex are also
important to the function, much as other professions, clients, and the general
public are essential for the evolution of each discipline.

Physical therapy can be viewed as an example of the points illustrated in the

25

 

 

above paragraphs. The many people and sectors of the profession - the
buildings - who make up the profession form the integrated whole - the
complex. Within the American Physical Therapy Association, for example, there
are “Sections“ which are special interest factions devoted to a specific part of
practice, such as pediatrics, orthopedics, private practice, or home care. These
sectors influence the core of the profession - the norms, values, and beliefs that
transcend boundaries between these various groups - that form the basis of the
professional ethos. Similarly,other professions (e.g., medicine, occupational
therapy, speech therapy, etc.) and social institutions (e.g., federal and state
regulating bodies and insurance companies) outside the complex of physical
therapy influence the development of the professional ethos of a field by
interacting with and sometimes exerting influence over the profession. To the
extent that physical therapy as a profession reacts to these influences, the core
or ethos of the profession can change over time.

.012 .m- o:2l 2 i.- - r._ Infl inha~ on Pro-f - i I r

There are many outside influences that contribute to the evolution of

professional culture. For example, in the book, W
W Danziger (1990) argues that the
development of a profession and its practices is a socio-culturaI-histoncal
phenomenon. He outlines the many forces that shaped the practice of
psychological inquiry and emphasizes the social nature of scientific inquiry and
the interactions that occur between the investigator and the subject, the
investigator and colleagues, and the investigator and society. He describes the
importance of political power in determining what will be investigated and how
the investigation will be carried out. For example, while educational
psychology originally was linked with teaching in the late 1890s, an alliance

26

$52

'32

that helped make psychology popular with the general public, after the tum of
the century psychologists began to ally themselves more closely with
educational administrators who were more powerful and changed the focus of
psychological research from issues related to classroom teaching to those
related to further increasing the power of administrators by demonstrating which
programs were successful in relation to what parents and the general public
wanted. In regard to broader societal needs and politics, Danziger (1990)
states:

. . . the cmcial point is that the successful establishment of a new
discipline is very much a political process in which alliances have
to be formed, competitors have to be defeated, programs have to
be formulated, recruits have to be won, power bases have to be
captured, organizations have to be formed, and so on. These
political exigencies necessarily leave their mark on the discipline
itself. . . . Being obliged to operate in an external political
environment, the community of knowledge producers is bound to
develop an internal political environment . . . . As the community of
knowledge producers grows it develops intemal norms and values
that reflect its external alliances. Its professional project is directed
at carving out and filling a particular set of niches in the
professional ecosystem of its society, and its internal norms reflect
the conditions for the success of this project. These norms tend to
govern both the production of knowledge and the production of the
producers of knowledge through appropriate training programs.

(p. 181-182)

In this quote, Danzinger is summarizing one of the major assumptions
underlying this study. That is, in order to understand the professional ethos of
any profession, it is necessary to understand the social, political, cultural, and
historical changes that have influenced its evolution. As stated earlier, each
profession is a subculture embedded in a larger societal culture. As a result,
those events and changes that affect the societal culture also affect the

professional culture.

27

 

 

mm. Other professions offer similar examples of the power
of larger forces outside the profession in shaping the culture and professional
ethos of that profession. Levine (1983), for example, describes how the field of
occupational therapy emerged during the period from 1890-1920 as a result of
the relationship between culture and medicine. She describes three major
forces that not only influenced the initial development of occupational therapy,
but continue to have an impact to this day. These include “(1) the selection of
crafts as therapeutic modalities, (2) the role of women at the turn of the 20th
century, and (3) the influx of Eastern European immigrants into American
society” (p. 187-188). The use of crafts as a therapeutic modality occurred in
response to the increasing isolation and decrease in family life that resulted
from widespread industrialization in the early 20th century. Americans turned to
the use of arts and crafts as a means of returning to a simpler life. At about the
same time several prominent physicians began to appreciate the use of these
modalities and modified their use as goal-directed occupational activities for
individuals with medical and/or mental health conditions. The role of women at
the turn of the century began to change as machines begin to take over some of
their traditional roles such as weaving and sewing. Although they continued to
hold lesser roles in society, more women began to go to college and continued
to look for professions where they could use their strengths as nurturing and
caring individuals. As a result, “some women entered health and social service
professions. . . . They were responsible for religious, moral, and cultural values
at home and now in their work" (Levine, 1983, p. 189).

Unlike the last two factors, the influx of Eastern European immigrants had a
more negative impact on occupational therapy. As the number of immigrants

increased, a need arose for vocational training, educational opportunities, and

28

g

 

health care services in their homes and communities. Occupational therapy,
however, did not become involved in this movement and remained involved in
medical care only in institutions such as hospitals and rehabilitation centers. As
a result, the profession did not begin to grow until the late 19405. “The slow
growth rate may have been influenced by the way early practitioners handled
the immigrant problems. Therapists, recruited from the middle and upper class,
were reluctant to expand their services to a foreign community. The present
dominance of the medical model continues as modern therapists move into the
community in greater numbers” (Levine, 1983, p. 190). It is only recently that
changes in health care and increases in cultural diversity have led occupational
therapists, like many other allied health care professionals, into more
community and home care based practice.

Ieaming. In the field of education, Warren (1985) describes the emergence
and development of the teaching profession in response to societal beliefs,
pressures, and needs. For example, he traces the use of memorization to a time
(i.e. the late 1800s) when people, including teachers, had very few books and
so used memorization out of necessity. Since the teacher had the information
in her head, this contributed to the routinized, teacher-directed Ieaming that is
still universal today. Teacher qualifications were usually most stringent on the
moral character of the individual, with less emphasis placed on the teacher’s
knowledge of education. This is seen as a reflection of the times (as noted in
the review of the development of occupational therapy above) when women
were supposed to reMct the Victorian values of morality and purity and were
viewed as nurturing and caring individuals without much need or capacity for
acquiring knowledge. In addition, because the numbers of students increased
rapidly during this time and most women were required to leave the profession

29

if they got married, the demand for teachers increased, leaving little opportunity.
for schools to be particular about the educational status of their employees.

These issues, as well as the low pay offered to women at the time, did little to
contribute to the need for schools of education to prepare teachers. As a result
of these factors, teaching was held in low esteem, leading to a further decrease
in perceived need for elaborate academic preparation of teachers. It wasn’t
until many years later that teacher education programs at the 4 year college
level emerged, and then only in response to the public outcry to improve the
quality of education (Warren, 1985). As with the fields discussed in the previous
paragraphs, it was the values society placed on women and the need to
improve schools as seen through the eyes of the general public that ultimately
shaped teacher education programs.

Liming. As another example of a societal change affecting professional
practice and education, Andrews (1992) describes the influence that increasing
cultural diversity in the United States has had on the nursing profession. Like
Danziger, she states ‘nursing does not exist in social isolation, but rather within
the broader political, economic, and sociocultural milieu in which its members
practice their profession” (p. 11-12). She cites statistics that predict that “by the
year 2080, minorities will account for 51.1 per cent of the total population. . . . (In
addition), as the 21st century approaches, there is projected to be a continuous
increase in the number of immigrants and refugees in the United States” (p. 8).
Unlike the immigrants of Eastern Europe that journeyed to this country in the
past, these immigrants, as well as the African-American, Hispanic, and Asian
minorities in the United States, are no longer looking for a “melting pot.” Rather,
they are looking for a place where they can live without losing their cultural and
historical identities. The need for understanding these different cultural groups

30

is imperative in order to provide adequate health care to people from other than
the white majority, and to avoid misdiagnoses and misinterpretation of actions
on the part of these different groups of people. In response to these changes in
American society, Andrews states that nursing curriculums and continuing
education must reflect the need to deal with cultural diversity. “During the
remaining decade of the 20th century, nurses should plan and implement
strategies that will prepare present and future members of the profession for
cultural diversity that will characterize both society and nursing” (p. 14). In
other words, the professional ethos of nurses and other professionals must

evolve in response to changes in society’s expectations if they wish to remain a

viable service provider.

 

Like the professions described above, the field of physical therapy has been
shaped by a variety of social, historical, and cultural factors. One purpose of
this study, therefore, is to describe the influence of these factors on the
profession. The historical events, such as wars and medical epidemics (e.g.,
tuberculosis and polio) and their subsequent cures, have obvious direct effects
on the profession as the clients of the practice and the types of problems to be
treated have changed. These events can be documented fairly easily. The
social and cultural factors, however, may not be quite so obvious and have not
been addressed directly in the past. For example, the emergence of the civil
rights movement during the 1960’s had an indirect but powerful impact on the
profession in many ways. As minorities began to demand equality and laws
began to reflect these demands, the view of the role of women also began to
change. Because physical therapy is primarily a female profession, this
changing view of women as capable, independent decision makers has helped

31

 

 

 

move the profession from a technically oriented one in which orders are
received from the traditionally male profession of doctors, to a more
autonomous practice where students must be taught problem solving and
critical decision making skills. These changes are reflected in the current
educational goals and accreditation criteria of the American Physical Therapy
Association, as well in physical therapy curricula across the country. Other
societal changes reflected in physical therapy education include such issues as
increasing cultural diversity, increased acceptance of individuals with
disabilities in our society (as evidenmd by special education laws and the
Americans with Disabilities Act), and increased societal emphasis on
accountability and liability in all professions.

P ' l' t'

Having defined culture, it is important to define the process by which
individuals are enculturated. According to Mehan, “socialization denotes the
process by which culture is transmitted from one generation to the next”
(Mehan, 1980, p. 134). Similarly, Merton, Reader, and Kendall (1957) define
socialization as “the processes by which people selectively acquire the values
and attitudes, the interests, skills, and knowledge—in short, the culture-current
in the groups of which they are, or seek to become, a member. It refers to the
Ieaming of social roles” (p. 287). Professional socialization, then, is the
process by which individuals, initially as students, are enculturated into
professional practice by assimilating the values, attitudes, norms, beliefs, skills,
and knowledge of their chosen profession in order that they may successfully
assume the roles of the profession (Merton, et. al., 1957; Stroot &
Williamson,1993; Sabari, 1985; Hayden, 1995; Levinson, 1977). 'T he student

becomes the professional by Ieaming the content, acquiring the skills, and

32

internalizing the values of the profession” (Hayden, 1995, p. 271 ).
i It i n

In order to understand professional socialization, it is first necessary to
understand the process by which individuals are socialized into organizations
in general. Organizational socialization, based on theories of adult
socialization, is defined as “the Ieaming on the part of the individual who is
adjusting to a new or changed role within the organization” (Chao, O’Leary-
Kelly, Wolf, Klein, and Gardner, 1994), with an organization being defined as "a
complex social system made up of individuals, their facilities, and the products
yielded. . . a small corner store qualifies as an . . . organization as does a
multinational corporation, a political party or a university” (Reber, 1985, p. 501 ).
‘This Ieaming occurs in two general content areas: Ieaming about the
necessary knowledge, skills, and abilities to successfully perform the job, and
Ieaming about the way the organization functions in terms of its culture” (Chao,
1988). Without this Ieaming, newcomers cannot be effectively socialized into
the organization. The result is “increased turnover, lower performance,
dissatisfaction, negative work attitudes, and stress” (Ostrofl and Kozlowski,
1992).

Although an in depth analysis of organizational socialization is beyond the
scope of this study, a brief review of the major components of organizational
socialization theory is included here for several reasons. First, the educational
settings in which students complete their formal training are themselves
organizations that will impact professional development and socialization
(Becker, Gear, Hughes, and Strauss, 1961). For this reason, it is important to
understand how these organizations work and what effects the organizational
structure may or may not have on students. In addition, although formal

33

 

 

education is the major focus of this study, the end product of this phase of
socialization is to prepare students to function as competent professionals
within a variety of organizations (i.e. hospitals, clinics, public schools, home
care agencies, etc.). An understanding of the organizations in which the
students will ultimately work and the processes by which students continue to
be socialized in these work environments once they complete the professional
education program may shed some light on what students need to Ieam while
still in school.

Finally, in a broad sense, a profession can be viewed as an organization.
While this organizational view is perhaps best exemplified by professional
associations, such as the American Physical Therapy Association, it can also
be seen in the day to day activities of professionals as they interact with peers,
clients, and administrators in a variety of situations. lf individuals are to be
successful in these professional roles, they must not only possess technical
knowledge and skills, but must also know how to make the transition from the
student to the professional role in order to be able to fit in with the
organization’s conception of competent professional (Chao, 1988). In order to
facilitate this transition, it is important that educators in professional programs
help students internalize the necessary values and standards of behavior to
assume a professional role in a variety of organizations in order to decrease
professional attrition and job turnover (Chao, 1988).

' ' ' .21-1Theoristsinthefieldof
organizational socialization have described the changes that newcomers go
through in order to attain successful socialization. These include anticipatory
socialization, surprise and sense making. Anticipatory socialization

 

'represents all the newcomer’s Ieaming experiences prior to joining a specific

34

organization” (Chao, 1988). For students in professional education programs
this period is often equated with the formal education or training process (Brief,
Van Sell, Aldag, and Malone, 1979). These students gather information about
their future roles in organizations through academic course work, internships,
written informational material, and interactions with professionals in volunteer
or work experience. Once the students graduate from their respective programs
and begin their careers, may often experience a sense of initial surprise, the
second phase of organizational socialization, as the things they Ieamed about
and anticipated do not occur exactly as expected (Chao, 1988). As they
continue to evaluate and adjust to the discrepancies between their expectations
of practice and those of the “real world " (Yelon, 1996), they enter the third
phase of sense making (Chao, 1988). Others (Brief, at al, 1979) have referred
to this third phase as one of role management. “In the final phase of
socialization, role management, individuals impose their own definitions on the
roles they occupy, negotiating or modifying the roles to fit both the expectations
of role senders and their own preferences” (Brief, et al., 1979, p. 161).
W. Another area of emphasis in organizational
socialization has been the study of how it is that newcomers actually attain the
necessary knowledge and values of the organizational structure as described
above by Chao (1988). Several authors (Ostroff and Kozlowski,1992; Ostroff
and Kozlowski,1993; Chao, O’Leary-Kelly, Wolf, Klein, and Gardner, 1994)
discuss the importance of understanding the Ieaming process that occurs as
newcomers ‘Ieam the ropes” in order to become a successful part of the
organizational culture. The success of the newcomer in an organizational
setting depends on the ability to gather information about four domains within
the organizational culture. These include 'job-related tasks, work roles, group

35

processes, and organizational attributes” (Ostroff and Kozlowski, 1993, p. 171 ).
Newcomers to an organization gather this information from a variety of
individuals, including supervisors, peers, and mentors. In addition, Ostroff and
Kozlowski (1992; 1993) describe other sources of information, such as
organizational literature, observation of others, and experimenting with new
behaviors. The choice of which of these various methods of information
gathering to use depends on which domain (i.e. job-related tasks, work roles,
group processes, or organizational attributes) they are trying to learn about and
whether they are trying to obtain factual information or attain knowledge about
their task, role, group, or the organization (Ostroff and Kozlowski, 1992; 1993).
Ostroff and Kozlowski (1992) report that newcomers rely primarily on
observation of others, followed by gathering information from supervisors and
coworkers to acquire information and knowledge, and focus primarily on ‘task
and role-related” aspects of the organization during the initial socialization
stage. In addition, these authors report that "acquiring more information from
supervisors or more task knowledge is related to positive changes in
socialization' (p. 867). In a related study, Ostroff and Kozlowski (1993)
examined the role of mentoring in the socialization process. They discovered
that mentors provided the most valuable information about the organizational
domain, producing newcomers who were more politically aware of the
organization’s social system, its culture, and its history. As a result, they feel,
well-mentored individuals are more successful in the organization and in their
careers. The authors conclude that mentors provide information not acquired
through other sources (i.e., coworkers or supervisors), and therefore suggest
that mentors be used to enhance assimilation of new personnel.

Scholars in the field of organizational socialization describe the importance

36

of early, positive experiences to enhance professional commitment and career
effectiveness. “Generally, people who are well socialized in their

organizational roles have greater personal incomes, are more satisfied, more
involved with their careers, more adaptable, and have a better sense of their
personal identity than people who are less well socialized” (Chao, et. al.,
1994).

f r i ni ' n
Since the 1980’s, those interested in organizational studies have begun to

look at “organizations as cultures“ as a way to understand how these complex
systems function in order to improve “morale, loyalty, harmony, productivity, and
- ultimately - profitability" (Frost, Moore, Louis, Lundberg, and Martin 1991, p.
7). In spite of the proliferation of studies on organizational culture, however,
there was little in the way of the development of a theoretical perspective,
causing some scholars to view the concept of organizational culture as a
passing fad. In response to this, Martin and Meyerson (1988, as cited in Frost,
at. al., 1991) developed theoretical perspectives that would account for
differences in thinking about cultures in organizations. In mm
W Frost, at al. (1991) describe these three theoretical
perspectives of culture as developed by Martin and Meyerson (1988; in Frost,
et al., 1991). The first of these, the integration perspective assumes that culture
is consistent. There is a consensus about what to do and why to do it, with no
ambiguity. “[110 the extent that inconsistencies, conflict, ambiguities, or even
subcultural differentiation appear . . . they are seen as evidence of the absence
of . . . culture“ (Frost, et. al., 1991, p. 13). In contrast, the other two perspectives
allow for inconsistencies and ambiguities. The differentiation perspective

allows for inconsistencies through subcultures which “. . . may co-exist in

37

harmony, conflict, or indifference to each other . . . subcultures are islands of
clarity; ambiguity is channeled outside their boundaries” (Frost, et. al, 1991, p.
8). These subcultures may exist as equal groups or may manifest themselves
in a hierarchical nature, such as that which might exist between salaried and
hourly workers. In the last of these perspectives, the fragmentation
perspective, ambiguity is always present. “According to this viewpoint,
consensus and dissensus co-exist in a constantly fluctuating pattern influenced
by changes, for example, in events, attention, salience and cognitive overload”
(Frost, et al., 1991, p. 8). Because of a lack of consensus at both the
organizational and subculture level, those who believe in this perspective focus
on what is unclear in organizational cultures as a result of the complexity of the
system or of unclear expectations of performance.
A ' t'P iv nPfililitin

ln thinking about the culture of the profession, the educational system, and
the work settings in which students will eventually be employed as
organizations that are considered important for this study, I have adopted a
view of culture that combines these three perspectives.2 I believe that there is
set of core beliefs and values of a profession that is manifested in the
profession’s ethos. For this reason, the integration perspective is well suited for
this study, particularly as it relates to the first purpose (Part 1) of the study, to
describe the culture and professional ethos of physical therapy. In contrast, I
also believe that there are subcultures within professions (e.g., specialty
sections of national organizations) that exhibit differences and result in

 

2 Frostet.al.(1991)acceptmatdlfluemmidlesmayfomsmeiflteroneorsewraldmese
perspectives. 'Thesethreeperspectlves.. arenotmeanttopigeonholelndivldualresearchersorevenall

thecltaracterlstlcsofaslnglepleceofwork'(p. 9).

38

inconsistencies and ambiguities within the profession. To the extent that issues
are related to the core beliefs and values of the profession, these subcultures
exist in harmony. To the extent that issues are not related to the core beliefs,
however, there may be disagreement or indifference among these subcultures.
Of the three perspectives, the fragmentation perspective is, I feel, least related
to defining the professional ethos and culture of physical therapy since it allows
for very little cultural clarity. I do think, however, that the emphasis on dissensus
and complexity of viewpoints of those who are part of the culture is very
important to consider when one is attempting to understand a professional
culture and its ethos. By keeping this perspective in mind, I think I have been
able to better understand the professional culture and its ethos since I looked
not only for similarities, but also for differences as a means of explaining the
evolution of the culture and the professional soCialization of students. These
differences may, in fact, be the impetus for changes in the professional ethos
over time and for the problems that students face as they move from the
academic to the professional world.

One example of a current controversy within the field of physical therapy that
is reflective of the fragmentation perspective is the recent increase in the use of
physical therapist assistants in a variety of settings compared to their use in the
past When there was an extreme shortage of physical therapists, the urgent
need for qualified personnel led to the creation of the physical therapist
assistant. In light of the pressure to lower costs in health care today there is an
increasing shift in work load in many settings from physical therapists to
physical therapist assistants. Many physical therapists are alarmed about job
security due to the use of physical therapist assistants and the increasing
number of educational programs for both physical therapists and physical

39

therapist assistants. Contrary to yesterday’s pressing need for more and more
physical therapists, a recent study (American Physical Therapy Association,
19970) described the need for physical therapists as shrinking. One offshoot of
this situation is that there is beginning to be job competition between physical
therapists and paraprofessionals, physical therapist assistants, who filled an
important need in the past. In addition, the House of Delegates of the APTA
recently passed a resolution to restructure the organization into two factions -
the American College of Physical Therapists and the National Assembly of
Physical Therapist Assistants. Although proponents of the resolution feel it will
give a greater voice to physical therapist assistants within the Association, there
are those who disagree and feel that the measure will decrease the power of
assistants, destroy the unity of the Association, and fragment the profession.
The combination of factors that has shifted the roles and responsibilities of
physical therapists and physical therapist assistants within the Association and
the clinical setting continues to create controversyand ambiguity within the field
as these two factions struggle to define their function within the profession. The
result has been an increasing disparity in opinions regarding which road the
profession should take to best serve both its members and its clients. As these
disparities disappear and some consensus is reached regarding the
relationship between the physical therapist and the physical therapist assistant,
I feel the profession will have evolved to a new level, one that is not necessarily
better or worse, but simply different.

In addition to being important for understanding the values and evolution of a
professional culture, the dissensus and complexity reflected in the
fragmentation perspective is also important in that it parallels that of the
postmodem perspective of Gergen (1991) discussed earlier. That is, the

40

emergence of a multiplicity of view points and diversity due to the increasing
pace of change in today’s world has lead to ambiguities within professional
cultures and society at large that need to be addressed in professional
education. Because the world is no longer one in which there are black and
white solutions to problems and because students and clients come from
increasingly diverse backgrounds, there is a need to focus more intensely and
explicitly on both the existence of diversity and methods for dealing with it in a
professional world.
P fPrf inl il'ztin

The process of professional socialization is a complex one that requires the
internalization of a multitude of influences on the developing professional.
These influences can come from personal sources such as family, school, and
religious affiliations, as well as from professional and societal sources such as
the work setting, professional organizations, cultural beliefs and values,
economic and political climates, and legislation that affects the profession and
society. Each of these influences is not enough in and of itself to determine
how successful one will be in being socialized into the profession. Rather it is
the integration of these multiple influences that shapes the developing
professional. The reader should keep in mind, therefore, that while each
influence is described in the following section as a separate entity for purposes
of description, it is the integration of all these influences that ultimately
determines the success or failure of the process of professional socialization.

W The fields of
education and educational psychology have begun to look at the development
and socialization of teachers in this regard. Goodman (1987), for example,

stresses the active role of beginning teachers in the socialization process.

41

Others (Ambrose, 1993; Bruner, 1987; Gee, 1990, Polkinghome, 1988; and
Steinem, 1992) describe the importance of interaction within a community
through narrative discourse and personal storytelling, the recognition of ever
changing selves that evolve as a result of this discourse, and the impact of
these different discourses on our many selves. The use of the words
“community' and “discourse” require definition in order to understand the role of
the active participant in the construction of a profession. First, the word
community must be thought of in a broader context than merely a group of
people living together. Schwab (1976) defines a community as a “state or
condition of person, of internalized propensities, of tendencies to feel and act in
certain ways with other people“ (p. 11). The sharing of values, goals, and
ideas are the essential ingredients that create a community. Harris (1995)
describes a community as follows:

A group can become a community, then, if there is a degree of
intimacy and perceived connection with the members that is
manifested through certain rituals, events, and interactions, that
take place over a period of time. In this way, even strangers who
initially may appear to have little in common with one another can
become a “community,“ if they are able to come together - either
in face-to-face interaction or over time and distance . . .
Communities do not spontaneously appear but are rather
“constructed” and maintained by a mutual sense of connection
and care among members. (p. 9)

In comparing this definition of community to the definition of culture, it
appears that it is through the community that the professional culture evolves
and is passed on to new members. That is, one comes to know about the
culture of the profession by interacting with others through communities of

practice.

42

W The second
word needing clarification, discourse, is defined by James Gee (1990) as both a
language interaction (discourse) and as a “way of being“ within the context of a
community (Discourse). In regard to the second definition Gee (1990) states:

Each Discourse is tied to a particular social identity within a
particular social group and to certain social settings and
institutions. Each is a form of life, a way of being in the world, a
way of being a “person like us,” in terms of action, interaction,
values, school, local drinking group, church, nation, ethnic group,
sewing circle, business, job site, profession, gender, club, peer
group, gang, and so on through a very long list. (p. 175)

Discourse within the field of physical therapy can be viewed as occurring in
two communities. First, professional organizations serve as one major
community of discourse for practitioners. Scholars share their knowledge
through presentations at conferences and publications in professional journals,
political action committees are formed, continuing education sessions are held,
items of interest regarding related fields are shared through magazines and
newsletters, and social gatherings are planned in conjunction with professional
meetings. For physical therapists, the American Physical Therapy Association
(APTA) is the primary professional organization. In addition to offering a means
of discourse for practitioners, this organization also provides the major
community, or Discourse, for physical therapists. As discussed earlier, a
community involves shared meaning, values, and ideas. An expression of
these shared meanings, values, and ideas can be found in the Code of Ethics
and Standards of Practice of professional organizations, as well as in the more
subtle forms such as how one dresses and acts when representing the
profession. In this way, a professional organization serves as a starting point

for entrance into the Discourse of the profession.

43

The second means of community discourse can be found in the everyday
lives of those who practice in the field. In many ways, this community is more
important than that of the professional organization, for while a professional
association offers a common forum for the sharing of ideas and beliefs, it is
within the day-to-day working life of a professional that the realization of these
ideas and beliefs is played out. Without practice, one could easily espouse the
values of the common organization without ever being put to the test. For-
physical therapy, a very “hands on" and people-oriented profession, the
interaction between the therapist and the client is one of the major ways in
which we exemplify professional ethics and high standards of care that are part
of the discourse of our practice. Within this same setting, therapists also interact
with other health care professionals, staff, and the general public. As with the
client, behaviors that reflect the identity of the profession are played out in these
interactions as a community is created.

.= 0 .: 0 3.01:1 2. m 0 .0 : 0.: ' v.2 n 0 cf: ~>10 I .0. II' 21101. A
number of socializing agents other than formal education have been identified
in the literature (Bradby, 1980; Eli, 1984; Rezler, 1974; Sabari, 1985). Students
in professional programs are not socialized in isolation within the educational
setting. Rather, they interact reciprocally with a host of others outside of and
prior to their educational experience (Kondo, 1990; Myers, 1982; Sabari, 1985).
The type of family upbringing, the individual’s religious beliefs, and the
influence of peers are examples of personal history that students bring with
them to the educational setting. Similarly, while enrolled in professional
programs students interact with others in home, work, and recreational settings.
The experiences of students in these settings and those with whom they interact
continue to influence the student’s response to efforts by educators to socialize

44

students into the profession. In addition to these more personal influences,
individuals are embedded within a societal culture that also influences their
thoughts, feelings, and actions as they enculturated into their chosen
profession.

Several authors (Abbott, 1988; Heck, 1995; Sabari, 1985; Stroot and
Williamson, 1983) discuss the issue of prior experiences and societal
influences on professional socialization. Abbott (1988), in a discussion of the
role of values and moral development in the professional socialization of social
workers, talks about the influence of societal values on personal values and the
subsequent influence of both of these constructs on professional values.
Professions exist within a larger cultural context and canmt be arbitrarily
separated from it. Rather, the values and standards of the culture as a whole
must be considered in any conception of professional socialization. The role of
personal values in the process of professional socialization not only is
important in helping social work students to develop a sense of professional
identity while in school, but also serves as a form of self-selection as individuals
whose values most match the profession’s will choose to enter that profession.
. The idea of

self selection into a profession is an example of how professional socialization

 

is both an active and reciprocal process. Students come into educational
programs with certain values and expectations that educators hope to alter, but
educators cannot dramatically change the basic norms, values, and beliefs that
students bring with them (Bradby, 1980; Eli, 1984; Rezler, 1974). Students are
not empty vessels into which faculty pour their own set of beliefs. In addition,
students are not only affected by what happens to them during their
professional education, they also affect those around them and, in at least some

45

sense, determine the extent to which they will allow themselves to be socialized
into the profession. Because of this several authors (Bradby, 1980; Eli, 1984;
Rezler, 1974) take the idea of the importance of a match between personal and
professional values further by suggesting that professional education programs
establish selection criteria that identify individuals who possess the qualities,
traits, and beliefs that the profession desires.

In the field of physical education, Stroot and Williamson (1993) describe the
various pre-admission factors that affect professional socialization of these
students. These factors include self selection due to early socialization
experiences in sport, early observation of coaches and physical education
teachers, and low GPA requirements for admission. In addition, although these
authors acknowledge the contribution of researchers in professional
socialization of physical educators, they recommend that future efforts be
expanded beyond the current focus on individuals and small groups.
“Influences of politics and socio-cultural factors require that we view
socialization from macro-perspectives as well as a micro-perspective. It
becomes imperative that we examine and understand values and perspectives
upheld within the society, in the context of study and work, and by researchers
and participants” (Stroot and Williamson, 1993, p. 343).

Levinson (1967) emphasizes the important role of “both the external, socio-
cultural aspects and the internal, personalogical aspects. Both are crucial in
the analysis of socialization. . . . The student is not only acted upon by the
environment, he is also an active agent who plays a vital part in his own
learning and development The kind of person he is at the start has an
influence upon, and is influenced by, the course of his scth experience“ (pp.
261-262). Furthermore, Levinson (1977) describes the importance of

46

considering the impact of other organizations with which professionals (In this
case, physicians) will come into contact, with the different roles they will play in
various settings, and with different encounters they will have throughout their
professional lives.

W. Societal and contextual influence in the form of power
in professional settings has also been examined. In Crafting Selves, Dorrine
Kondo (1990) discusses the importance of power relationships in the
construction of personal and professional identity. She states that it is important
“to make issues of power central to our discussions of self (because we) . . . are
shaped by relations of power“ (p. 9). Power relationships, both those that are
present in our immediate surroundings, as well as socio-cultural and historical
influences that are more indirect are an important consideration in professional
socialization.

In a study of nurses in a hospital setting, for example, Myers (1982) describes
the process by which “neophyte nurses Ieam to behave like old timer nurses”
(p. 11). Myers stresses the importance of considering socialization as a
“reciprocal process by which neophyte nurses Ieam what others will demand of
them in a specific role and in turn, Ieam how to exert control over their
environment“ (p. 1). She discusses the importance of the power structure for
socialization. “Registered nurses or medical doctors exerted social control over
neophyte nurses through the temporal, spatial, social, and medical organization
of activities“ (p. 113). When assisting doctors, however, all nurses
subordinated their positions of power. “During verbal interactions, doctors
talked; nurses listened. Doctors led in pacing and timing; nurses following.
Doctors initiated interactionsto parents; nurses listened“ (p115). This
hierarchical structure helped shaped the socialization process of neophyte

47

nurses. In addition, prior training and other life experiences also influenced
both the rate and degree to which these participants were able to take on a
more professional role in the work setting. Overall, the degree to which
neophyte nurses were able to find a fit between idealistic and real world views
of nursing and to adapt to inconsistencies between these two views ultimately
shaped their professional socialization.

1 2'11: 1.~.:ofuini . v t» ork .ttino on oorfe - io.nl .o. il' 1otin.
Lurie (1981) studied the socialization process of nurse practitionersato try to
determine if the professional socialization that occurs during training or the
expectations and constraints of the work setting are more powerful in
determining professional behaviors in this group. Self-report, observations,
and interviews were used in a longitudinal study that examined professional
socialization in five cohorts of nurses who graduated from the Allied Health
Nurse Practitioner Training Program at the University of California. In addition,
nurse practitioners were compared with non-practitioners through self report
and observations, and the views of physicians and nursing supervisors toward
nurse practitioners were compared through interviews. Results of this study
indicate that while the educational setting is the initial, primary determinant of
professional socialization since “without this initial socialization, there would be
no professional at all“ (p. 46), it is the work setting that is the more powerful
socializing force because it is within the work setting that professionals
ultimately must live. If professionals are to maintain employment, they must
work within the constraints of the organizational setting where they are
employed. These constraints include not only the mles or standards of

 

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48

behavior of the organization itself, but also the roles different members of the
organization play in terms of power. In Lurie’s study, for example, only those
work roles prescribed by the training program that were consistent with the
views of physicians (i.e. clinical assessment and management activities), the
ultimate power authority in health care settings, were supported and practiced
regularly, while those that were inconsistent with physicians’ views were not
(i.e. patient education and counseling). Lurie speaks to the power of the setting
and the individuals in the setting in determining the success of carryover
between formal education and work settings. The extent to which there is
consistency in the goals of each and the degree to which individuals, as
employees, are willing to challenge the power structure of their employment
setting will determine the ultimate success of the professional socialization
experience.

WWW Based on these
studies, there are number of issues related to professional socialization that
need to be considered by educators as they attempt to help students internalize
a professional ethos. First, educators are not the only people who influence
students. Prior experience and significant others, such as family members and
friends, have at least the same amount if not more influence on the developing
professional. By recognizing and acknowledging the role of influences outside
the academic setting educators may be able to help students deal with
inconsistencies between the values, norms, and beliefs of the profession and
those outside the field. This issue also has implications for program selection
by students and program admissions. As discussed by several authors (Sabari,
1985; Abbott, 1988; Stroot and Williamson, 1983; and Heck, 1995), students
most often select those professions whose values and beliefs are consistent

49

with their personal beliefs and values. When this is not the case, and the
student’s values and beliefs are so inconsistent with the profession that the
possibility of reconciling the differences seems remote, educators may be wiser
to advise the student to find a career whose ethos more closely matches the
personal ethos of the student rather than trying to change the beliefs and values
of the student.

Based on the descriptions of power and the nursing studies cited in this
section, it also seems that the ability to deal with issues of power is an important
skill to teach. One of the responsibilities of faculty in the socialization process,
then, may be to help students recognize and deal with those in positions of
power so that they can be successful in their careers. The ultimate ability to
any out this skill, however, would seem to go beyond the mere logistical
processes of doing so, and would instead rely on the belief that what one does
is important to the client (whether that client is a patient, a student, or a
customer). Recognition of one’s worth within the organizational setting as part
of the professional ethos is one way to help empower students and novice
professionals.

WWW

For students in health care, as well as in other professional programs, the
socialization process can be seen as occurring in three separate stages: formal
education within the academic setting, practical experiences within a clinical or
apprenticeship setting, and work related experiences following graduation
(Sabari, 1985; Myers, 1982). The questions posed in this study address the
socialization process that occurs primarily during preparatory education within
an academic setting. Specific practical experiences within the apprenticeship
setting and work related experiences are beyond the scope of this study and

50

are addressed only to the extent that they are related to and influenced by the ‘
socialization that occurs in the students' initial training in schools.

Most studies of professional socialization in health care fields have been
conducted with medical and nursing students. Other fields reviewed here
include dentistry, occupational therapy, public health education, and
educational administration. At this time, no research could be found that
specifically addresses the process by which students are socialized into the
profession of physical therapy. The findings and conclusions of those in other
professions, therefore, are used as the starting point for the description of
professional socialization applied to physical therapy. Table 2 summarizes
these studies as they are related to the idea that professional socialization is a
complex process and as recommendations or implications for educators in
professional programs.

Pf'l il"Drin l 'n

In Mite (Becker, et al., 1961 ), the classic study of medical students,
the authors describe the process by which medical students move through the
medical education system. According to these authors, the medical student is
never a “young doctor.” On the contrary, medical students are simply “students
(who) occupy a defined position in the medical school and interact in ways that
are specified by institutional roles with people occupying other socially defined
positions“ (p.34). They participate, not as members of a professional culture,
but as members of a “student culture.“ When viewed from this perspective, the
authors contend, students are fulfilling their role in the organization of medical
school. As a result, these future doctors display behaviors that are reflective of
their efforts to deal with problems that they face as students, such as passing

exams and pleasing faculty. It is only as students near the completion of

51

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56

medical school that they begin to imagine the roles they will play in new
organizations when they begin the practice of medicine. While life as medical
students may offer a glimpse of the culture of real doctors, as students they can
only identify with the culture of medical students. In fact, the only change that
Becker, et al. (1961) report is that students move from a feeling of idealism
regarding the medical profession to cynicism throughout school to a final
feeling of pragmatic idealism at the end of medical school. This temporary
cynicism is thought to be the result of the tremendous demands of medical
school. As such, they represent the students’ feelings toward medical school,
as a temporary response to their educational situation, rather than their feelings
toward medicine as a career.

Levinson (1977) offers a different perspective and a critique of W.
He feels that Becker and his colleagues do an injustice to the importance of
medical education and theories of adult socialization by not giving more credit
to medical school as the first step in socializing students into the professional
culture of medicine. In contrast to Becker, et. al. (1961), Levinson (1977) states:

One need not assume that the characteristics of the graduating
students are fixed and immutable, and that they prefigure his
entire medical career. However, socialization theory does involve
the premise that the most significant changes wrought in the
student are the relatively enduring ones, and that they will exert an
appreciable influence on his further professional development
even though they may also be modified in the process. (p. 258)

This view is also supported by Merton, Reader, and Kendall (1957) in one of
the earliest studies on professional socialization in medicine and by Baszanger
(1985) in her study of the professional specialty of general practice. Similarly,
professional socialization literature in nursing supports the idea that formal

professional education is the basis on which the professional ethos is built

57

(Cohen and Jordet, 1979; Brief, Van Sell, Aldag, and Mellone, 1979; Lurie,
1981). Lurie (1981) states, “In professional socialization, training or education ,
may be seen as the fundamental building block of all further socialization. It
conveys the basic knowledge, skills, and 'theory’, the world view and attitudes,
that are the essence of each profession” (p 45).

Similar to Levinson, Flezler (1974), in a review of the literature on attitude
changes in medical school, reports that medical students do experience attitude
changes to some extent during medical school. Rezler’s (1974) review
supports the change from cynicism to realistic idealism reported in 5000.
Mite (Becker, et. al., 1961). In a further analysis of the literature on
comprehensive care programs4 and high interaction specialties such as family
practice, Rezler (1974) reports that cynicism could be decreased and a more
humanistic attitude toward patients could be fostered, but many of the changes
reported in the studies she reviewed were weak and/or temporary due to a
number of other factors. The factors that positively influenced the degree to
which attitude changes could be fostered include positive faculty role models;
systematic and consistent rewards for desired behaviors; consistency in
expectations throughout courses and clinical work; and consistency in attitudes
of those groups with whom the students come into contact (i.e. peers, interns,
faculty). In spite of some changes in attitudes, Rezler concludes that, based on
the studies she reviewed, “attitudes are highly resistant to change, unless
supported and reinforced by the total environment“ (p. 1029). In addition, she
suggests that promoting consistency in training is not enough. As described

earlier, she feels that educators also need to place a greater emphasis on

 

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58

“selecting students who possess certain attitudes prior to entrance, attitudes that
the medical profession considers important, instead of trying to develop such
attitudes in students after they enter medical school” (p. 1029), rather than
selecting students primarily on the basis of their intellectual qualifications.
Further, she suggests that this type of attitude assessment be used to select
faculty if medical schools are to provide students with appropriate and
consistent role models for quality and humanistic care.

Like medical students, dental students display increased cynicism and
decreased humanitarianism throughout their formal education (Sherlock and
Morris, 1972; Morris and Sherlock, 1971, cited in Eli, 1984). In order to
determine whether these attitudes were permanent, or were merely a result of
being in a “student culture” as described by Becker, et al. (1961), Eli (1984)
conducted a longitudinal study of expected professional rewards in dentistry.
Individuals from an educational system in which dental and medical students
complete identical course work during the first three years of professional
school and complete clinical work in their respective professions in the last two
years participated in the study. All students completed questionnaires about
their expectations for professional rewards prior to admission, and at the end of
their fourth, fifth, and sixth years of study. In addition, the questionnaire was
completed by the dentists eight years post graduation. Two findings Eli’s study
are particularly applicable to my research with physical therapists. First, Eli
notes that there was no change in the relative ranking of expected rewards in
either group during their period of formal training, indicating that there was no
significant change in the students’ basic norms and values. Secondly, a
comparison of responses between medical and dental students revealed that
dental students displayed more cynicism and materialism than medical

59

 

 

 

students and placed increased emphasis on extrinsic rewards (i.e., high
income, job status, high social status). In spite of the fact that these students
displayed even more cynicism than medical students, after eight years of
practice, these same individuals returned to a more idealistic outlook on their
profession and placed a higher value on intrinsic (e.g., opportunity to help
others, intellectual challenge) rather than extrinsic rewards. On the surface,
these findings support the conclusions of Becker, et. al. in stating that the
increased cynicism in medical students is a situational response to medical
school that is replaced by a pragmatic realism at the time of graduation.
However, because a significant amount of time (i.e., eight years) had elapsed
between the time of graduation and completion of the final questionnaire, it is
also feasible that many other factors affected the respondents’ answers. For
example, because these dentists were well established in their practices after
eight years, the material rewards they were receiving may have been taken for
granted allowing a shift in their thinking to the idealism of their early school
years and an emphasis on more intrinsic rewards. In addition, the process of
professional socialization throughout the time from graduation may also have
helped them to learn to respond to the questions in a more socially desirable
manner.

Sabari (1985) describes the process of socialization of occupational therapy
students, a group that is most likely to resemble physical therapy students. Two
types of socialization patterns are present in occupational therapy education.
First, in the initial academic component of the program students are socialized
in a collective (i.e., group) and serial pattern, in which they have opportunities to
interact with “previous members who have experienced the same process and
who can teach them about the setting . . . This structural factor has implications

60

for the role of the peer group in the professional socialization process. The
students are in contact with other members of the collective group. In addition,
students in advanced classes are available to share their experiences and
teach entrants about the setting” (p. 97). In contrast, as students begin their
clinical training, they usually interact individually and in a disjunctive pattern,
where neither a peer group or members of a previous cohort are available. At
this point in the socialization process, Sabari feels that individual interaction
and the absence of other students ultimately leads to the students having a
stronger identification with their clinical supervisors than with the faculty. Other
aspects of professional socialization in occupational therapy include selective
admission, which Sabari feels increases motivation and commitment to the
program; separation from other socializing influences as a result of a unique
program; the large amount of work required to successfully complete the
program; and certification of graduates upon completion of their education.
She stresses the importance of active and responsible Ieaming, having
appropriate role models in the form of faculty and clinical instructors, the
availability of clear and consistent goals that are articulated and reinforced in
both the academic and clinical settings, the influence of clients’ expectations on
professional self image, and realistic expectations for practice in the real world.
Hayden (1995) examined the extent to which public health education majors
are professionalized during formal education training. She surveyed 179
students from 30 programs in health education. Subjects completed the
Occupation Inventory (OI), “an instrument used to measure the extent to which
students are professionalized" (p. 272), and gathered information about student
involvement in various professional activities (09... taking the certification exam

in health education, membership and participation in professional

61

organizations). High OI scores indicated a moderately high degree of
professionalism with only the intent to take the certification exam having any
significant impact on the degree of professional socialization (other factors
included class status, age, race, sex, program, and membership in professional
organization). In regard to the positive relationship between plans to take the
certification exam and increased professionalism, Hayden states, “this supports
the assertion that credentialing and professionalism can and should co-exist'
(p. 273). The author also states that the fact that there were no differences
between junior and senior students in the program supports the idea that
socialization in these students occurred early in the program. Another
possibility, not considered by Hayden but evident in other studies cited earlier,
is that students possessed certain professional traits of health educators prior to
entrance and so self-selected into the profession.
V I W rl ti n

Anticipatory socialization is often viewed as the first phase of training or
professional socialization, which occurs before and during formal educational
training as students complete courses and come into contact with other
individuals who are knowledgeable about their chosen career (Chao, 1988).
The importance of anticipatory socialization is described by Chao, who states
that ‘the degree to which the anticipatory socialization experiences of
newcomers match the organizational reality of a prospective employer can be a
key determinant of an individual's ability to quickly and successfully adjust to
the new environment and demands” (p. 34). Presenting a realistic view of the
professional world through the anticipatory socialization that occurs as a result
of formal education in professional programs is an important precursor for

predicting success in one’s chosen profession.

62

Brief, Van Sell, Aldag, and Melone (1979) examined the discrepancy
between anticipatory socialization and real world expectations that resulted in
role stress for new nurses. They found that the degree of incongruence
between role definitions acquired during formal education (i.e. anticipatory
socialization) and those of employing organizations is related to the amount of
role stress experienced by nurses. Further, these authors report that role
management, defined as the ability to modify role expectations based on both
personal and organizational ideals, does not occur over time when there are
significant discrepancies between these two models of role expectations. The
authors conclude that formal educational programs must present a realistic
view of career and organizational demands if the profession of nursing wishes
to decrease role stress and professional attrition in their graduates.

Bradby (1990) examined the role of status passage from student to nurse.
Status passage is described as “a life transition from one social status to
another . . . (including) the anticipations and anxieties experienced prior to the
event. This may be accompanied by some preparations such as asking about
the rights and obligations associated with this new position, actually making an
attempt to experience it to some extent, or gaining work experience in a similar
work setting“ (Bradby, 1990, p. 1220). Bradby concludes that although
anticipatory socialization during professional training is an important
component of successful status passage from nurse to student, there are some
aspects of the professional role that “can never be completely revealed and
assimilated while the person is not part of the organization” (p. 1224).
Although Bradby acknowledges that individuals will always experience some of
the problems associated with status passage, she suggests that students will
anticipate less stress and feel more in control of their passage from one social

63

status to another if, as students, they are both nurtured and made to take
responsibility for their own actions and Ieaming; if there is someone in the work
organization who can serve as a mentor to help the newcomer “Ieam the
ropes“; if individuals are emotionally and psychologically prepared for the
changes and feelings that they will experience as they move from student to
nurse; and if the individual has high self esteem and low anxiety. In regard to
the last finding of high self esteem and low anxiety, Bradby suggests that
educators examine their selection process to allow for a preference for students
who display those characteristics prior to entering the formal training program.
In addition, she urges educators to consider the impact of previous life
experiences and the role of interacting with patients and others outside of the
formal training session when evaluating the effectiveness of the educational
institution in helping students cope with the change in roles from student to
professional.

Heck (1995) studied the effect of organizational and professional
socialization on new school administrators. He cites the importance of success
in both professional (i.e., formal training, including internships) and
organizational socialization on a new assistant principal’s job performance.
One hundred and fifty beginning administrators and their immediate
supervisors completed a questionnaire evaluating the assistant principal’s
school year performance. Results revealed that organizational socialization
had the most powerful effect on job performance, with professional socialization
exerting an indirect effect via its effect on organizational socialization (e.g.,
administrators who had completed an internship during their formal training had
more real world experience, and, therefore, functioned at a higher level than
those who had not completed this type of training). Personal attributes,

64

especially gender (e.g., women had higher job performance ratings), also
affected job performance rating. This study supports the findings of Lurie
(1981), discussed earlier, who also found professional socialization to be a
necessary but less powerful influence than organizational socialization on
measures of professional success in nursing. Similarly, Myers (1981),
discussed earlier, described how neophyte nurses’ observations of power
relationships in the work setting ultimately shape their perceptions of
professional roles more than prior training or life experiences.
WW

There are a number of issues related to these studies that can shed some
light on the questions posed in this study. First, educators should keep in mind
that there are several socialization processes occurring while students are
enrolled in formal training. While the faculty are working hard to help students
attain a professional ethos, the students are also attaining a “student ethos" as
they become part of the student culture (Becker, et al., 1961). Although the
professional socialization process that occurs while students are in school is a
powerful influence (Baszanger, 1 985; Levinson, 1 977; Merton, et al., 1957),
students also need to deal with “getting through the program” before they can
ever hope to apply what they have Ieamed outside the academic setting. This
finding may have more implications for faculty than for students. In particular,
being aware of this phenomenon may keep faculty from becoming frustrated as
they expect students to assume professional roles while they are still students.
In addition, knowing that the values and beliefs of students do come closer to
those of the professional ethos when students graduate and begin practice may
also help faculty gain a more realistic outlook on the process of professional

socialization. Time becomes an important element when professional

65

socialization is viewed from this lens. Faculty cannot expect students to
internalize the professional ethos entirely during the short time they are in the
professional preparation program.

Next, the process by which students internalize the professional ethos of a
culture and subsequently display behaviors that reflect that ethos is a complex
one with multiple interactions occurring among students, society, and the
professional culture (Abbott, 1988; Bradby, 1990; Levinson, 1977; Stroot and
Williamson, 1993). The student does not appear one day as a blank slate
ready to be inscribed with the professional ethos of choice. They bring with
them a multitude of life experiences both related and unrelated to the
profession that influence their professional values, norms, beliefs, and
behaviors (Myers, 1982). In fact, the idea that students self-select into careers
because of a match between their own personal beliefs and those espoused by
a profession has been postulated by several of the authors included in this
review (Abbott, 1988; Stroot and Williamson, 1993). Moreover, they are
influenced not only by faculty, but also by peers (Becker, et al., 1961; Sabari,
1985; Stroot and Williamson, 1993), other professionals (Levinson, 1977; Lurie,
1981), clients (Sabari, 1985; Stroot and Williamson, 1993), and other outside
forces (Levinson, 1977; Sabari, 1985). Some of the students’ attitudes can be
altered, but it appears that none can be substantially changed (Bradby, 1990;
Eli, 1984; Rezler, 1974). Instead, educators can hope to capitalize on those
values and beliefs that students already possess and that are consistent with
those of the profession (Baszanger, 1985; Levinson, 1977; Merton, et al., 1957),
helping them to apply personal values and beliefs in professional situations.
The firm establishment of a professional ethos during formal training is

important. Formal training not only provides the base of socialization (Brief, et.

66

al, 1979; Cohen and Jordet, 1979; Hayden, 1995; Levinson, 1977; Lurie, 1981;
Merton, et. al, 1957), but also must be extremely successful in this endeavor if
educators wish students to be able to overcome any alternative or questionable
views once they begin the organizational socialization that occurs in the work
force, a more powerful influence than that of formal training (Heck, 1995; Lurie,
1982)

This review of the literature offers several recommendations for socialization
of students in professional programs. The most often cited of these is the
existence of clear and realistic goals that are explicitly presented to students
and are applied consistently across the situations and people with whom
students come into contact, and that represent the real world (Fox, 1957; Lurie,
1981; Myers, 1982; Sabari, 1985). These goals would not include descriptions
of exactly how to act in all situations, but might include such things as the fact
that faculty do expect students to behave in the best interest of their clients to
the best of their ability, and that they expect students to be problem solvers and
lifelong Ieamers.

As discussed by Bradby (1990) some sense of surprise (“reality shock“) and
eventual sense making is a normal part of the developmental process in
organizational socialization. It appears, however, that educators can minimize
the trauma of this transition and the role stress that accompanies it by providing
students with a real world view of professional life. This includes things like
letting students know that they may experience these feelings and that they are
a normal part of the developmental process (Bradby, 1990) and training them
for uncertainty as proposed by Fox (1957) and Floden and Clark (1988). The
second most often cited way in which educators can hope to successfully
prepare students to function as effective and ethical practitioners is to be sure

67

that the student is an active, reflective, and responsible learner (Bradby, 1990;
Fox, 1957; Levinson, 1977; Sabari, 1985). Students who actively take
responsibility for their education appear to develop more problem solving and
information seeking strategies, are more adaptable, and experience less role
stress than their peers.

Other methods, while not as common as those described above, also
deserve consideration as possible ways to facilitate the internalization of a
professional ethos in students. These include clear admissions criteria that
allow selection of students who already demonstrate behaviors indicative of the
values and beliefs of the profession (Bradby, 1990; Sabari, 1985), positive and
consistent role models (Bradby, 1990; Sabari, 1985), and the use of
appropriate mentors to help students through the period of organizational
socialization that occurs as new graduates enter the job market (Bradby, 1990;
Ostroff and Kozlowski, 1993; Stroot and lMlliamson, 1993).

In addition to these various methods, the authors cited in this review also
after several words of advice for educators in professional programs. First,
based on the work of Becker, et al. (1961) and Eli (1984) there is some
evidence to suggest that some of the behaviors and attitudes exhibited by
students during enrollment in a professional educational program are
situational and temporary and will reverse themselves once the students attain
their own sense of professional identity when they are out in the field. Personal
experience and conversations with other physical therapy faculty reveal that
this is often the case in physical therapy education. Many students who display
negative behaviors and attitudes in the educational setting often do well in the
clinical setting. This is not to say that all students will successfully graduate and
begin their careers with a strong sense of professional ethos, but it certainly

68

offers hope to faculty who feel that many of their students are behaving
unprofessionally while in the educational setting. Other factors that may be
important considerations for educators, as cited in this section, include the type
of socialization pattern (Sabari, 1985), separation from other outside influences
(Sabari, 1985), and certification processes following the educational period
(Hayden, 1995; Sabari, 1985). Finally, several authors discussed the
importance of power and politics in any organizational setting (Kondo, 1990;
Lurie, 1981; Myers, 1982). I feel these are important issues to discuss with
students as they develop more realistic views of the professional world they are
about to enter.

69

Chapter 3

Gathering Evidence for Describing the Process of Professional Socialization

WWII

This study is designed in two parts, each of which addresses different
questions (See Table 1 for an overview of the design). In Part 1, I used several
sources to gather data about the history, culture, and ethos of the profession of
physical therapy. Because I was seeking information about the evolution of the
professional culture across the years, I interviewed senior members of the
profession who have been and, in some cases, continue to be leaders in the
field. These individuals offer a more historical outlook and draw on their
experiences across their lives and the life of the profession to come to some
conclusions about the core characteristics of the ethos of physical therapy. This
data was gathered in several ways. First, I conducted and analyzed individual
interviews with three physical therapists who are Fellows in the American
Physical Therapy Association (Pan 1A) to look for major themes that address
the questions posed in this study. Next, a focus group interview was conducted
with 11 members of the Prime Timers (Part 1B), an unofficial subset of the
American Physical Therapy Association composed of members of the
Association who are over the age of fifty. While fifty is the lower limit for
membership in the Prime Timers, most members are of retirement age and
continue to serve the Association by providing guidance to younger members
(Ketter, 1995). As with the Fellows of the APTA, these older members of the
profession offer insight into questions that younger members cannot. In Part
1C, the Mary MacMiIlan Lectures (28 Mary MacMiIlan Lectures have been given
since 1964) and APTA Presidential Addresses (29 documents) were used to

70

gather information on major themes addressed over the history of the
profession. These two lectures, presented at the Association’s annual
conference, are given by leaders in the field and reflect issues that the
profession is struggling with, as well as those topics in which we have
established a strong sense of identity and success.

The contemporary culture of physical therapy was described using these
three sources of data and this description was used as the basis for developing
the second part of the study, which addressed methods used by physical
therapy faculty to instill a professional ethos in their students, and to gather
information about the professional socialization experiences of physical therapy
students and their educators (academic faculty and clinical educators). The
program directors of two physical therapy programs were contacted to inquire if
they, the program faculty, and students would be willing to participate in the
study. Six faculty members, six students, and six clinical instructors5 from two
physical therapy programs (three of each from each program) were interviewed
about the various ways program faculty attempt to instill a professional ethos in
students and about their views on the experiences of students and educators in
the socialization process.

WW5

Pam. Drawing from a list of physical therapists who are Fellows in the
American Physical Therapy Association (APTA), input from a variety of
practitioners, and personal knowledge of the influential people in the profession
in the areas of research, practice and education, three APTA Fellows were
identified as being knowledgeable about past events and peeple who have

 

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71

influenced the practice of physical therapy, as well as the values espoused by
the profession (See Appendix G for a description of the subjects). This group
was chosen because it was felt that more mature individuals (both
chronologically and in terms of years of practice in the field) would be able to
shed the most light on the evolution of the profession since they have
witnessed, and may have even been major contributors to this evolution.

Those physical therapists identified by the above methods were contacted by
mail, by phone, and in person to determine their availability and willingness to
participate in a pilot study. Participants were interviewed in a private location
convenient for the researcher and the participant.

W. A semistructured interview was conducted by the
investigator with three physical therapists who had been determined to be
knowledgeable leaders in the field, as discussed above. Interview questions
(Appendix B) were used as a guide and were administered in a
nonstandardized format. In addition, demographic information was obtained
prior to beginning the interview and participants were asked for permission to
be contacted for any clarification or follow up questions. Interviews lasted
approximately one to one and one-half hours. All interviews were conducted in
person and were audio recorded for later transcription and analysis. Because
this information was initially gathered as part of a pilot study, a new signed
consent form (Appendix A) was obtained and this information was incorporated
into the present study.

Earl 13 - Bogus gmups MD' Prim ijrs

flame“ (pants. Eleven veteran physical therapists were recruited for a focus
group discussion from the “Prime Timers," a group of American Physical
Therapy Association members who are at least 50 years old (See Appendix G

72

for a description of these subjects). These individuals have formed this group
because they “do not want to work full-time anymore, (but) many are still
interested in staying active in the physical therapy profession” (Ketter, 1995).
Subjects were contacted by phone, by mail, and in person to determine their
availability and willingness to participate in the study. Because the Prime
Timers are from a variety of geographical locations in the United States, they
were invited to participate in the focus group at the American Physical Therapy
Association Annual Conference held in June of each year. As with the APTA
Fellows who were interviewed individually, this group was chosen because I
believe that more mature individuals are able to shed the most light on the
evolution of the profession since they have witnessed and/or been involved with
many of the changes that have occurred as part of this evolution.

W- Following receipt of a signed consent form (Appendix C)
and verbal assent, a focus group was conducted by the investigator with 11
members of the Prime Timers of the American Physical Therapy Association for
approximately two hours. Focus group questions can be found in Appendix D.
In addition, demographic information was obtained and a request was made for
permission to contact the subjects after the study for any follow-up questions or
for clarification of data collected during the focus group. The focus group
interview was video taped for later transcription and analysis.
P - ' ' m

While primary data analysis focused on the views and descriptions of the

professional ethos and culture offered by the individuals involved in the
interviews, historical documents were also reviewed as a supplementary source
of information about issues of importance to the identity of the profession
throughout its history.

73

W. The Mary MacMiIlan Lecture is given each year by
a person chosen by an awards committee within the profession. It is considered

to be a reflection of the issues most important to the field at the time. This very
prestigious honor is named in honor of Mary MacMiIlan, the first physical
therapist in the United States. The first Lecture was given in 1964. There have
been 28 Mary MacMiIlan lectures.

 

the Mary MacMiIlan Lectures, the Presidential Addresses are a reflection of
issues of importance to the field. Although Presidential Addresses have been
given since the inception of the professional organization in 1921, some of the
addresses that have been given by the same person during their consecutive
years in office have been condensed into one published document. In addition,
there are a number of years (1974-1988 and 1990-1991) for which the
Presidential Address was not published. As a result, 29 documents were
reviewed for this portion of the study.
W

This portion of the study addresses the question of how physical therapy
educators in professional programs attempt to instill a sense of professional
ethos in physical therapy students. The description of professional culture and
its professional ethos obtained in Part 1, as well as the information obtained
from the review of the literature on professional socialization (see pages 57-61
for a summary of this literature), was used as the basis for the development of
questions asked of interviewees in this section (See Appendix F for a list of
guiding questions). Questions focused on the means by which faculty attempt
to socialize students during the period of formal educational training, and the

experience of students and educators in the process of professional

74

socialization in physical therapy.

M- A purposive sample (Bogdan & Biklen, 1992) of six educators,
six students, and six clinical instructors (three of each from two different
programs) were interviewed to obtain their views on methods used by program
faculty to instill a sense of professional ethos in students and the success of
these methods in doing so (See Appendix G for a description of the subjects).
According to Bogdan & Biklen (1992), purposive sampling “ensures that a
variety of types of subjects are included. . . . You choose particular subjects to
include because they are believed to facilitate the expansion of the developing
theory' (p. 71 -72). In this study, purposive sampling procedures consisted of
identifying programs having different philosophies regarding the level of explicit
instruction necessary to help students internalize the professional ethos of
physical therapy. Program directors were contacted by mail, phone, fax, e-mail,
or in person to determine their availability and willingness to participate in the
study. They were asked to identify faculty, clinical instructors, and students
willing to be interviewed for this project. Newly hired faculty were excluded from
the pool, and clinical instructors selected as participants had to have personally
supervised at least one student from the program. Students had to be
completing their final internships or have graduated no more than six months
before the interview. Once identified, these individuals were contacted by
phone (by myself or the Program Director) to assess their willingness to be
interviewed. Interview times were arranged by phone or through the Program
Director for those who responded favorably to the request for participation.
Following receipt of a signed informed consent and oral assent, interviews were
conducted by the investigator in person in a private location convenient for the
participants and the researcher.

75

Questions asked of faculty and clinical instructors emphasized the process .f
by which they feel they socialize students into the profession, as well as their
views on how they feel the students experience the socialization process in
their program (See Appendix F). Student interviews focused primarily on the
student experience of being socialized (See Appendix F). A comparative
analysis of the views of students and educators (faculty and clinical instructors)
was also conducted.

In addition to obtaining demographic information about the participants, a
copy of the mission statement, philosophy, and curricular goals, as well as
those of the academic institution with which they are affiliated were obtained
from or discussed with the appropriate person designated by the Program
Director. Demographics regarding such things as type of institution, size of
student body, and organizational charts indicating where the physical therapy
program is situated were also obtained.

W911. Following receipt of a signed informed consent and verbal
assent, a semistructured interview was conducted with individuals meeting the
above criteria and willing to participate in this study. Interview questions (See
Appendix F), based on the findings of Part 1 of this study and the review of the
literature, were used as a guide and were administered in a nonstandardized
format Demographic information was obtained, along with permission to be
contacted at a later date for any future questions or clarification. Interviews
lasted approximately one to one and a half hours. All interviews were
conducted in person and were audio recorded for later transcription and

analysis.

76

An I i

While some qualitative researchers prefer to conduct data analysis following
the collection of all data, several authorities on qualitative research
methodology (Erickson, 1992; LeCompte & Priessle, 1993; Miles & Huberrnan,
1994) suggest that data analysis is not a separate component of the qualitative
research process, but rather an integral component that should occur at all
phases of a study. Following their suggestions, data obtained as part of this
study was reviewed as it was collected in order to search for emerging concepts
and themes, noting regularities in the data as well as negative cases
(LeCompte & Priessle, 1993). As the data was reviewed prior to completion of
the project, the information was used to guide subsequent data collection and to
begin to formulate inferences and hypotheses about how the culture of physical
therapy might be described and possible ways to instill the professional ethos
that reflects this culture in students. (As previously noted, the description of
physical therapy culture obtained from Part 1 of this study was used as the basis
of the interviews for Part 2. The description of data analysis described below
was used for each portion of this study.)

Once data collection was complete, all materials (i.e., transcriptions of all
audio and videotaped interviews, Mary MacMiIlan Lectures, and Presidential
Addresses) were reviewed in their entirety, a process called “scanning” by
LeCompte & Priessle (1993). Scanning “means rereading the data. . . . (in
order to) recheck the data for completeness. . . (and) to wander through the
record, jotting notes and observations as the reading progresses. The notes
serve to isolate the initially most striking, if not ultimately most important, aspects
of the data” (p. 236).

The notes obtained through rereading all materials and the guiding interview

77

questions were used as a broad, initial organizational framework for organizing
the data (LeCompte & Priessle, 1993; Miles & Huberman, 1994). Each data
source was then reviewed individually and further coded inductively for
common concepts or patterns that emerged as distinct units of analysis (Miles &
Huberman, 1994). Codes were revised (i.e. expanded, collapsed, or deleted)
as needed (i.e., too many discrepant cases emerge or some categories become
too cumbersome) based on the emerging conceptual framework. Miles &
Huben'nan (1994) also suggest that memos, reflections, and marginal remarks
be written throughout data analysis in order to record ideas, interpretations,
elaborations, and connections among the various data sources.

Once coding was complete, the codes were reviewed for discrepancies
(which may lead to changes in coding) and common themes were identified.
Themes from all data sources were compared using the constant-comparative
method (Glaser & Strauss, 1967). As such, data were compared across the
variable data sources, and changes in themes were made as necessary.
Relationships among themes and common descriptions were used to generate
a framework that served as the basis for describing the culture and professional
ethos of physical therapy (Part 1). In addition, a framework was devised to
begin to identify methods that are used to socialize students into the profession
and which, in some instances, are claimed to be effective in helping students to
internalize the professional ethos (Part 2) (Schmoll, 1993). As common themes
and concepts were identified, vignettes and exemplars were used to illustrate
what they look like in context and to establish their validity.

78

Chapter 4

Part 1: The Evolution of the Professional Ethos of Physical Therapy: Passing
the Torch from One Generation to the Next

Aflrjfllflm

The profession of physical therapy in the United States began in 1917 during
World War I when then surgeon general, William Gorgas, commissioned two
orthopedic surgeons to go to France and England to study medical programs,
called reconstruction programs, whose purpose it was to treat individuals
wounded in the war. Based on these visits, the Division of Special Hospitals
and Physical Reconstruction was formed in the United States upon their return
and a woman named Marguerite Sanderson was assigned the task of
supervising the training of more than 200 young women who volunteered for
duty as reconstruction aides, later to be called physical and occupational
therapists (Murphy, 1995). The first volunteer for the job of reconstruction aide
was Mary MacMiIlan, who was soon placed in charge of training the
reconstruction aides to rehabilitate young soldiers who were hurt in combat.
The Reconstruction Aide Training Program, under the direction of Mary
MacMiIlan and Marguerite Sanderson, was soon up and running with seven
War Emergency Training Centers across the country (Murphy, 1995).

Following the end of World War I, some of the volunteers returned to civilian
life, but others continued and in 1921 the American Women’s Physical
Therapeutic Association (in 1922 the name was changed to the American
Physiotherapy Association and in 1947 the name was again changed to the
American Physical Therapy Association, the name of the professional
organization today) was formed with Mary MacMiIlan as its president

79

(Pagliarulo, 1996). Under Ms. MacMiIlan’s leadership, the term reconstruction
aide was changed to the title of physiotherapist (in the 1940s the term physical
therapist began to be used), educational standards were established, annual
meeting dates were established in conjunction with meetings of the American
Medical Association, and a professional journal, the ET. Review (today the
journal is named Physiml Therapy) was published (Murphy, 1996; Pagliarulo,
1995). In spite of these great strides, however, these women, and later the few
men that joined them early on, remained in a technician role as they worked
under the strict supervision of physicians and the business and actions of the
professional organization were conducted under the direction of the American
Medical Association.

Since the early days of the reconstruction aides, the profession of physical
therapy has grown in number and professional stature. World War II and the
polio epidemics of this century were a great boost to the profession as these
events increased the patient papulations with which the physical therapists
were to work. As the number of wounded veterans decreased and polio
disappeared when the Salk vaccine was introduced in the 1950’s, physical
therapists turned to other types of patients and treatments. Today there are
approximately 109,000 practicing physical therapists in a variety of capacities
from direct patient care to consultation to education and research (APTA staff,
personal communication, June 29, 1998). In addition, the types of settings in
which physical therapists practice has expanded tremendously with therapists
now treating patients in hospitals, outpatient orthopedic clinics, public schools,
homes, nursing homes, wellness and prevention centers, and research centers.

The physical therapy professionals of today have come a long way from the
era of the reconstruction aides. The purpose of Part 1 of this study is to trace the

80

evolution of the profession and its ethos from the early days of the
reconstruction aides to the present time. How was it, for example, that these
professionals evolved from technicians who treated wounded soldiers under
the watchful eye of a physician to the increasingly versatile and autonomous
practitioners that exist today? From an all female profession to one that readily
welcomes males? From a professional organization that relied on the American
Medical Association to help run its professional association to an independent
agency with approximately 75,000 members? These are but a few of the
questions that l have explored and hope to provide some answers to in Part 1 of
this study.

As I analyzed the data to look for answers to these questions, I found that
many changes were noted by the participants in the study. These changes are
important in trying to describe the evolution of the profession. Equally
important, however, were the participants’ descriptions of those traits and
values that have survived throughout the history of the profession, what I refer to
as the core of the professional ethos. It is these enduring traits and values that I
turn to first, followed by an analysis of the changes that have occurred both from
within and outside of the profession. An overview of the results of Part 1 can be
found in Table 3.

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Not surprisingly, the most often cited value of physical therapists is the
premium that they put on caring, on helping people to be the best they can be.
All respondents, in both parts of this study, mentioned caring as the most
important, enduring trait of the profession. For example, participants in the
Prime Timers Focus Group said:

I entered the profession to help people with my head and my
81

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82

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hands and we’re a service profession...You want to help people.
Therapists like to help people...you use your knowledge and
experience [to do so]. (Prime Timer 2?, p. 8-9)

I think most PTs are still basically caring people. (Prime Timer 10,
p- 23)

This is a caring profession. I don't see a lack of that. There is a greed
that...wasn’t there before... but when they are working at the

moment that they are hands on, the caring seems to come out.

(Prime Timers 9, p. 23)

Similarly, one of the Fellows conveyed this message about caring and
helping others:

They [the values of the profession] certainly were [when I started
practice] ones of providing service to others, for caring for others,
for helping others to become independent and functional as they
could become...and actually those core values persist today. If you
were to ask people thirty years ago why they chose to be a
physical therapist and compared it with what people would say
today I would guess they would be very similar. (FAPTA 3, p. 3)

As predicted in this quote, even the newcomers, the students who were
interviewed for Part 2 of this study, described themselves and their cohorts as
eating, helping individuals. Students expressed this notion in one way or

another, using such terminology as ‘providing quality care to patients’ (P281, p.
1). “having to be patient oriented’ (P282, p. 1), or “helping people the best way
you know how’ (P181, P1S2, P183, p. 1). ‘

A second enduring trait described by a variety of people was the amount of
ha I'd work and dedication exhibited by members of the physical therapy
D'Ofession, not only to their patients, but also to the profession itself.

I think, as a whole, physical therapists are some of the most

 

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83

dedicated pe0ple you could possibly find...it’s the dedication by so
many people to help other people.” (FAPTA 2, p. 7 )

(The goal for most physical therapists I know is] dedicating one’s
self to a life of service. (FAPTA 1, notes)

One Prime Timer described how there was a love of the profession and a
warmth and openness by all members of the profession regardless of age or
time of entry into the profession. Others in the group echoed her ideas:

You know something that hasn’t changed...when you go into the
clinic...you see the same fun...in all these young people, you know,
that we always had and they still, there's something about being
with physical therapists. You just feel at home, you know. I think
all my colleagues have often felt like, they felt in just a real
atmosphere of trust and love, I mean, really among colleagues
even if they know them just...tangentially and I think I see that
among the young people even now...they really do put their arms
around each other, you know, have some openness and warmth
and it really brings [me]...close to tears...l love to watch the love
they have for each other...l love to watch the love they have for the
profession. It’s just so fun to watch them. (Prime Timer 7, p. 9)

It is warmth. (Prime Timer 11, p. 9)
And absolutely unique, I think. (Prime Timer 7, p. 9)
Students interviewed for Part 2 of this study also recognize this warmth and

GXCitement in the profession as they are socialized into the field. One student
Said:

I think the profession is one that you feel very welcome in. You get
that feeling from everyone. There is a lot of excitement, you know.
Even though there are changes, there is a lot of excitement and
that’s what my big feeling was. Like I always felt good about the
community and who is around you and supporting you, which is
really nice. (P283, p. 6)

'3mm my perspective, it was also interesting that all the individuals
interViewed for this study, including those students, faculty, and clinicians who

84

participated in Part 2 exhibited a very positive attitude-a knack for seeing
the best in every situation. Although no one specifically mentioned this as an
enduring trait or value, it was apparent throughout all the data, including the
Mary MacMiIlan Lectures and Presidential Addresses. I first noticed this trait
when reviewing the focus group interview, particularly in relation to two
negative changes noted in values between those who had been in the
profession for a long time and newcomers who had been out of school for a
short time. These two changes, an increased emphasis on monetary rewards
and a decrease in professional standards were cited by both the Fellows and
the Prime Timers (see Changes in The Profession, below). In both of these
instances, someone in the group, or in some cases even the person who made
the initial accusation found something good to say about the newcomers or
offered excuses, usually in the form of societal changes, for why these students
and new graduates would act as they do.

It was a time when you didn’t have the worries that you have
today. There weren’t law suits and there weren’t all the problems
of filling out insurance forms, none of those things. I mean, I’m
sure that if I went into physical therapy today, I would have a
different attitude, because you’re so burdened with some of the
problems that you can’t give yourself totally to the patient. (FAPTA

1,p. 2)

I agree with all of you that that’s what we’re seeing. I’m teaching in
school regularly and . . . the majority of the young people coming
through are really absolutely wonderful citizens, and wonderful
individuals who humble you when you’re with them. They do - just
like the kind of people we are talking about. . . we never had to
separate the personal, you and l, our citizen’s responsibility and
privilege before. . . I wonder if you and I might not also be reacting
in different ways had we been brought up in this; because they’re
subject to some stresses. I’m not forgiving them, because I see it
out there too, but they don’t seem to me to be basically changed. I
mean when you talk with them, clinically you don’t see them
cutting comers...they’re doing their best. They’re staying long
hours. They are saying they want to help. They’re kind to their

85

clients. But the things that we see are the things that are...instilling
habits in them. For example, most of them are . . . much deeper in
debt even proportionately than they’ve been before and they have
to get through school. And when you’re talking, “Shall I go ahead
and take a scholarship from a place that I have never visited or
heard of in my life” or even know who they’re going to work with -
to you or I that would be impossible - “and they’ll give me [a] first
year salary to do so or shall I wind up out of school and keep this
kind of principle and be fifty thousand dollars, sixty thousand
dollars in debt?”, and . . . they don’t think of this as doing a bad
thing...their actions in relation to society are very different. They
can’t survive economically. (Prime Timers 7, p. 2—3)

Sexual harassment was something none of us even talked about,
thought about. . . . But now youngsters are going out to
environments in which they find themselves . . . innocent to my
way of thinking, innocent bystanders and become involved in the
most horrendous and very difficult problems that you’ve ever seen.
I don’t know that that happened to any of us. It just wasn’t there.
(Prime Timers 7, p 3)

I think . . . that we do need to have standards, but how can you
teach these standards when they have not been taught in the
home, because these are college students and they have a lot of
years of other kind of training. You might be able to do it with a six
year old, but it’s pretty difficult to do it in an 18 year old. (Prime
Timers 6, p. 19)

This same attitude was present not just when speaking about the people in the

profession, but also in describing the changes that have occurred in the

profession over time. These types of changes included a more rigorous form of

note writing first mandated by Medicare and Medicaid, reimbursement for

services from insurance companies, delegation to paraprofessionals (physical

therapist assistants) and aides, and a more autonomous relationship with

physicians as evidenced in the clinics by more latitude in providing services to

patients. These types of changes, when first discussed were mentioned in a

more negative tone within the Prime Timers group, but eventually someone in
the group talked about the “good part“ of the change. For example, the

86

following dialogue took place in regard to more stringent requirements for note
writing:

One of the things that really [changed] . . . for years . . . no one
wrote notes. (Prime Timers 10, p. 11)

That’s true. (Prime Timers 11, p. 11)

We did not write notes. When I . . . took a new job in 1969, . . .
there were no notes from a physical therapist. . . the job I had
before that I was just Ieaming how to write notes. (Prime Timers
10,p.11)

[T]his is one of the things that came out of public regulations and
Medicare specifically, regulations that you have to have a
progress note

. . . every day on an acute patient and once a week on a chronic
patient. (Prime Timers 2, p. 11)

Forget the once a week, they want it everyday, every time you visit.
(Prime Timers 11, p. 11)

The fact that we didn’t write notes had a lot of impact. I mean, you
spent your time with the patients, and you had time to talk to the
patients. (Prime Timers 10, p. 11)

And the fact is that the people are more concerned about getting
that note in than they are in the care of the patient. (Prime Timers
1 , p. 1 3)

but that also has a good ramification because now therapists have
to think about what they’re doing and why they’re doing it, and we
didn’t do that . . .You have to think through the reasons for doing
things. (Prime Timers 10, p. 13)

Medicare made us do what we should have been doing, what
87

some of us didn’t do before. (Prime Timers 3, p. 13)

In her Presidential Address of 1996, Marilyn Moffatt epitomized this positive
attitude as she traced the evolution of the profession throughout its seventy-five
year history. Moffatt (1996) described the evolution of the profession as one
that, in spite of ups and downs, of having to fight and search for a professional
niche in the health care environment has provided the field with a good impetus
for positive change. The pioneers in the field, as well as the current active
members of the professional association have managed to find an approach to
meet the problems of the profession head on. The end of World War II and the
use the Salk vaccine that ended the polio era, for example, may have been a
signal for some professionals to conclude that their work and their profession
was finished since their primary patient populations had dwindled to almost
nothing. But this was not the case for physical therapists. Instead they saw this
as an opportunity to help other groups of individuals with disabilities and looked
to other avenues of helping people, most specifically to the treatment of children
with cerebral palsy and adults with strokes and other forms of neurological
disorders (Moffatt, 1996).

More recently, in the last ten years, physical therapists, as well as other
health care providers, have been forced to deal with changes in the health care
delivery system. The introduction of DRGs‘or diagnosis related groups, which
limited hospital stays for patients and the more recent introduction of managed
care systems of health care delivery have had a major impact on the provision
of therapy services to patients. Rather than simply lamenting the effect of these
devastating changes on physical therapists in this country, Moffatt (1996)
encouraged her fellow practitioners to see the opportunities this change in

delivery models has produced for the profession. A greater emphasis on self

88

monitoring, outcomes effectiveness studies, and appropriate charges for
therapeutic services, all described as good changes for the profession, also
emerged as managed care and health care reform wreaked havoc on the
delivery of health care services to those in need. Moffatt described these effects
of health care reform, as well as some positive changes that were occurring in
the system as follows:

We are often caught up in the downsides of rapid change,
confusion about our roles, and a health care environment that has
been threatening to us. . . In contrast to these trends, we are
seeing litigation against provider organizations for withholding
services. Successful managed care corporations. . . are now
considering payment systems that use quality of care as one
criterion for reimbursement. We see physical therapists
reevaluating whether it is appropriate and right to treat more than
20 patients in a normal practice day. We also hopefully will see an
appropriate pricing of our services that is equitable with the
services we actually render. . . And we must always look at the
positive aspects that do emerge from any change. We surely will
have Ieamed many things during this time of upheaval; we will
have Ieamed to provide high-quality services in even less time
than we have had in the past with the patient or client as a true
partner, whenever possible, in the recovery or rehabilitation
process; we will have Ieamed the importance of practice patterns
that represent appropriate provision of services and, when
possible, that are supported by data; and we will have Ieamed that
we must be ever more cognizant of the need to provide services in
a financially responsible manner. . . Not one of our predecessors
has had the opportunity that we have today, and that is to leap
from one century to the next. As a profession and as an
association, we are well poised to take that giant step for
humankind. (Moffat, 1996, p. 1252)

 

Some the changes that have shaped the development of the culture of
physical therapy that occurred outside the profession are quite obvious as they
are related to the change In the type of patients served. Within this

89

category are such events as World War I, World War II, the Korean War, and the
Vietnam War; the development of a vaccine for and eventual eradication of
diseases such as polio; legal mandates such as the Social Security Act and the
newly reauthorized Individuals with Disabilities Act of 1997 that have dictated
who will be serviced and how the services will be carried out and paid for; the
graying of America, resulting in the treatment of more older patients with more
complex, multiple, and serious conditions; and the advent of the atomic age with
subsequent improvements in medical technology that have resulted in earlier
diagnosis and treatment and are allowing individuals to live who would have
died in the past. Other societal changes, not related specifically to historical
events, but ones which are fairly clear cut in terms of their impact on not only
physical therapists, but all health care practitioners, include such issues as
increased litigation in our society (Prime Timers 7, p. 7; Prime Timers 1, p. 8),
changes in health care delivery systems (Moffatt, 1995, 1996, 1997; Prime
Timers 2, p. 22), increased economic pressures on students in terms of the
increased cost of education (Prime Timers 7, p. 3, p. 6), and technological
Changes that have resulted in different systems of communication and record
keeping (Prime Timers 1, p. 10).

While these events are certainly very important in the role they have played
in the evolution of physical therapy, the more subtle Influences of social
change are much more interesting to explore. The influence most cited by
participants in the study and by those whose documents were reviewed in the
Mary MacMiIlan Lectures and the Presidential Addresses was the overall
change in the values and standards of society. Early Presidential Addresses
and Mary MacMiIlan Lectures emphasized the need to set high standards for
the profession based on the needs of the patients and the values and standards

90

of society. These early pioneers aimed high in the areas of patient care,
education, and ethical practice. This legacy of high standards is seen in the first
Presidential Address delivered in 1921 by then President Mary MacMiIlan who
stated, “One of the most important tasks for the National Association is to set a
standard for physiotherapy and neither in act, word, or deed to lower that
standard” (MacMiIlan, 1921, as cited in American Physical Therapy
Association, 1971, p. 622).

In contrast to this emphasis by previous generations of physical therapists,
the Fellows and Prime Timers who looked back over the profession through the
interviews conducted for this study, described how the standards of the
profession and the newcomers into the profession have been lowered as a
result of societal changes. The following excerpt from the Prime Timers
illustrates this change in standards:

One of the things that existed then that doesn’t exist now is
standards, and there was just a certain standard. It wasn’t so
much the background that you came from, the amount of poverty,
or how affluent you were, or what culture you came from. There
was, in this country, something called a standard and you just kept
it. There were right and wrongs. There was black and white. No
gray areas. (Prime Timers 9, p. 4)

And everybody respected the flag. (Prime Timers 10, p. 4)
There were things that were just respected. (Prime Timers 9, p. 4)

Similarly, one of the Fellows described this adherence to high standards and
expectations in professional behavior.

I wouldn’t have thought it was necessary, hardly to have started it
outwith ethics . . . ltwas as ifwejustdidthethingswe oughttodo
and we were expected to do them. (FAPTA 2, p. 2)

On a more positive note, participants noted that one of the changes in the

profession that reflects social change is the more relaxed atmosphere with

91

which practitioners interact with each other and with patients. For example, the
Prime Timers felt that the less formal way of interacting with each other in
society today compared to days gone by has resulted in a closer relationship
with patients and with peers. One Prime Timer, for example, discussed how
today's students are very open in their love of the profession and the people in it
and how one way she sees that expressed is when students just appear to be
having fun and hug their fellow classmates at graduation (Prime Timers 7, p.9).
In response, others in the group offered the following:

Well, I think that has a lot to do also (with the fact that) we were
taught not to do that. (Prime Timers 6, p. 9)

Oh, yes, absolutely. (Prime Timers 7, p. 9)

I know I that I practically never hugged my patients, and I didn't
start doing it until I retired and started working with Huntington’s
Disease and I felt those people needed to be touch. (Prime
Timers 6, p. 10)

You know the old expression that’s coming to me, “Friendly, but
not familiar.” (Prime Timers 3, p. 10)

An increase in the diversity of American society is another outside factor
thought to have influenced the evolution of the professional ethos of physical
therapy. The decreased emphasis on America as a melting pot in the years
when great numbers of Europeans migrated to the United States has been
replaced with an era of cultural diversity where individual cultures from all over
the world take pride in their heritage and their differences. This sense of ethnic
and cultural ownership is seen not only among immigrants to this country, but
also within the realm of our own citizenship as African Americans, Hispanic
Americans, Native Americans, and Asian Americans openly acknowledge their

pride in being unique in their cultural background. This same sense of

92

difference that has resulted in and from much of the Civil Rights legislation of
the early 60s, and which has continued to the present day, has impacted the
professional ethos of physical therapy in two ways. First, we can no longer
assume that students are created in our image. We must not only consider
differences due to their cultural background, but also to generational values and
beliefs. No one would dispute the fact, for example, that individuals born during
the Baby Boom years and those who are identified as Generation X see things
in much different ways. This change in diversity was noted by many of the
participants. One Prime Timer discussed the impact of this diversity on
facilitating the ethos of the profession:

[We’re seeing such an enormous diversity of background that
you’ll get a classful of students who you can't predict what they’re
going to do individually or collectively, and so ethically we’re much
more in the process of having to be very, very overt instead of
operating on assumptions. So we need to bring out, “Where did
you come from? How do you think you developed the ideals that
you think you’re going along with? How do you think you are
going to make decisions? How do you judge right and wrong in
finances or in patient care or in what you are doing in your
professional life?“ We just can’t assume that their backgrounds
are going to be like our backgrounds. (Prime Timers 8, p. 3)

Of the generational differences noted by the Fellows and Prime Timers, the
most disturbing to them was the increased emphasis on monetary rewards in
some students and new graduates. It was felt that this was something that was
very damaging to the ethos of the profession and needed to be stopped. Some
newcomers to the profession were described as “more interested in financial
matters“ (Prime Timers 5, p. 2) or “money driven” (Prime Timers 11, p. 7). As
mentioned earlier, the positive attitude displayed by the participants in the study
was an enduring theme that I noted. This positive attitude was very evident in ‘
one Fellow’s perspective on how to solve the temptation of greed on the part of

93

the newcomers to the profession. Rather than seeing all the health care
changes as bad, this Fellow felt they would help to decrease, if not eliminate,
those who come into the profession simply because it sounds lucrative.

One of the things that really bothers me is that when new grads
come out and they’re looking for jobs and the first thing they want
to know is how much is the pay. I think that’s really sad, [but] . . . I
think it’s [this increased interest in monetary rewards] going to take
care of itself. It’s going to take care of itself in many ways because
salaries are going to come down, there’s going to be a lot of
competition. There’s going to be a lot of people who are going to
just be real glad they have a job. . . When people find that they
have to do much better and satisfy professional demands if you
want to keep patients coming, it’s going to change. (FAPTA 2, p.
10)

Finally, the changes in the political frame of mind during the Vietnam War
and the sixties was cited as a major outside influence on the development of the
Professional ethos of physical therapy. While in one sense this era of equal
rights for minorities and women and the view that everyone should “do their
Owli thing” created a generation that is more “self sewing“ (FAPTA, 1), it also
influenced physical therapists to more aggressively pursue their quest for
autonomous practice, away from the American Medical Association (AMA). One
Way in which this fight for independence from the AMA was played out was in
the arena of accreditation of educational programs for physical therapistsand
Physical therapist assistants. After many years of battling with the AMA, the
Al”TA was recognized by the Council on Postsecondary Accreditation as a
$9<=ond independent accrediting agency (in addition to the AMA) for physical
therapist and physical therapist assistant programs in 1977, and in 1983 APTA
Was finally approved as the sole accrediting agency for these educational
programs (Moffatt, 1996; Murphy, 1995; Pagliarulo, 1 996).

94

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According to the participants, some of the most drastic changes within the
profession occurred as a result of the appearance of males in the
profession after World War II. As males entered the profession during this era of
inequality between men and women, female physical therapists began to
realize more of their worth within the health care community. This may have
been the beginning of the more autonomous, less technician oriented
professional that the average physical therapist is today. The entrance of males
in the profession, for example, provided more continuity of staffing within the
profession since they were not expected to leave the profession if they were
married or had a family. In addition, males received significantly greater
Salaries than females since it was felt they needed to make enough to support a
family. One Prime Timer who was a director of a department at the time stated,
“I began to feel a change . . . in the male therapists coming in versus the female
therapists. They were looking at the future as heads of household, whereas the
female was more service oriented, more career, PT minded, the males had to
I“aka a living” (Prime Timer 2, p. 5). What was thought of as a “need to make a
“Ving' resulted in higher wages for men, particularly in light of the fact that
‘many women, pick a time, 1945 or later, used nursing or teaching or physical
therapy as a stepping stone before they got married“ (Prime Timer 1, p. 5).
This increase in wages for men, as well as the increased independence that
Was fostered during World War II as women entered the work force to replace
"‘8 men who had gone off to War, resulted in greater demands by women in the
field. One Prime Timer, for example, explained how she realized that she
Should demand the same pay and benefits as her male counterparts. '[Fjor me,
95

when I saw what the men could do, it just made me think, well there’s no reason
I can’t do that too, and I think a lot of women did the same thing and this sort of
helped women to empower themselves by saying, ‘If you can do that so can I' . .
. . Before that I didn’t ask for it [a higher salary]” (Prime Timers 10, p. 22). In
addition to higher salaries, males were also more aggressive in opening up
other areas of practice, most notably private practice (Prime Timers, p. 22).
Although therapists were still required to strictly treat under the orders of a
physician, this move to private practice was the beginning of practicing in a
setting that offered much more autonomy than a hospital.

Next, as the demand for physical therapists rose8 and the educational levels
increased, the members of the professional association saw the need for
paraprofessionals to fill the gap created by this shortage and to perform the
more technical aspects of the job. As a result, physical therapist assistants

Were created by the APTA House of Delegates in 1967 and the first class of
physical therapist assistants graduated in 1969 (Murphy, 1995). While many
therapists were not sure how to delegate to these paraprofessionals as they first
e“tered the field, the advent of managed care in the last few years has quickly
led to an Increase In delegation of therapeutic exercises and modalities not
orIly to PTAs, but also to aides, other professionals, such as athletic trainers and
eXercise physiologists, and patients and their families. As a result of the shared
responsibility and delegation that occurred with the use of physical therapist
assistants, the appearance of these paraprofessionals in the profession was

thOught to be an impetus of change for physical therapists.

 

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96

 

A lot of the young therapists, and older ones, too, do not want . . .
to delegate to the physical therapist assistants or to other
supportive personnel . . . we have to change . . . We have to
recognize that there are levels of care and where do we fit in that

chain.” (Prime Timers 1, p. 24)

Another important change from within the profession was the change In
educational level required to practice as a physical therapist. The
requirements and training of today’s students have come a long way from the
time when the first seven War Emergency Training Centers opened in several
locations across the country to train the then called reconstruction aides. At that
time, the major educational requirement for entering one of these training
sessions was to have completed a four month course “in any two of the basic
modalities of reconstruction - hydrotherapy, electrotherapy therapy,
mechanotherapy, and massage” (Murphy, 1995, p. 47), or to have graduated
from either a nursing of physical education program, or to have been
individually trained by a recognized orthopedist (Murphy, 1995). In addition, “to
be considered for training and ultimately for work in physical therapy . . .,
Candidates had to be citizens of the United States or in the process of being
naturalized. They also had to pass physical fitness standards, which included
standing between 60” and 70” tall and weighing between 100 and 195 pounds,
With no ‘marked disproportion’ between the two. Cheerful demeanor, coupled
With ‘powers of personal subordination, able to cooperate generally and
capable of demonstrating team play,’ were also deemed essential. Because
the army was particularly sensitive to the potential strains of bringing men and
Women together in the highly charged atmosphere of wartime hospitals,
candidates were also expected to be able to ‘associate with young men on a
f"endly footing without encouragement of undue familiarity’ ” (Murphy, 1995,

97

pp. 47-48). As World War I came to an end and the reconstruction aides formed
the first professional association, the American Women’s Physical Therapeutic
Association, in 1921, the leaders in the field began to look more closely at the
educational requirements in order to standardize them even more and to
eliminate personal requirements such as height, weight, and the ability to
“associate with young men on a friendly footing without encouragement of
undue familiarity“ (Murphy, 1995), and in 1928 the first standards for
accreditation for physical therapy education programs were established
(Moffatt, 1996). By 1947 four schools offered bachelor’s degrees in physical
therapy (Murphy, 1995), and in 1956, the baccalaureate degree was
established as a minimum for entry-level practice (Moffatt, 1996). By 1979 the
House of Delegates, the legislative body of the APTA, passed a resolution to
require a postbaccalaureate degree as the entry level degree for physical
therapy practice by 1990. Unfortunately, there was much opposition to this
movement and the current date for the establishment all programs at the post-
baccalaureate level has been moved to 2001. In addition, there is currently a
move by some Individuals within the field to establish a doctorate (primarily a
clinical DPT instead of a PhD) as the minimal educational requirement for
practice. While there is still much controversy regarding this move, several
entry level DPT programs have become established throughout the country. All
of these changes in and results of increased education were recognized by the
Prime Timers.
One of the most cited effects of this move to increasing education was that
With an increase in education, comes Increased responsibility and
autonomy and more delegation to others.

We’re not recognizing that the more education we require or want,
. . . [also will affect] what they’re asking of us, it’s not just what we

98

 

 

want, it’s what we’re asked to do and we have to have that higher
education to be able to make good judgments, etc. (Prime Timers
1, p. 24)

Increased education and more delegation, as well as the changes in health
care noted earlier, have also led to changes in educational requirements in that
as therapists delegate more responsibilities to paraprofessionals and patients, it
becomes increasingly important for them to become good teachers and
communicators (Prime Timers 2, 10, and 11), so that a need then arises for
educational programs to prepare students to function in this capacity. This has
indeed become the case as accreditation standards now require that
information on teaching and Ieaming be included in every physical therapy
curriculum (American Physical Therapy Association, 1997a; American Physical
Therapy Association, 1997b).

Finally, as physical therapy has increased its professional status through
increased education and autonomy, there has been an increased emphasis on
developing a body of professional literature and unique knowledge,
one of the hallmarks of a profession (Friedson, 1994). While there has always
been an identified need for scholarly activity, as evidenced by the establishment
of the first professional journal, the P.T. Reviaw, in 1921, scholarly activity has
become increasingly important as the field of physical therapy strives for an
increased professional status in the health care arena. In addition to this desire
for increased professional status, changes in health care have also made
practitioners in the field more aware of the need for outcomes studies to prove
the efficacy of their work with patients. As a result, more and more members of
the profession today are becoming increasingly involved in conducting
research resulting in the production of scholarly publications. This change was

noted as a needed and exceptional one by all members of the Prime Timers

99

group and the Fellows. As with the increased emphasis on autonomy and
delegation, this need for a growing body of literature has also resulted in
increased demands on educational programs as courses on research theory
and design have become required components of educational curriculums
(American Physical Therapy Association, 1997a; American Physical Therapy
Association, 1997b).
of n- '..:l eno D :l- m: :.l lntrviw .no Do. mnt Anl i

Data analysis of the interviews and documents revealed that there are core
values and norms within the professional ethos of physical therapy. These core
values and norms primarily reflect the role of the physical therapist as a clinician
and include an emphasis on caring and helping, hard work and dedication, a
warmth and openness within the profession, and a positive attitude. Changes
in the professional ethos occurred both from within and outside of the
profession. Changes from outside that were felt to affect the ethos of the
profession and the ways in which students needed to be socialized included
changes in the types of patients served due to wars, new medical treatments
such as the invention of the polio vaccine, legislation, improvements in
technology that are keeping people alive longer, and the “graying” of America;
changes in society in general that affect students in all professions such as
increased litigation, changes in health care delivery systems, increased
economic pressure on students, and technological changes; and subtle
influences in society including changes in social values and standards, less
formality, an increased emphasis on diversity and monetary rewards, and
political changes that occurred in concert with and since the Vietnam War.
Within the profession, the appearance of males resulted in increased salaries

and increased autonomy. Changes in educational requirements from the first

100

four month courses to the present masters entry level requirements have
resulted in increased responsibilities. This increase in autonomy and
responsibilities, coupled with changes in health care, have resulted in
increased delegation to paraprofessionals, other professionals, and patients
and their families. Increased delegation has, in turn, led to an increased
emphasis in educational programs on teaching and the need for improved
consultative and supervisory skills. Finally, the move toward a more
professional posture has resulted in an increased need for scholarly activity

within the field.

101

Chapter 5

Part 2: Professional Socialization in Physical Therapy: The Experience of Two
Programs

The two programs selected for this study were chosen because of their
explicit perspective on and methods used to socialize students into the
profession of physical therapy. Faculty at both programs have made a
conscious effort to incorporate a strong emphasis on professional socialization
into their programs as described below. An overview of the methods used by
these two programs can be found in Table 4. In addition, a description of the
feelings and experience of students during the socialization process is included
in this chapter.
marviaw 9f Prgggam 1

Program 1, which has been in existence since 1945, is an urban, Midwestern
university of approximately 40,000 students overall. The physical therapy
program enrolls 60 students each year. Students completing this program,
receive a bachelor of science degree in physical therapy (although the program
is moving to a masters level within the year). Students are admitted to the
program after completing two years of prerequisite courses and complete
another two years of a professional program once admitted. Clinical internships
comprise 24 weeks of the two year program, with students completing three full
time internships of six weeks each at the completion of the academic program.
Program 1 has eight full time faculty positions.

Program 1 accomplishes their goals for professional socialization primarily
through the use of what has been termed ability based assessment which

“involves multidimensional observation and appraisal, based on explicit

102

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103

behavioral criteria of the individual leamer in action” (May, Morgan, Lemke,
Karst, and Stone, 1995). The behavioral criteria used for professional behavior-
are the Generic Abilities (GAs). Generic abilities are “attributes, characteristics,
or behaviors that are not explicth part of a professional's core of knowledge
and technical skills but nevertheless are required for success in that profession”
(May, at al, 1995). Using the Delphi technique of research, ten generic abilities
were developed by the faculty from the physical therapy program at the
University of Wisconsin-Madison (UW-M) based on input collected from
practicing clinicians. The generic abilities consist of ten behavioral
characteristics that physical therapy graduates should possess, including
commitment to Ieaming, communication skills, interpersonal skills,
communication skills, effective use of time and resources, use of constructive
feedback problem solving, professionalism, responsibility, critical thinking, and
stress management. In the early 1990s, when the generic abilities were first
developed for the University of Wisconsin-Madison, each was accompanied by
a beginning, developing, and entry level set of behaviors that indicate the
student’s level of functioning on each of the generic abilities. The initial set of
GAs was adopted and put into use by Program 1 in the fall of 1993. In 1997,
using feedback from clinicians, students, and faculty from their own and other
programs, the GAs were revised to include a post-entry level category (Warren
May, personal communication, June, 1997). (See Appendix H for a list of the
generic abilities and a sample of the behavioral criteria for several of the
abilities.)

The GAs are used on a regular basis by Program 1 to assess the level of
professional behavior of their students. Students are introduced to the concept,
use, and specific expectations of the GA scale during program orientation and

104

are told that they must function at acceptable levels on the scales if they are to
continue in the program. That is, failure to meet the expectations of the faculty
in generic ability functioning can result in dismissal from the program, just as
failure to meet academic expectations can result in dismissal. Each semester
during the program, students complete a self-assessment of their level of
function on the generic abilities scales, establish goals and objectives for
themselves that will move them along the behavioral criteria, and set time lines
for accomplishing their goals. Students meet with their advisors to discuss their
self-assessment and the advisors then present the students’ self-assessments
to the entire faculty. Each student is discussed every semester. Students
whose self-assessment accurately matches the faculty's have their
assessments returned following a brief meeting with the advisors. Students
whose self-assessments are inconsistent with the observations of the faculty
meet with their advisors to devise a remedial action plan, including goals,
objectives, a time line for accomplishing the goals and objectives, and the
actions that will be undertaken to accomplish the goals and objectives.
Students continue to meet with their advisors to monitor progress toward their
goals. If, after several attempts are made to remediate a student on the generic
abilities, no progress or little progress is observed, that student can be
dismissed from the program. To date, two students have been dismissed from
Program 1 for failure to meet the professional expectations outlined in the
generic abilities.

For students who successfully complete the academic portion of the
curriculum and move on to their clinical internships, the generic abilities
continue to be used as part of the assessment process in the clinics. At the

beginning of each clinical rotation, students complete a self-assessment, listing

105

their strengths and weaknesses and goals and objectives for the clinical
experience. Both the students and their clinical instructors periodically
complete an assessment of student progress toward their goals. As in the
academic portion of the program, failure to meet generic abilities expectations
can result in remediation or dismissal from the clinical site or the program just
as easily as failure to meet expectations of clinical expertise.

The success of the generic abilities approach to professional socialization in
Program 1, coupled with the enthusiasm of the original proponents of the use of
the GAs for professional socialization in physical therapy has led many other
schools to adopt the use of the generic abilities for their own programs. In
addition, other programs are adopting the generic abilities for use in other areas
of the program such as using them as admissions criteria (Warren May,
personal communication, June, 1997).

Wht’ aaizlPr..o.-Juz_ 1?: --nri Ailiti o." ritmri .
ti n lf-A n R larF k

All participants in Program 1 identified the use of the generic abllitles as a
very strong socializing force in the program. Students, in fact, answered many
questions simply with the words “generic abilities” and one student apologized
for “sounding like a broken record” (P181). Beyond a mere description of the
term generic abilities, however, all participants were able to identify ways that
the generic abilities behavioral checklists helped facilitate professional
socialization and internalization of the professional ethos of physical therapy.
The use of speclflc crlterla and expectatlons for the goals and .objectives
of socialization in the program, for example, were cited as important by
students, faculty, and clinicians, as illustrated in the following quotes:

I believe [that] raising the students’ awareness is at least 80% of it.
I think most people are just dying to know, ”What are the

106

expectations?” That is where the problem in your professional
behavior in our profession is because it has not really been dealt
with, the affective domain, etc., etc. We had difficulty getting
across to students what our expectations were. If there is one
thing that the behavioral criteria has done it, it spelled out, these
are the expectations. I’ve had student after student say, you
know, “Thank you. Now I know what you’re looking for.” It goes
back to if you give them expectations, they’ll meet them. The
higher the expectations, the better they’ll do. . . I can tell you what
my expectations are. I know exactly how I want you to behave. If I
tell you 99% of the time, they’ll do it. They’ll just figure it out.

(P1 F3, p. 14)

‘ Students are very aware [of our expectations for professional
behavior] because of this program that we have of ability based
assessment. (P1 F2, p. 4)

I think that since the advent of the generic abilities, it has really
made them a lot more aware of what it takes. Not only with
psychomotor skills, but all the other intangibles, so called
intangibles. (P1Cf, p. 8)

I think that with generic abilities, that [program expectations and
goals for professional behavior] is pretty much laid out for us.
( P1 82, p.5)

Not only were these expectations presented clearly, but the fact that clinicians
were very involved in the development of the behavioral criteria is also made
quite clear to students. Because students often have a visions of clinicians,
versus the faculty, as “the real physical therapists,” I feel that passing this
information on to students as something that was developed by and expected
by clinicians is a very important part of motivating students to aspire to the
professional behaviors delineated in the behavioral checklists. This was also
recognized by the faculty in Program 1.

Of course in our program we do that [help students internalize the
professional ethos] through generic abilities, and we share with
our students that these are the abilities which have become
accepted as professional behavior. More importantly, they are the
expectations of the clinicians they are going to be working with

107

and for, which then gives it credibility. (P1F3, p. 3-4)

The incorporation of self-assessment into the generic abilities evaluation
process was also cited as an important component of developing into a
professional.

The process, the way in which they [the GAs] . . . are used to
facilitate professional development is that each semester we do a
self-assessment based on the generic abilities, which would mean
you would sit down and look at each generic ability and rate
yourself . . . based on the number of different criteria . . . and then
give examples of why you felt you met these criteria. Then you
give a plan based on knowing where you are and where you’d like
to be eventually. . . That really was very effective because lo and
behold, every semester there it was again, and you would once
again be reviewing yourself, doing your self-assessment, and then
. . . you would submit your self assessment to your advisor [who
would share it with the faculty]. . . Then you would arrange a
meeting with your advisor to discuss [if] . . . my assessment
matched up with the faculty assessment. . . . That felt like it was a
very effective means of communicating and helping students be a
very active participant in their own evolution professionally.

(P181, p. 9—10)

One faculty member thought that self-assessment should be part of an ideal
program for socializing students into the profession. He stated, “[In an ideal
program] students would be mature enough to actually do a self-assessment
and know what they’re looking for and how to do a self-assessment' (P1 F 1, p.
22).

The use of regular feedback through the assessment process was felt to
be a significant factor in facilitating professional development.

We get feedback on a regular basis, and that is part of the generic
abilities, but it’s not necessarily just generic abilities based.
They’ll give you feedback on other aspects as well. (P182, p. 2)

Each semester we sit down with the students and bring feedback
from the faculty as whole and say here is where we see you. So
they already get accustomed to getting feedback. . . With the
students’ increased level of awareness of these issues, all of them,

108

from professionalism to the effective use of resources . . .
something happens by them being more aware and by being
asked to review these and keep these in their minds on an
ongoing basis. The importance of these and the value of them, I
think, becomes integrated and the students take ownership of that.
(P1 F1 , p. 6)

This program also does other things that help the students internalize the ethos
of the profession (e.g., role modeling), but they are program features that are
also present in Program 2, and in other physical therapy training programs and
will be discussed in subsequent sections of this chapter.
W

Program 2 is a Midwestern university that has approximately 17,000 students
and is located in a semirural area. Forty-eight students are admitted to the
physical therapy program after completing three years of prerequisite courses.
After an additional three years of enrollment in the professional program,
students are awarded a masters degree in physical therapy (a bachelors of
health sciences is awarded after four years of schooling). Clinical internships
comprise 34 weeks of the program and students complete two fourteen-week
internships after the academic phase of the program. Program 2 has 10.5 full
time faculty positions. It admitted its first class in 1994.

Of particular interest in regard to this program is that 28 weeks of fulltime
clinical internships at the end of the academic portion of the program is on the
high end of that recommended by the APT A. In addition, this program has
regional coordinators of clinical education who meet with students individually
and in groups during their internships to discuss cases and to address
questions or concerns students are having. While all programs have one
person who is designated as the Academic Coordinator of Clinical Education
(ACCE), a requirement of accreditation by the APT A, who meets with students

109

and their clinical instructors periodically to evaluate student progress during
internships, the use of regional coordinators and group meetings during the
final, full-time internships is, to the best of my knowledge, unique to this
program.

Program 2 has a strong emphasis on the use of reflective Ieaming. During
the academic phase of the program students complete reflective journals every
two weeks as part of a 1 credit professional issues course offered each
semester. Journal entries are also completed at regular intervals during the
clinical education component of the program. Feedback regarding journal
entries is provided on a regular basis. In addition to journal writing, students
participate in entry, mid-program, and exit interviews to discuss their goals,
accomplishments, and meaningful experiences in the program. In conjunction
with the mid-program and exit interviews, students also submit portfolios
consisting of written information that will be discussed at the interview, as well
as samples of their work since the last interview.

In regard to course work, a three credit ethics course is included as part of
Program 2. While all programs incorporate an ethics unit or component into the
curriculum, Program 2 includes ethics as part of a separate three credit course.
Finally, Program 2 has instituted the use of “Mock Clinic”, a course, or in some
cases, a unit of a course, that is specifically geared toward imitating a real world
clinical experience in which students role play the parts of both the therapist
and the client in the clinical setting. Mock clinic was first described in the
physical therapy literature by Sanders & Ruvolo (1981). These authors
describe some of the advantages of mock clinic as providing an avenue

for the students to see themselves in situations and to learn from
errors without involving real patients . . . [to allow students the
opportunity to] practice over and over again, . . . [to] allow earty
clinical contact in which newly acquired skills and knowledge can

110

be practiced and student motivation and interest maintained at a
high level . . . . [and to allow students to practice] the same skills
that will be used with real patients in other clinical settings.
(Sanders and Fluvolo, 1981, p. 1164)

Further, students are active participants in the Ieaming and problem solving
processes and instructors can provide immediate feedback without worrying
about what effect their feedback may have on patients, as occurs in the clinical
setting (Sanders and Fluvolo, 1981). In Program 2, in addition to receiving
feedback from peers and instructors during mock clinic, some of these “therapy
sessions” are videotaped for student review and self-assessment of their

psychomotor skills, as well as their interpersonal and professional behaviors

with the “patient.”

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lntrviw trnEmhionEthicsLnrli'llnmh' 'nl
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As just discussed, the primary ways in which Program 2 socialized students
into the professional culture of physical therapy involves the use of reflective
journals and portfolios, a separate ethics course, longer clinical internships with
the use of Regional Clinical Coordinators to meet with students in groups during
their final clinical rotations, and the use of mock clinic. These methods were
apparent to all students, faculty, and clinicians that were part of this study.

All participants in Program 2 cited the facilitation of reflectlon through
journals and portfolios as a strong socializing force for professional
socialization.

[Tjhe journal helped us to reflect on what our experiences were
and maybe understand them better and it helped us to be a little
more empathetic or kind of step back and grow and see what we
were doing with people. . . They [the faculty] really emphasize
reflection-based practice in my curriculum and they emphasize it a
lot . (P283, p. 6-7)

111

[l]t [reflective journal writing] really made you think about your
profession and . . . it helped you to focus more on the lectures and
get a sense of what you felt about any issues that came up if you
talked about an ethical issue or if you had different people come
in. (P281, p. 7)

Another thing that we did was we had a professional portfolio.
Within the portfolio we had to ask ourselves what . . . we had
Ieamed from that particular year. We did a portfolio for each year,
and we would pick two to three items from each semester that
were important to us and we would incorporate that in our portfolio
and we would answer questions as far as what we thought we
were weak in and what we had benefited from that year as far as
knowledge. . . and [we would write] long and short term goals. . .
we had a pre-interview which was the first semester and then
midterm, which was in the second year and then in the final year,
the exit interview. . . I think they [all the above mentioned methods]
helped us to kind of develop into the role. It helped you to focus
on particular goals. What your strengths and weaknesses were
and from that I felt like I just walked into the role. (P281, p. 5-6)

My understanding is that there is a focus in their curriculum on
reflective Ieaming and that they encourage students to spend time
after they have had a particular Ieaming experience, thinking
about it in a way such that they can integrate what they Ieamed.
And I think that [reflection] is missing in a lot of programs. (P201,

P- 4)

The strong emphasls on ethlcs in the profession, incorporated into the
program in the form of a separate three credit ethics course, was cited as a
strong factor in the socialization process. All students and faculty discussed the
ethics course as part of socialization of students into the profession (P2F1,
P2F2, P2F3, P281, P282, P283). One faculty member said:

The ethics course is directed toward that aspect . . . [the instructor]
emphasizes very heavily the ethics of care . . . and people’s work
on that and tries to introduce them to that concept and also what
the professional role of physical therapists is in relationship to a lot
of virtues. (P2F1, p. 2)

The longer cllnlcal Internships and use of Regional Coordlnators

112

of Cllnlcal Educatlon were also thought to be a very important contributor to
the socialization process.

[Hjaving the long clinical internship, our whole clinical internship
program. The way it is set up allows them such a greater
opportunity to make that transition [from student to professional].
We think socialization in the field is best accomplished . . . in [that
way]. That is one of the reasons we moved to the longer clinical
format, where the students are able to get much [more] involved in
many more activities than they do in six weeks. If they have
fourteen weeks, they have time to really get involved in the ethos
of that whole clinic and Ieam a lot more things than they would
have [in a shorter clinical internship]. And also having [the
clinicals] over two semesters (helps). (P2F1, p. 6)

I think the things that Program 2 has in place that helps them [to
help students internalize the professional ethos] are the regional
meetings [with the students and the Regional Coordinators of
Clinical Education], the longer clinicals, and the reflective Ieaming.
(P202, p. 5)

In our last year we did our clinicals, which were 14 week clinicals .
. . I think that was very helpful because when you're there long
enough, you get to Ieam what to do. You’ve got to juggle
insurance information, discharge planning. Critical decision
making was enhanced, or you got to actually take a bigger part in
that decisions rather than sort of collaborating with your Cl. You
got to really grow and Ieam like what your judgment call should
be. More responsibility. That way they weren’t doing everything
for you . . . You did everything mostly yourself and I think that really
helped me [when I started my first job]. (P283, p. 9)

In contrast to those who felt that the longer internships were extremely helpful
in the socialization process, one clinician felt that the longer internships were
not as necessary since other students, who complete shorter rotations, also do
well in the area of professional socialization (P2C3, pp. 10-11). This different
opinion, I think, addresses concerns of efficiency. If students can intemalize the
ethos of the profession in less than 14 weeks, is that longer time, although

helpful, necessary? Another comment made by this same clinician, however,

113

speaks to the goal of the program faculty in socializing students. They (the
program faculty) discussed how these longer internships were a way of helping
students to transition into the profession, a way to help them internalize the
subtleties of how to behave and think as a physical therapist -- to go beyond
simply the skills needed to be an effective physical therapist. The clinician’s
comment was that one of the reasons she felt that 14 weeks may be too long
was because the clinical instructors often had a hard time identifying something
to 'teach" the student on the last several weeks of the internship (P203, pp. 13-
14). Perhaps, as suggested by the faculty comments, this is the time that
students have achieved clinical competence in the areas of cognitive and
psychomotor skills, and are working on affective development, part of which is
the internalization of the ethos of the profession. This question, however,
cannot be answered by the data gathered as part of this study and remains a
question for future research.

“Mock cllnlc” was felt by participants to be a useful tool in socializing
students into the profession. Some of the factors about mock clinic that were
thought to contribute to professional socialization included opportunities for
practicing professional behaviors, problem solving, self-evaluation and
evaluation by peers.

To get us set up for clinicals, one of the things we did was we had
the patient care labs, where we had mock clinic, and I think that
helped us

. . . one student would be the therapist and one student would be
the patient and they videotaped us and we got to see the
videotape of how we acted. It was really interesting to see how we
were when we first started the program compared to the second
year when we had mock clinic again. (P282, p. 5)

We have mock clinic. We have a lot in the labs. We have a lot of
patient scenarios and we are trying to get the students to think
through and come up with different solutions. (P2F2, p. 5)

114

ht th P r hvin mmn?: hredEx tin

rt niti f r Pr i on ist nt Ex tions Prof ional Dev l m nt
u e F k Ad ltL min Ev l ti n fEff iven of
i liz tion n R niti n f ializati n Develo m n lPr

While certain processes by which students are made aware of and socialized
into the ethos of the profession in these two programs were identified as unique
or special by the participants (generic abilities assessment in Program 1 and
the use of reflective journals and longer clinicals, etc. in Program 2) , many
other instances of professional socialization were noted, some of which are
typical of most physical therapy programs and some of which are shared by
fewer programs, and may, in fact, be unique only to these two programs.

A strong emphasis on sharing expectations of professional behaviors
with students was felt to be important. Both Programs included expectations of
professional behaviors in such documents as the university catalog, student
handbook, course syllabi, APTA documents such as the Code of Ethics and
Standards of Practice, and clinical policies and procedures manuals. Faculty
explicitly shared their expectations for professional behavior. In addition, faculty
in Program 1 made the program expectations and consequences of failing to
meet expectations, known quite explicitly through the generic abilities.
Interestingly, the faculty in Program 2 felt that they did not make their
expectations as clear and explicit as they wanted to and felt this was a
weakness in their program. Consequently, they had plans to incorporate the
generic abilities into their curriculum for the next incoming class. This trend is
also being instituted in many programs across the country, including the one in
which I currently teach.

Next, both of these programs offer the students many opportunities to

practice professional behaviors as a way to help them internalize the

115

ethos of the profession.

Well, I think it [the use of GAs] gives them a clue what clinicians, or
people outside of the school expect. They’ll know what people out
there are expecting the first day that they show up as an intern. i
mean it just helps with instilling all of those qualities that they’ll
need . . . I think it is just practice for what they’re going to have to
do when they get there. (P1 F2, p. 6)

I think when we had mock clinic we had our labs and we have
every kind of . . . hands on experience. That helped a lot because,
like I said before, the first time you go in there and you are very
uncomfortable even talking to your own classmates and it is not
even a real situation where somebody is in pain. After two years
of doing this, it just becomes very natural and after your first
clinical, you get used to interacting with the patients. . . . I think [it
is] just practice. (P282, p. 5)

The fact that expectations and practice are part of the entire
curriculum, rather than simply being presented as part of one or two courses
or units of courses, and are consistent across settings was also felt to be
important.

“I think even the instant we step into the program it’s kind of
ingrained into us - respect, treat patients how you want to be
treated. I think every class emphasizes good care and skills.
(P181, p. 5)

[T]his [professional socialization] is something that you have to
give students over a period of time to develop, and it has to be part
of the curriculum at every single level, starting with pro-admission.
If you’re going to expect students to be socialized into the
profession at entry level by the time they graduate, you have to
give them time to do that because the socialization process takes
time. . . and we can do this in part of every course. (P1F3, p. 5-6)

It was basically expected that you would conduct yourself that way
[as a professional] throughout all your education. (P283, p. 2)

There are a lot of things that have been consistent from day one of
coming into the program through this moment, in any setting
whether that was in the professional classes that we had at
[Program 1] . . . or in any given clinical setting that We been going

116

through or, . . . any [state Physical Therapy Association] function
that I’ve been part of . . . I mean that that [ways of socializing
students into the profession] has been articulated very clearly in
[Program 1] . . . , and I think it is implicit in the clinical settings, if
you’re following what I mean by that. it’s been stated pretty clearly,
“T his is what’s expected of you if you’re acting in a professional
manner.” (P181, p. 5-6)

One method of socialization that these two programs shared that is not
present in many other programs is a series of professional development
courses, one per semester, in which students are exposed to and discuss
current ethical, societal, economic, political, and professional issues that affect
practice and, ultimately, the evolution of the profession. These seminar courses
were described by participants in both programs as a strong force in the
socialization process.

[Tjhere are credit/non—credit courses that are each semester.
Professional issues, professional development, things like that
[are covered in these courses]. During those classes there is a lot
of ability to interact and it [helps] . . . to explore the evolution of the
generic abilities on one level, and the professional qualities that
we’ve been talking about on another level. (P182, p. 7)

[Me had seminars and we would break up into small groups and
we did a lot of just talking amongst ourselves. . . I think that really
helped to just talk about different ideas that were out there . . . we
just got used to hearing about these issues and how we [the
profession] were dealing with it and everybody got to talk about
how they would deal with it. So you got to hear everybody’s ‘
ideas and Ieam from that. (P282, p. 2)

Throughout our academic course we had seminar courses that we
had speakers talking about current topics and controversies within
our profession. We do a lot of reflective journal writing on subjects
that were presented there. A lot of dialogue and discussion [in
those courses]. (P283, p. 3)

Educators in both Program 1 and Program 2 provide feed back not only on a

regular and consistent basis, but also provide feedback to correct

117

problems as soon as they occur rather than letting unprofessional
behavior go unnoticed or waiting for a scheduled appointment with a student. - ‘
Faculty felt that this method of immediate feedback would decrease the chance
that the unwanted behavior would continue or get worse.

Well, we get feedback on a regular basis, and that is part of the
generic abilities, but it’s not necessarily just generic abilities
based. They’ll give you feedback on other aspects as well.

(P1 82, p. 6)

I always correct unprofessional behaviors as soon as I see it.
(This statement was made by several faculty members and
clinicians)

[W]e have more students who are having problems [because they
are being identified now]. The thing is, we are identifying them
early and they're not as big of problems. We don't have students
dropping from the program in the final six weeks rotation, that have
been all the way through the program (and have been having
problems) . . .If we have a student like that, it’s somebody that
we’ve known about all along and we’ve been working with it and it
just hasn't worked out. (P1F3, p. 9)

Both programs used principles of adult learning. There was an
emphasis on being self-directed, being an active learner, being responsible for
one’s own Ieaming, and being reflective. In addition, as mentioned earlier,
Program 2 placed a great emphasis on reflection through the use of reflective
journals and portfolios; and Program 1, through the use of the genericabilities,
stressed self assessment and self direction.

He [one of me faculty] believes himself to be in the “Socratic”
method of teaching to help you discover what you know, and I felt
that worked for me. i liked that a lot. I know that some of my
classmates, that was hard for them, but I do believe that that really
is a good preparatory tool as each of us goes on to continue in our
professional lives. There will always be times where we’re not
going to go, “Chris, what’s the answer?” We’ll need to go to our
own resources within and find out, well, what journal can i look up
to figure this out, or how can i put together what knowledge I
already have at my fingertips to solve part of the puzzle, or

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perhaps all of the puzzle. (P182, p. 13)

There are also specific parts of the didactic curriculum where we
try to incorporate this responsibility for lifelong learning and
responsibility for evaluating new literature that deals with our
profession. Responsibility for creating new knowledge. (P2F2, p.
2)

i’m trying to get away from the 50 minute lecture format as much as
possible . . . I think they Ieam things better when they are asked to
get it on their own . . . I think if you are careful in your selection of
assigned readings toward the textbook and that sort of thing, the
information will always be there and students can benefit from
using the in class time to do some sort of active work rather than
just listen to a lecture. (P1F2, p. 7)

I think that we have instituted a whole bunch of ways throughout
our curriculum to try to encourage active Ieaming and also
reflective learning and i think looking at the development [course],
reflective journals, the seminar series, all those things are
methods that are trying to get them to reflect on a lot of topics.
Active Ieaming is something that we’re working on . . . I think we
have quite a bit of that in our curriculum where we try to do a lot of
case kind of studies and try to get the students to simulate kinds of
continuing education . . . Getting to go on to do it and trying to get
them to search out things on their own. I think we are continuing to
work on that. (P2F1, p. 5)

Another shared quality of these two programs was the process by which they

attempted to evaluate the effectiveness of their program. All physical

therapy programs must perform outcomes effectiveness studies of their students

to meet the accreditation requirements of the American Physical Therapy

Association. While all programs do make some efforts to assess professional
behaviors as part of this accreditation criterion, Programs 1 and 2 not only made
efforts to design their curriculum to explicitly include methods to help students

internalize the professional ethos of physical therapy, but also attempted to

evaluate the effectiveness of the program in this area. Faculty from both

programs were able to cite specific evidence of the effectiveness of the program

119

in facilitating professional development.

I think it is effective, particularly because the students relate well to
that [professional seminars]. Students consistently cite the
seminar series as being very helpful, enlightening in their
professional socialization, in their identity with the professional
and Ieaming more than just technical or practical issues. We do
this consistently. (P2F3, p. 3)

We have journal writing, too. in each of our seminars we do
journal writing and we do portfolio reviews and they have to write
evaluations of their own. From those kinds of things and the exit
interviews and things like that, you get a sense, and also on the
papers they write in ethics and other courses, you get certainly a
sense that they are incorporating some of those values into their
own values and solidifying some of the values. (P2F1, p. 3)

Well, we think they [the GAs] (are effective]. . . I could give you a list
of as many clinicians as you would want to talk to that will tell you
that our students are more professional than they were a few years
ago. The only thing that is any different is the generic abilities. . .
from the clinical point of view, I have students with less problems
when they go into the clinical in the last internship, and when they
do have a student who has a problem, they are much easier to
address. . . As another quick example, I got a call from a 1996
graduate who called me up and said, . . . “I’m about to be a clinical
instructor for the first time and we just had a student here from
another program and . . . we had a lot of issues with the student.
None of these issues related to the school’s evaluation tool. They
all related to the generic abilities.” She said, “When I was there in
school, . . . [I thought] this is common sense . . . I took it as a given .
. . Now i realize how important it is.” Of course, I said to myself,
“Another student has another ah-ha experience.” (P2F3, p. 8-9)

Finally, faculty, as well as students, from these two programs recognized that
the process of professional socialization Is a developmental process.
As such it takes time, with students progressing through the process at different
rates and in different ways. In addition, there is a recognition that some
students will never make it to the final stages and truly internalize what it means
to be a physical therapist.

[T]here are still some students that come through and no matter
120

how hard you work with them, at the end of two years it still seems
like they want the answer to memorize rather than trying to use all
they know to [find the answer]. (P2F2, p. 5)

[Slome students will get it and some won’t have a clue. . . we tell
them that this is more than just facts and skills that we expect from
them, that we expect certain behaviors and values to also be taken
on as part of their professional socialization. Some identify with it
and some do not. (P2F3, p. 8)

[At the beginning] they sort of a little bit [looked down on] the
seminar and having speakers come in and talk about why we do
this or talk about professionalism. But by the end of that, almost
everybody felt that these were the most important things that they
learned. There were things that just made them ready to go into
the clinics. (P2F1, p. 7)

The process of GAs is hard, it takes a lot of time, and it is worth it
because it lasts a lifetime. (P1F3, p. 4)

I think they [the students] are aware [of the socialization process, . .
. but] students see the value more once they graduate. (P2F2,

p.10)

I’ll be honest. My first year I was a lot more dissatisfied than i am
now. I think maybe a lot of it is because I’ve matured as a student,
and I’m sure that has a lot to do with it. (P182, p. 13)

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Of the other means of socializing students into the profession, those methods

that these two programs share with other physical therapy programs, role
modeling was felt to be the most important by faculty and clinicians. They

discussed their personal role in socializing the student as one in which they had
to “teach by example” or “by demonstration” (P1F1, p. 3; P1 F3, p. 4; P2F3, p. 2),
and to, first and most importantly, “be a good role model for students' (P1F2, p
2; P102, p. 2; P103, p. 4; P2F2, p. 2; P201, p. 1; P202, p. 3; P203, p. 3).

121

Students also noted that they Ieamed by watching and role modeling their
clinical instructors and other therapists they observed. One student said,
“These values are implicit in the clinical setting and are exemplified by what I
see rather than that they are [just’ explicitly spoken of in those settings” (P181,
p. 6). In addition, although students identified behaviors in some clinicians that
they did not find they would want to role model, overall all participants felt that
the academic and clinical expectations for behavior and the role models were
consistent across these two settings (P1,P2 all participants). More specifically,
one student from Program 2 described the Ieaming that occurred as a result of
role modeling as follows:

[T]hat is the way I would Ieam from the therapist, is by watching
them first, and by seeing another professional. I think that you
kind of pick up on . . . how they are doing things and incorporating
that into your well-being. I think that is something through all my
clinicals that I have had as far as just observing the different
therapists . . . you agree or disagree with certain things and you
incorporate that into a whole and I think you kind of come up with
your own recipe that you like and you use that and that is what I
have done. (P281, p. 2)

Other methods that I have personally encountered that these two programs
share with other physical therapy programs include presentation and
discussion of professional Issues In other courses such as an
Introduction to Physical Therapy, Research, or an Administration course; the
use of real-life examples to the greatest extent possible in the form of paper
patients, role-playing, evaluation and treatment demonstration with real patients
in the classroom, evaluation and treatment of real patients by students,
exposure to real patients with one day visits to practice clinical skill, and, of
course, exposure to real patients during clinical internships; provision of

examples and nonexampies of professional behaviors in various classes;

122

and encouragement or expectations to be socialized into the profession by
joining professional associations and attending professional meetings.
Each of these methods was cited as a way in which students are socialized into
the profession by the participants in this study.

It seems like anytime they go to a professional meeting or read
some article, they come back and they say, “This is really what the
profession stands for. Read this article." This is the gist of what we
heard from clinicians and I think that type of thing and I think that
helped us too. (P183, p. 4)

Going through practice practicals. Going through having actual
patients come in to work with them in class in small groups, or
going out to see the clinic and seeing patients. Seeing actual
patients. All of those, I think, are very valuable bridges [from being
a student to being a profession]. (P181, p. 17-18)

([1 use clinical examples from my past experience to try to get
across a concept. (P2F1, p. 5)

The faculty has been very supportive of student enrollment in the
APT A and the . . . [State meetings], and participation in those
annual meetings and/or regional meetings, student conclaves.
(P182, p. 2)

I help teach the spinal cord injury unit . . . [and] we ask the students
to personally interview patients and not only get a subjective
history from them, but also ask them questions like, “What does it
feel like to have this?”, or “What did you do when you were
confronted with that?” (P203, p. 11)

It seems like most schools are really' encouraging professional
involvement in the association, as well as . . . district meetings.
(P203. p. 8)

The . . . clinical education series . . . and then the social psych
course [help address issues of professional socialization. (P2F1,

P- 5)

123

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The previous section described the methods used in Programs 1 and 2 to
socialize students into the profession of physical therapy and to help facilitate
lntemalization of the professional ethos. The views of both educators and
students regarding these methods and their effectiveness were integrated into
this description. In contrast, this final section of the chapter emphasizes the
views and feelings of students only. It highlights their perception of the
experience of professional socialization,

W. The need to behave professionally
was cited as a definite plus when interacting with patients, colleagues, and the
general public. Students identified such issues as interacting appropriately with
patients, explaining what will be done and why, treating patients with respect,
open communication with team members, being willing to help coworkers,
being active in the professional association, and behaving appropriately both
within and outside the clinical setting as important characteristics of
professional behavior. In general, they recognized that a professional
demeanor is not just something that is put on upon entering the work setting as
one would put on a lab coat or name tag to indicate job status. One student
summed up her feelings on professional behavior as follows:

I think basically it [professional behavior] is shown in how we act
towards them [patients], [and] how we act when we are in public,
just pretty much everything that you do, and not just when you are
at work. I think, just in general, not only when I am at work, but
whenlamoutltrytoheip peopleiflcan. iflseesomebodywho
needs help, even if they are just lost or need directions, I just try to
help them. (P282, p. 1)

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Aw r n f r m ith r f i n l h vi r. Like the educators who

socialize future colleagues into the profession, students also expressed
awareness of and disappointment with unprofessional behaviors they had
witnessed in both the classroom and the clinic settings. For the students who
participated in this study, classmates who behaved unprofessionally were felt to
be an embarrassment to their cohort, the program, and the profession in
general. This sentiment was expressed in a variety of ways.

I can think of specific cases [of unprofessional behavior] maybe in
the classroom when we have speakers come speak to us and
maple are maybe, I don’t want to say short tempered because it
isn't the right word, but they’re very unaccepting. Not that we have
to accept what everybody says, but I think tolerance is a big key in
showing respect . . . We had somebody come to speak to us
about [tape unclear]. She had come and she specifically said that
the example she had given was non-functional, but this was they
only way she could make us kind of apply it to our knowledge at
that point. One student specifically, I remember, kept saying, ‘I
don’t understand this. It doesn't make sense’. He literally said to
her, ‘I don’t see why we even have to listen to this’. I was really
disappointed. I was really more embarrassed for all of us than
anything else. (P182, p. 3)

I think it is really rude to talk when a professor is teaching a class
and giving a lecture. I think that was one of the things where in
this particular class, people had a little bit more laid back attitude
than they should . . . . I though it was unprofessional [to talk when a
professor was teaching]. (P281, p 3)

Unprofessional behavior on the part of professionals in the clinic was also
considered to be unacceptable by these students, and students recognized
times when they (the students themselves) may have not acted as
professionally as they could have. Several instances of unprofessional
behavior on the part of clinicians and the students themselves were described.

I guess one of the first clinical instructors that I had on my two
week was somebody who tended to use excuses for not knowing
certain procedures or ideas. Excuses being, ‘They didn’t teach my

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that in school, the program wasn’t very good where l was’. Instead
of taking it upon himself to go to continuing ed courses or to
develop himself as a clinician, instead he chose to make excuses.
Because of that, at that time it was only my two week [clinical] after
my first year, but I didn’t think he was necessarily practicing all the
values that he should have. (P182, p. 3)

I guess one example of just myself, is that at my first clinic i found
myself getting frustrated with patients. I was kind of like wishing
that they could do more and finding myself becoming frustrated. I
think now after just a little more schooling and a little more
experience that would not happen any more. I think back and I
should have been more patient. (P282, p. 2)

I had a boss that had been practicing for 14 years and she’s never
been to continuing ed. There are people out there . . . well some
people are out there making money and they’re not dedicated to
maintaining that [professional] standard. (P283, p. 14)

On the other hand, students also readily discussed positive examples of
professional behavior they had witnessed.

I think the majority of educators and our staff were extremely
professional and they were all very active in the state PTA
(Physical Therapy Association) and the APTA. They went the
extra mile to make sure our needs were met in terms of our
Ieaming needs and stuff like that . I think they represented the
profession in excellence of care and things like that with their
teaching. (P283, p. 4)

Well, at the last clinical l was at, my clinical instructor had been
working for about 20 years and she had a difficult patient and she
just knew how to handle him, his family, and his doctors. She just
knew the right thing to say, the right tone to say it in. I don’t really
remember a specific situation or exactly what it was, but she just
always knew what to say, how to say it, how to act and how to
approach the patient. (P282, p. 2)

Overall, although students said that they were aware of some
problems, they also felt that part of the process of socialization was this

witnessing of many different types of behavior in order to mold their own

126

view of how they should function as professionals. Consequently, they
felt that exposure to different role models, including negative ones, were
an important part of the socialization process.

I guess for me, that is the way I would Ieam from the therapists, is
by watching them first and by seeing another professional. I think
that you kind of pick up on . . . how they are doing things and
incorporating that into your well being. I think that is something
through all my clinicals that l have had as far as just observing the
different therapists . . . you know you agree and disagree certain
things and you incorporate that into whole and I think you kind of
come up with something of your own recipe that you like and use
and that is kind of what I have done.

In any given professional that I’ve encountered, faculty or clinician,
I do feel that each of them exemplifies all of them [the values of the
profession] quite well, and some of them better than others, and
some of them not quite as well as others, . . . [but they] do
exemplify these values that we talked about that are important to
physical therapy. (P181, p. 17)

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in addition to being aware of problems with professional behavior and being
able to provide examples of both professional and unprofessional behaviors,
students were also aware that professional socialization was a goal of their
programs. All students felt that goals and expectations were made very explicit
throughout the program. In addition, they stated that the faculty goals were
realistic and, for the most part consistent with those of the clinical settings. They
used terms like ‘there are a lot of things that have been so consistent from day
one coming into the program” (P181, p. 6), "I think with the generic abilities that
is pretty well laid out for us” (P182, p. 5), “It was basically expected that you
would conduct yourself [as a professional] throughout all your education”
(P283, p. 2), “I think even the instant we stepped into the program it’s kind of
ingrained into us” (P182, p. 2), and “it was very structured and very organized

127

and written out as far as goals and objectives” (P281, p, 4).

Students were also able to describe methods educators used to help
evaluate and facilitate professional socialization. In general, students’
perception paralleled those of educators. They clearly identified the same
methods of socialization identified by educators that were discussed earlier.
For Program 1, these included primarily the generic abilities and all their
component parts (i.e., explicit goals and expectations for behavior, regular
meetings and feedback with advisors, self assessment, etc.) (P181 ; P182;
P183); feedback in other classroom situations unrelated to the generic abilities
assessment; consistent role models (P1 81 ; P1 82; P1 83); encouragement to
join and become involved in the professional organization (P182); and
professional development courses (P181; P182; P183). Students in Program
2 described the longer clinical internships (P281; P282; P283); the strong
emphasis on reflection and ethics (P281; P282;P283; mock clinic (P282;
P282) consistent role models (P281; P282; P283); and the professional
development courses (P281 ; P282; P283) as effective means of professional
* socialization. it should be noted, however, that all students reported that they
were relatively unfamiliar with what methods of socialization were used in other
programs, and, therefore, their perceptions of the effectiveness of these
methods in relation to other methods that might be used in other programs is not
available from the data in this study.

Students provided many examples of how these methods helped them to
internalize the professional ethos. They specifically noted that it was important
for faculty to use methods that would allow them to be active and responsible
Ieamers who could perform self assessment and goal setting; to reflect on their

Ieaming; and to become aware of and involved in addressing professional

128

issues. In addition, they said it was helpful if faculty created opportunities to
allow adequate time to practice the skills they would need to be successful in
the profession; to discuss important issues with classmates and educators; and
to lntemet with a variety of professionals and patients through course work,
clinical internships, and involvement in professional activities.

[T]he journal helped us to reflect on what our experiences were
and maybe understand them better and it helped us to be a little
more empathetic or kind of step back and grow and see what we
were doing with people . . . . I think it [the use of journals] did [help
with professional socialization]. Just to look at your thoughts and
things again and see what you could change or what you couldn’t
change. It gives you a sense of perspective on what you’re doing.
(P283, pp.6-7)

[Reflective journal writing] really made you think about your
profession and . . . it helped you to focus more on the lectures and
get sense of what you felt about any issues that came up if you
talked about an ethical issue or if you had different people come
in. (P281, p. 7)

We are constantly writing goals and objectives and for each
clinical we have to write them and we have to keep journal for our
clinicals and we have to read them over and thin back of how we
felt the first week and how we felt the last week . . . . I think it helps
a little, [but] for me personally, just kind of doing it [helps, too].
Getting out there and just knowing that each week you grew a little
bit more. (P282, p. 4)

Even the first day when we have our little orientation, they [the
faculty] talked about being active Ieamers and that we are
responsible for our own Ieaming and that they have the reflective
journals and we have to look back and see how we are doing. I
think it is just something that was always talked about so we just
grew to expect it . . . once you are out there actually working, it just
becomes natural. You just come to expect it and this is how it is
and this is how it should be and it’s not anything that is new or
something that you have to get used to or think about. It is just
natural. (P282, pp. 45)

[To help us make the transition from student to professional] I think
that we had mock clinics, we had our labs, and we had every kind

129

of hands on experience. That helped a lot . . . . After two years of
doing this, it just becomes very natural and after your first clinical
you get used to interacting with patients. (P282, p. 5)

The faculty has been very supportive of student enrollment in the
APTA and the . . . [State meetings], and participation in those
annual meetings and/or regional meetings, student conclaves.
(P1 82, p. 2)

In our last year we did our clinicals, which were 14 week clinicals.
We just did two and while we were out, we didn’t have any other
classes to go to, so you were done after you were finished with
your clinicals. I think that was very helpful . . . . You really got to
grow and Ieam what your judgment call should be. More
responsibility. That way they weren’t doing everything for you, like
the little things. You did everything mostly yourself and I think that
really helped me [when I started my first job]. (P283, p. 9)

I think that the things that they did were probably right on track in
terms of what they did in my program. If we didn‘t have the
seminar courses, there are a lot of issues and things going on in
the profession that I just wouldn’t know about. That was really
helpful. (P283, p. 11)

I think [the generic abilities] helps with that [making the transition
from student to professional] a lot. The affiliations that are set up
help with that a lot . . . . there are lots of things within the program
the way it is that feel like it facilitates that. I’ll give you a couple of
examples. Going through practice practicals. going through
having actual patient come in to work with them in class in small
groups, or going out and seeing patients. Seeing actual patients.
All of those, I think, are valuable bridges. (P181, pp. 17-18)

It seems like any time they [the faculty] go to a professional
meeting or read some article, they come back and say, 'This is
really what the profession stands for - read this article.’ This is
[also] the gist of what we heard from clinicians and I think that
helped us too. (P183, p. 4)

[The faculty help us make the transition to being a professional] I
think definitely by having the generic abilities and then the forms
they’ve set up [as part of the generic abilities]. We keep having to
sort of check back after every clinical . . . we have to be to a certain
level in our generic abilities. We have to make sure that we have
either gotten a skill or developed that professional behavior in

130

order to go onto the next one.

That [the use of the generic abilities] felt like it was a very effective
means of communicating and helping students be a very active
participant in their own evolution professionally. (P181, p. 10)

[W16 had seminars and we would break up into small groups and
we did a lot of just talking amongst ourselves. . . I think that really
helped to just talk about different ideas that were out there . . . we
just got used to hearing about these issues and how we [the
profession] were dealing with it and everybody got to talk about
how they would deal with it. So you got to hear everybody’s ideas
and learn from that. (P282, p. 2)

Another thing that we did was we had a professional portfolio.
Within the portfolio we had to ask ourselves what . . . we had
Ieamed from that particular year. We did a portfolio for each year,
and we would pick two to three items from each semester that
were important to us and we would incorporate that in our portfolio
and we would answer questions as far as what we thought we
were weak in and what we had benefited from that year as far as
knowledge. . . and [we would write] long and short term goals. . .
we had a pro-interview which was the first semester and then
midterm, which was in the second year and then in the final year,
the exit interview. . . I think they [all the above mentioned methods]
helped us to kind of develop into the role. It helped you to focus
on particular goals. What your strengths and weaknesses were
and from that I felt like I just walked into the role. (P281, p. 56)

While most methods and most educators were viewed as helpful in the
socialization process, there were also ‘negative” methods used by some faculty
that students felt did not contribute to their professional growth. One student in
Program 2, in particular, mentioned several aspects of her education that were
not helpful for her or her classmates.

I can think of one faculty member who I think has shown maybe a
condescending attitude, not so much maybe condescending, but
has treated students and colleagues, I think with . . . disrespect . . .
. I think [that] was not appropriate. (P182, p. 5)

i think some methods are effective and some aren’t . . . .
Encouragement and feedback are really effective. But i think

131

threatening students, or we’ve not really had threatening, but
we’ve been told previously that we’re not a very good class, . . .
our first semester we had a practical and it said we were below
average and that was very frustrating. (P182, p. 11)

Finally, although students overall felt that their programs were doing a fairly
good job in the area of professional socialization in general, they had
suggestions for improving the process even more. They realized, however, that
some of their suggestions might be beyond the realm of what could be
accomplished during their enrollment in a program due to constraints such as
time, money, and the logistics of carrying out the program. For example,
students felt more time in the clinic and interacting with patients would be a very
effective way of facilitating professional socialization even more than their
programs did (P181, P182, P282), but they realized that the time, money and
the logistics of arranging more clinical time might make this desire an
impossibility. Similarly, one student discussed how the program could have
been longer, but realized that a lot of time and money on the part of both
students and faculty would be needed to do so. Several students suggested
that putting more emphasis on ethical and socialization issues might help, but
acknowledged that the faculty were doing a good job of doing so within the
financial, time, and logistical constraints of the educational system.

I feel, at times, that our program was too short. I mean, in two
years we stuffed in all these classes, and I think we could have
maybe spread things out and really focused in more . . . my
Patient-Practitioner Interaction class, which I know was a really
important class, was kind of pushed lower on the agenda because
other classes took over. I think making things like that have more
emphasis would be a really good thing to do . . . . [but] l’m sure
funding is a big obstacle. With more time spent on the ethical and
social issues, I’m sure people just aren’t going to be interested.
There’s always students who aren't interested, who have other
things they’d rather be doing. Maybe there are faculty members
who aren’t just interested in teaching them. (P182, pp. 12-13)

132

I just think that there is so much information that you need to know
before you go out on your clinicals that your first concern isn’t . . . ‘l
have to act this way when I get there.’ [Instead it’s] ‘Am I going to
know the information that I need to know?’ so that might be part of
it because you are so worried about knowing everything before
you get there, that that part might be overlooked . . . . [One way to
get rid of that obstacle is] kind of what they are doing in my
program, where even though you have all this academic work that
you have to worry about, you always talking about [professional
issues]. So even though you might not be thinking about it, you
kind of have the sense of, ‘OK, yeah that’s right. I have to act this
way and l have to be professional.’ (P282, p. 7)

 

students acknowledged their role and responsibility in the socialization process
and recognized that it was not enough to just be familiar with knowledge and
technical skills of the profession. They seemed to readily accept this
responsibility while in the program and acknowledged the relationship between
continued professional development and good patient care.

Most of what they said was that the skills, I mean you can come in
with set skills and that’s fine and skills can be improved, but when
students come in and they don’t have a good base as far as the
generic abilities, that’s where they really struggle. They don’t
necessarily become good therapists than. (P183, pp. 3-4)

They [the faculty] talked about being active Ieamers and that we
are responsible for our own learning. (P282, p. 4)

They [the reflective journals] were more for you, the student, just to
help you reflect what was going on for you. (P281, p. 7)

It [the generic abilities] encourages and fosters students being
responsible for their own Ieaming. (P181 , p. 12)

[Flostering students’ thinking for themselves is also critical, as i
see it, to facilitating patient care. That I need to be able to, you
know that’s not to say that it’s inappropriate to ask somebody else
for something, but I do need to take responsibility on my own for
what it is that I think and what it Is that I’m wanting to do and how

133

am I going to get there. (P181, p. 16)

I think [being an active learner and being responsible for myself is
an important part of getting an identity as a physical therapist],
although I don’t know that I so much realized that while I was in the
classroom. I think it was emphasized, but I think now that I’m in the
clinic, these things are kind of coming out and I’m seeing them
more. (P182, p. 7)

[I think the program] definitely [prepares students to be active and
reflective Ieamers who are responsible for themselves]. i think
[they do this] partly through the generic abilities because may
have critical thinking and problem solving. Partly [by the fact that]
we had an instructor who believed very strongly in active Ieaming
and we were really forced into that model which helped a lot of
people to get out of their old way of Ieaming . . . . He really just
gave use a backbone of knowledge and expected that we would
go out and fill in the blanks. If we had trouble doing that, then we
could go to him and ask for advice . . . . The clinical instructor
“have now really believes in active Ieaming as well, and he
questions your rationale at every step that you take. I think that
forces you to think about why you’re doing what you’re doing. I
think that helps you provide better care for patients. (P183, p. 5)

to 1. Like their

 

educators, the Prime Timers, and the Fellows, students recognized that the
society and health care are changing and that professions must change with
them in order for the profession to continue to survive. They realized that they
would have to personally deal with these changes and respond to and change
with the profession if they wished to continue to develop as a professional.
Overall, students felt that the faculty in their programs were up to date with the
latest changes in the field and society that would affect practice, and that faculty
had adequately prepared them to deal with these changes.

My belief is that things are changing so fast. Medicare, the whole
picture is changing so rapidly that I don’t know . . . . Three years
ago is a huge amount of time in terms of what it’s like to be a
student in trying to prepare yourself professionally . . . . it [the
profession] was different [years ago] and it can’t help but be

134

different. I mean, the world’s changing . . . . It’s just the nature of
the beast. (P181, p. 19)

Well, certainly, what is happening in health care [will affect the
profession], and who knows what will happen ultimately. It
certainly looks like we’re moving this way, but you can’t, as a good
friend once said, ‘You can’t predict tomorrow’s dream.’ So it looks
like it’s moving in a certain direction, but it sure could do an about
face and who knows? (P181 pp. 23-24)

i would say it’s [the faculty being in touch and up to date with
changes in the field] is stellar on all accounts. (P181, p 5)

They [the faculty] were very up to date [with professional issues].
(P281, p. 4)

I think they [the faculty] are well read or they knew what is going
on. Most of them are very active within the therapy community
even though they're in the academic setting. There are a few of
my instructors clinically that were still practicing and some of them
were just doing academics. But they were still very, very active
within the organizations and knew the political things going on.
They would keep up with that. (P283, p. 5)

Well, there are changes that seem to go on every year. As I was
going through the program, one thing they did that was good is
that they always kept us updated. They had the president of the
APTA come in and talk to our class, just about different issues that
were going on. They had somebody from the ethics committee
come in . . . just to talk about ethical issues. (P281, p. 11)

We talked about a lot of this [changes in health care and their
effect on practice] in our seminar, about actually just how physical
therapy is changing. How it was, how it started out, and how it has
changed through the years, and how it is probably going to
change in the future. They [the faculty] talked about what we need
to do to keep up with it . . . . We need to be knowledgeable for the
insurance companies, . . . we know that we have to be educators
to our patients. Basically, they just talked about all that and how
we have to be on top of everything. (P282, p. 8)

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Students recognized that, like the profession, they also go through a series of
changes as they progress through their respective programs. They discussed

1 35

how the process of professional socialization is really a lifelong process that
actually begins prior to entering the program and continues past the time of
graduation. They were able to reflect on their growth and see the relationships
between socialization methods used by faculty and their professional
development. Like faculty, however, they realized that students progress
through the socialization process at different rates and that some students will
fail to internalize the professional ethos, at least by the time they graduate.

I think it [professional behavior] kind of has to be who you are too.

I think that there is just no way that everybody can go through
school and come out exactly what you think a professional is
going to be. Everyone is brought up differently. I think it has to be
a sense of who you are to begin with and then you grow on that . . .
. I think that some people can change and some people can’t
change. I think the time you grow up, your values that you are
taught when you are younger, i think it makes a difference. (P282,

PP- 7'9)

I’ll be honest. My first year I was a lot more dissatisfied than I am
now. I think maybe a lot of it is because I’ve matured as a student,
and I’m sure that has a lot to do with it. (P182, p. 13)

To get us set up for clinicals, one of the things we did was we had
the patient care labs, where we had mock clinic, and I think that
helped us . . . one student would be the therapist and one student '
would be the patient and they videotaped us and we got to see the
videotape of how we acted. It was really interesting to see how we
were when we first started the program compared to the second
year when we had mock clinic again. (P282, p. 5)

My belief is that if you were to ask the class as a whole and they
were candidly to answer in the beginning, that you would have
gotten a significant number that would feel like, geez, this is a
joke. if you were to do an exit poll, I think you would find that there
is a significant difference in the way people viewed them [the
generic abilities] . . . . I think that as a collective, there weren’t a lot
of peeple that were like, ‘Oh great, we get to work with the generic
abilities,’ but I think that by the time we ended, I think that a lot of
people, if they really allowed themselves to reflect on it, would
have said, ‘This was a valuable process for us.’ (P182, p. 10)

136

I felt for me . . . [the first year] was a transition year. I was still at the
point where grades were still really important to me, and if I got an
A . . . somehow between by first and second year I realized, okay,
the A doesn’t matter. Can I apply this knowledge and be
functional and effective? I think the way one of our professors
teaches specifically, really emphasizes that. (P182, p. 6)

I think part of the reason why it’s kind of hard to make the transition
and really feeling like I’m the professional now and l have all this
down, it’s just the fact that you from ‘I’m the student’ and they
respect you, but you’re still the student, [and then] suddenly you’re
the one making decisions. I think with anyone the transition for
you to feel like you’re really competent is just going to take a little
time to feel out, you know, l’m this professional and things like that.
i think it just has a transition period and that is going to happen no
matter what. (P283, p. 11)

[I think our program helps us make the transition from student to
professional by] just emphasizing the continuing education and
that we should continually try to keep Ieaming and that that is
something that helps you strive to be more comfortable as far as
what area you chose . . . . some facilities offer a mentor program
and that was something they did here [at the current place of
employment]. They have a buddy system where you have one
physical therapist that you can ask questions to and it is almost
kind of like having a clinical instructor, but not as stn'ct, I guess. So
that is how I adjusted, and that is something that they
recommended to us in the program . . . . Toward the end of the
program they had a speaker come in just for us to ask questions
as far as interviews . . . getting us ready as far as having an
interview and what questions we should be asking and what we
should be thinking of, and asking if they have some kind of mentor
program. That is kind of how they helped integrate us into the
profession. (P281, pp. 9-10) '

Just because you get out of school, you don’t stop Ieaming.
Always going to continuing education, reading, asking others
around you and Ieaming from them [are important]. (P282, p. 8)

WW. Overall, students felt that professional
behavior was an important part of the physical therapy culture and was

something that should be facilitated in professional education programs . They

137

recognized both inappropriate and appropriate behaviors in themselves, their
classmates, and professionals and were able to provide specific examples of
both. They stated that exposure to a variety of behaviors was an important part
of their professional socialization and was part of the process that was
necessary for the internalization of the professional ethos.

Students recognized the role of faculty in providing them with explicit and
realistic goals for professional behavior. The establishment of clear and
consistent goals and objectives, either those of the faculty or their own, was
viewed as an important first step in the socialization process. The ability to
establish goals for themselves as part of reflection and self assessment and
their ability to assume responsibility for their own Ieaming were felt to be skills
that would help them continue to develop once they completed the program and
were practicing therapists.

Students were able to describe methods used by faculty to facilitate
socializafion and their descriptions of these socialization methods matched
those of educators. More importantly, their descriptions went beyond a mere list
of what the methods were to how they enhanced Ieaming about what was
expected of them as a member of the professional community and how they
were helpful as a means of facilitating the intemalization of the professional
ethos. For example, they described how reflection helped them identify
strengths and weaknesses, establish goals, and see how much they had grown
over the course of their programs, and how active Ieaming in the program
served as the basis for continued professional development following
graduation. They also described how traditional teaching methods such as the
provision of information about professional issues in the seminar courses,

practice, interaction with real patients and clinicians, and role modeling were

138

important in helping professional behavior to become a “natural” part of who
they were.

Finally, students were aware of the evolutionary nature of professional
cultures and the need to be aware of and Ieam to deal with changes in the
profession as the culture evolves. They were similarly aware of their own
development and the need to continue to engage in Ieaming and professional
activities following graduation if they hoped to remain a contributing member of
the professional community. They felt that educators had prepared them to
recognize and deal with changes in the profession and had provided them with
avenues to pursue in order to continue to develop professionally. These
avenues included such as activities as self assessment, reflection, active
Ieaming, continuing education, using mentors, asking questions, and becoming
involved in professional organizations.

Overall, students were satisfied with the process of socialization that was
used in their respective programs. As noted earlier, however, they were not
familiar with methods of socialization used in other programs and, therefore,
had no basis for comparing their experiences with that of other students. In
spite of being unfamiliar with any other models of professional socialization,
however, they did offer a few suggestions for improving the process within their
own programs, recognizing that some of their suggestions might be helpful but
were unrealistic.

W112.

Although each participant in Part 2 had their own unique way of describing
the socialization process and what was expected as an end result, there was
overall agreement as to the general process used by each program to facilitate

internalization of the professional ethos in their students. Participants from

139

Program 1 credited the use of the generic abilities with providing the most
effective means of professional socialization in the program due to the fact that
they provided specific expectations for behavior, opportunities for self-
assessment, and regular feedback on the self-assessment as part of the
process of abilities based assessment. In Program 2, participants felt that the
use of reflective journals and portfolios, a strong emphasis on ethics, longer
clinical internships, the use of Regional Coordinators of Clinical Education, and
mock clinic were strong factors in the socialization process. Both programs
were felt to share all program expectations with students and required
professional behavior throughout all phases of the curriculum, offered a series
of professional development courses, offered many opportunities to practice
professional behavior throughout the curriculum, gave feedback that was
regular, consistent, and immediate, used principles of adult learning, and
recognized that socialization is a developmental process that takes time.
Finally, in concert with other physical therapy programs, Program 1 and 2 used
role modeling, courses or units of courses about ethics or professionalism, real
life examples of patients and case scenarios, personal examples and
nonexampies, and encouragement to become involved in the profession by
joining the professional association and attending professional meetings.

In addition to these methods of socialization, both Programs attempted to
evaluate the effectiveness of their programs. For example, faculty in Program 1
discussed how clinicians reported an increase in professional behavior in
students with the advent of the generic abilities. in addition, faculty reported
how graduates of the Program would call the school to get a copy of the generic
abilities to use with problem students if they were working in a facility where

they were not available. Finally, faculty and clinicians in Program 1 discussed

140

how the generic abilities were felt to be so effective that they were being
incorporated into staff assessments of practicing therapists. Faculty from
Program 2 described how information gathered from student journals, exit
interviews, and outcomes assessments revealed that their methods of
professional socialization were apparent to and successful with students.

Like educators, students felt that professional socialization was an important
part of their education. Their perceptions of methods used to help them
internalize the ethos of the profession as part of the socialization process
paralleled that of clinicians. They described how these methods helped them
become part of the professional community and how they would lead to more
effective practice. In general, students were satisfied with the methods of
socialization used in their respective programs and felt that these methods were
effective.

141

Chapter 6

Putting It All Together: The Relationships Between Values, Teaching, and
Professional Socialization in a Changing World

Although the data from the two parts of this study have thus far been
presented separately in order to address each purpose of the study and the
views of the different participants, Parts 1 and 2 of this study have their strongest
meaning when considered in relation to each other. As mentioned earlier, Part
1 of this study was conducted in order to define the professional ethos of
physical therapy, to trace its evolution since the inception of the profession, and
to identify both static and dynamic aspects of the ethos. Once defined, the
description of the culture and ethos of physical therapy was used as a basis for
deciding what it is that physical therapy educators hope to socialize students
into and to describe their methods for doing so.

When considered on their own merit, the findings of Pan 2 offer a framework
for understanding how contemporary physical therapy educators attempt to
socialize students into the culture of physical therapy. However, when
considered in light of the historical values identified in Part 1, the description of
the socialization methods of physical therapy educators moves beyond a list of
techniques to a reflection of the changing world and changed ethos of the
profession in several ways. First, the necessity of increased content on ethics
and professional issues is a reflection of the fact that the world and the
profession have changed over the years. Participants discussed the fact that it
was not even necessary to discuss such issues in the past because everyone
had similar values and just “did the right thing.” Unlike the diverse students of

today, much of the professional ethos was already a part of student’s personal

142

ethos and did not need to be emphasized in professional education programs.
Next, the role of the faculty in the past in regard to professional issues was
simply to serve as good role models to students. In contrast, faculty must now
apply other teaching methods to facilitate professional socialization to account
for the changed views of the world, expectations of professionals on the part of
the consumers of services, and the need for increased involvement in the
professional and political arenas. Finally, contemporary teaching methods,
such as reflection and active Ieaming, discussed by the participants in Part 2,
reflect the new values of physical therapists preparing to practice in the twenty-
first century, as well as an increased emphasis on adult learning in higher
education in general. Following a brief comparison of the values discussed by
the participants in Parts 1 and 2, the need for an increased emphasis on content
about professional values, the changed role of faculty in regard to professional
socialization, and the need for applying both more traditional and contemporary
teaching methods to socialization in professional education programs are
described in more detail. A summary of these changes can be found in Table 5.
VI :imilriti nDiffr ' P

As described earlier, data from Pan 1 (i.e., interviews with Fellows and Prime
Timers and review of historical documents) revealed the core values of the
professional ethos to be caring and helping, hard work and dedication, warmth
and openness, and a positive attitude. Of these, the most important overall was
helping and caring for patients. Similarly, when asked to describe the ethos
(i.e., core values, norms, and beliefs) of physical therapy today, all participants
in Part 2 described the importance of providing good patient care at all times as
the number one value of the core of physical therapy. This value was described

in a number of ways including: “providlingj quality care to patients through

143

Table 5. Putting it All Together: The Relationships Between Values, Teaching,
and Professional Socialization in a Changing World

ntnt VI :ARfltlnfth rEth
Bringing Core Values to the Forefront
History
Code of Ethics
Standards of Practice
Application of Core Values to Contemporary Issues
Legal Issues
Political Issues
Professional Issues

Tr llan hn Mth :AChan R frF I
Role Modeling
Expectations
Practice
Feedback
Motivation
Transfer

itnt VI w-. -. » ol’Pfad l-i- : ;- ”-tt'l of
Changing Ethos
Research
Teaching
Delegation
Supervision
Consultation
Diversity

 

Changing Ethos
Active Learning
Autonomous Practice
Responsibility
Problem Solving
Critical Thinking
Self-Assessment
Independent Thinking
Life Long Learning
Reflection
Creating Meaning in Communities of Practice

144

expertise and knowledge” (P281 ); “we have our patients’ best interest at heart
at all times” (P2F2); “we are probably one of the strong caring professions”
(P2F1); “help the patient in any way you can to make their life more functional
and more rewarding for them” (P183); and “a sense of responsibility to provide
the best patient care” (P1F1).

Interestingly, although students discussed many of the contemporary values
indirectly when describing socialization methods, they mentioned only patient
care, issues related to patient care, or very general professional traits such as
following the Code of Ethics or “acting like a professional” when specifically
asked to describe the ethos of the profession. In contrast, faculty and clinical
educators described the ethos in much broader terms. They mentioned many of
the same issues discussed by the Fellows and Prime Timers that describe the
roles and responsibilities outside of the clinician role of caring for patients. For
example, they discussed critical thinking, problem solving, independent
thinking, a desire for more autonomy, educating patients and other health care
professionals, research, valuing diversity, taking responsibility for one’s own
Ieaming and continued professional development, and the importance of being
involved in political, professional, and legal issues. In this respect, the values
identified by participants in Part 2 as important in a contemporary culture
echoed and elaborated those in Part 1.

[T]he bottom line is that as physical therapists we have the core
belief that there is value in human life and that everyone,
regardless of [what] their external appearances or their behaviors
are, has value as a human being. (P201)

A commitment to Ieaming and continued professional growth [is
important]. i think the person needs to be self-motivated, as well
as able to motivate others . . . . you should be responsible for
[your] self and accountable for your actions ..... being an
independent thinker.” (P203)

145

In physical therapy, particularly in the last few years, meaning in
the last ten or so, is the change to really being a professional as a
physical therapist, as opposed to when I graduated and we were
nothing more than glorified technicians. I think as we’ve grown as
a profession, the whole area of professionalism and everything
with that involves or includes the ethics of it [has grown] . . . . we
value ethical behavior. We have ethical dilemmas that we didn’t
have twenty years ago. We were never put in that position .....
We certainly value, particularly commitment to Ieaming, because I
think we particularly value the responsibility which relates to our
desire for autonomy which is another value . . . . [problem] solving
skills, critical thinking and being able to deal effectively with other
people and their personal skills. (P1 F3)

Well, it even extends beyond the patient care arena, I think, in
terms of the value system as to working and integrating and
educating . . . with other health care providers. Making sure we
are cognizant of these issues . . . the value, too, in terms of what
we provide for research. Looking at outcomes and quality in terms
of what we do and provide. (P103)

In [regard to] professional autonomy . . . I think we are attempting
to be better at our political agenda regarding our profession more .
. . . Finding that we need to be a little more politically active to save
our license. (P202)

The differences in the description of the values and ethos of the profession

between students and educators reflect other aspects of professional

socializafion and development described earlier in this study. Students’

inability to identify values outside those essential to practicing as a clinician or

practicing in an ethical manner is similar to the view proposed by Becker, et. al.
(1961). Becker and his colleagues found that students in medical school were
part of a “student culture.” They behaved and functioned as students - fulfilling

their roles by attending class and completing course work. They had little time
to think or do anything about their roles as professionals. The students in these

physical therapy programs are also part of a student culture. Although they

146

have begun the process of professional socialization, they still function in the
role of a student. Consequently, they identify and participate in activities in the
only way they can as students -- by identifying with and behaving ethically in
their student culture and role. They see their role as functioning as educators
expect them to, knowing that ethical practice is part of what they are expected to
do as both students and professionals. Second, they see the role of the
physical therapist through the eyes of a student, with limited exposure and
experiences, and have difficulty moving beyond the primary value they place on
helping people. Because the role of “clinician as helper” is the primary one they
have observed, they fail to see other roles such as manager, researcher, or
teacher as important. Students who have not yet been admitted into a physical
therapy program, for example, rarely spend time observing therapists
performing research or- administrative functions, or attending professional
meetings. Their role models are clinicians and it is clinicians they wish to
become without awareness of the additional roles that physical therapists have
had to assume in a changing world. Because all physical therapists with whom
they come into contact are usually in the process of “helping someone,” they
easily identify this most important function of helping as the core ethos, and
often self select into the profession based on their desire to do the same. In
addition, during clinical internships, students are primarily assigned the role of
clinicians, focusing on tasks that are part of being in a helping profession. This
is another factor that might influence them to better identify with values at the
core level - values necessary to fulfill the role of a clinician.
t nt V : R fl '
Participants from both Parts 1 and 2 of this study identified the need for an

increased emphasis on values, ethics, and professional behavior as a result of

147

changing societal values and increasing diversity among students and clients.
As described by participants, students no longer share exactly the same values
with either educators or peers. They come from varied social, economic,
religious, and ethnic backgrounds. Even students recognized that today’s
students are different than their predecessors. Several students discussed
changes across time:

I think the road of being a student in a physical therapy program . .
. is an incredibly difficulty and austere row to hoe. My belief is that
things are changing so fast . . . . I think that there are levels that the
faculty have empathy, but I’m not sure they really do . . . . each
faculty member . . . has been a student 40 years ago, 30 years
ago, 20 years ago, 5 years ago, and as much a neophyte as I am,
it feels like my gosh, it’s changing so rapidly . . . It was different,
and it can't help but be different. I mean, the world’s changing.
(P181)

I think that the time people grow up, your values that you are
taught when you are younger, I think it makes a difference.
Demographic and economic standards [make a difference].
(P282)

Because there have been so many changes since the inception of the
profession, even the core values and beliefs, which students may possess on
an unconscious level, may not be obvious to students and must be made
explicit. Without the presentation of information that represents core beliefs,
students may not even be aware that they exist or that their personal values
may be in conflict with those of the profession.

Content related to core values and the professional ethos that was felt to be
important to emphasize in contemporary curriculums includes the history of the
profession and professional organization, the Code of Ethics and Standards of
Practice, and legal, professional, and political issues. Exposure to the history,
ethics and standards of practice primarily involves bringing core values to the

148

forefront. The addition of professional issues courses that include content on
professional, legal, and political issues exposes students to the application of
ethics and standards of good practice to contemporary problems of the
profession. Current issues discussed in the professional issues courses
included dealing with managed care and other types of insurance
reimbursement, the importance of outcomes effectiveness studies, patients’
right to refuse care, dealing with cultural diversity, and treating patients with
communicable diseases such as AIDS and Hepatitis-B. These issues did not
exist to the same degree in the past. There was little need to prove the
effectiveness of treatment for reimbursement purposes, for example, and
awareness of the epidemic of AIDS is relatively recent. Educators in Part 2 of
this study described the importance of presenting this information to students in
order to help them understand how the profession has grown and changed over
the years in response to societal and health care changes. Students echoed
this sentiment, stating that they would never have known about certain issues
and would have not been adequately prepared for practice if information about
core values and current diagnosis and problems had not been presented to
them.

The emergence of new ethical problems discussed by the participants in this
study is also supported by other authors in the field. In the book, EIDIQQL
WWW). PUTWO (1993). 10' example
uses case studies involving problems with reimbursement or confronting a
physician in order to best serve a patient to help students understand the
importance of the difficult ethical decisions that they will be faced with as
professionals. Similarly, in a recent study, Treizenberg (1996), identified four
ethical issues likely to occur in the future for physical therapists that have not

149

been a problem in the past.

[These issues include] the responsibility of physical therapists to
respond to environmental issues of pollutants and health hazards
associated with physical therapy treatment, the duty of physical
therapists to report misconduct in colleagues, the need for
therapists to define the limits of personal relationships within the
professional setting, [and] the sexual and physical abuse of
patients by physical therapists or those supervised by physical
therapists. (p. 1 104)

In addition, Treizenberg includes a discussion of a “health care as a business”
orientation, an issue that has not previously been addressed in the physical
therapy literature as an ethical one.

Based on the findings of this study, as well as the writing of authors such as
Purtillo and Treizenberg, the importance of exposing students to the values and
ethical beliefs of the profession takes on new urgency. Although these ethical
standards and beliefs have been part of the core ethos for many years, there
are increasing challenges to maintaining high ethical standards. This is due not
only to the fact that students entering programs have more diverse values, but
also to the rapidly changing world where new ethical issues and dilemmas
continue to surface. Students must, therefore, have greater confidence in their
ability to apply high ethical standards to professional practice. Several
participants discussed the need for belief and confidence in standards as
follows:

80 somehow you have to instill [in them], you have to have
discussions where they’re going to believe it, not you’re telling
them, but they’re going to believe it, and they’re going to go out
there and say, well maybe . . . [I] can help to change [the things
that are wrong]. (Prime Timer 1, p. 17)

I think a lot of people have these values and understand them
intellectually, what we do and what we are talking about. But I
think a lot of times they need to establish not only their own values,
but a confidence that those are the right values and that they are

150

able to act on them. I think there is a difference in that. I think that
is one of the things . . . that our students will need to have. When
they get out there and they have to make a decision, that they are
able to act on it. (P2F1, p. 13)

Tr " I hi t :Ahn RI rF

One change in methods of professional socialization due to increasing
diversity and a changing society is the application of traditional teaching
methods to this area. The most often cited method of professional socialization
by all participants in this study was the use of role modeling. As previously
discussed, however, role modeling alone may no longer enough to facilitate the
internalization of the professional ethos due to the increasing diversity of the
student population and the increasing pace of change in our society as
described earlier by Gergen (1991). It is also now necessary to apply explicit
and direct teaching methods to professional socialization in order to help
students internalize the core values and develop confidence in their ability to
apply them when faced with difficult professional decisions. Educators from
Programs 1 and 2, as well as the Prime Timers and Fellows interviewed for Part
1 of this study, identified the need for explicit expectations about professional
behavior as a result of increasing diversity and a changed world. In addition,
educators cited the importance of providing opportunities to practice
professional behavior throughout the program and the need for consistent
feedback from both academic and clinical faculty regarding students’ behaviors.
The importance of motivating students to demonstrate professional behaviors
and informing them that clinicians and other professionals will also expect this
behavior when they go out to clinics was also discussed.

In addition to providing a motivating force for students to begin to internalize
the professional ethos while still in the academic portion of the program,

151

consistency in expectations in the academic and apprenticeship settings also
helped reinforce issues related to transfer. Other methods related to transfer
discussed by participants included practicing in as realistic a manner as
possible through case studies and clinical visits and allowing adequate time to
practice professional behaviors throughout the curriculum so that these
expected behaviors became automatic and internalized as part of the students’
professional ethos. Many of these instructional methods were also discussed
by the Fellows and Prime Timers as they described what educators need to do
today in order to help students internalize the professional ethos and cope with
today’s changing world. The following quotes illustrate their feelings about the
need for explicit methods to help students internalize the professional ethos:

I think when we talk about values both for ourselves and others we
need to . . . put things in context so they can understand where our
values emerge and we do have certain things in common, and
also that we’re very tuned into our own set of values and what
makes us tick, and we recognize that other people have different
sets of values that may or may not be different than ours, and we
need to be prepared for how to deal with that . . . . Then when you
start to talk about the Code of Ethics and what that means to the
professional, versus legal things, versus what is just important to
you and why you make the choices you make, they can begin to
build a continuum of different kinds of concerns that relate to
values, but to begin with you need to start with yourself, and ldon’t
think a lot of curriculums spend enough time starting with those
kinds of things. (FAPTA 3, p 10)

We have to get the students into a dialogue about where they see
[themselves and] how do they feel about these types of issues.
(Prime Timer 1, p. 14)

If some way they could develop the self-monitoring, with perhaps
their own checklist in a way that they would enjoy doing it . . . If
some way they could just do it as part of being a professional --
that self monitorjing] and have a check list that these are the things
that will make me better, improve me . . . this is going to improve
them and be a part of becoming a good physical therapist. (Prime
Timer 10, p. 21 -22)

152

The therapist must be aware of our association and support our
association. As a group we have strength, as a single therapist we
have nothing. (Prime Timer 2, p. 15)

[E]thically we’re much more in the process of having to be very,
very overt instead of operating on assumptions. (Prime Timers, 9,

P- 3)

. t t al : : anwFfl f-.rPr itin :_ ..Rf:l:mo of: -_rtIo 0.
m

As with the need to be explicit about content that represents the core ethos of
the profession, there is also additional content that is now part of the curriculum
of physical therapy programs that is indicative of the new ethos that has moved
beyond the role of the clinician. While the clinician role of helping patients
remains the primary focus of the profession, other roles such as teacher,
consultant, and researcher have emerged and must also now be assumed if the
profession hopes to remain a viable one in a changing world.

Specifically, there were several areas mentioned as important content that
need to be passed on to students if the profession is to move successfully into
the twenty-first century. These include research, teaching, delegation,
supervision, and consultation. In addition, the increasing diversity of society
that produced the need to make professional values and expectations explicit to
students from a variety of backgrounds has also led to a need for educators to
prepare students to interact with culturally diverse clients, other professionals,
and the general public. The need for increased content that moves beyond the
role of the clinician is also recognized by the American Physical Therapy
Association and is included in core documents such as the W
Accreditation (American Physical Therapy Association, 1997a) and the

WW (American Physical Therapy

153

Association, 1997b).
P Vlu: ntmr T hi Mth for hninEth
Many of the methods used to facilitate socialization of students into a
professional culture in Programs 1 and 2 reflect the new ethos of the profession
and the changed world described by participants in Part 1. Although these
methods are important as a means of helping students internalize the
professional ethos, they are even more essential when considered as an end to
the new values themselves. This is particularly true of the use of more
contemporary teaching methods that are part of an adult Ieaming model and
reflective practice. The fact that the current values of the profession include a
more autonomous and active learner, for example, can be seen in the fact that
the goal of these more contemporary methods is to teach students a process
that will last them a lifetime -- a process that will allow them to continue to learn
and keep up with future changes in the profession and the evolving
professional ethos. In contrast, the methods described in the previous sections
describe the role of faculty in providing an appropriate Ieaming environment
(e.g., sharing expectations, allowing opportunities for practice), content related
to the core ethos (history, ethics, professional issues), and content related to the
contemporary ethos (e.g., research, teaching) that students need to learn in
order to understand and internalize the professional ethos. The major role in
the educational process related to these issues is played by the faculty, with
students cast as the recipients of knowledge. This does not mean that active
teaching methods such as discussion or role playing are not used to help
students in the process of professional socialization, but it is educators who are
primarily creating the Ieaming environments that students take advantage of as
they progress through the program.

154

In contrast, contemporary teaching methods currently being used in the two
programs in this study can be described as facilitating active Ieaming and are
also intended to produce graduates who will continue to be more active in their
own professional development and who will exemplify the more active and
autonomous role that is reflective of the contemporary professional ethos. Not
only were these teaching methods described by faculty as a means of
producing a more independent and active Ieamer, but students also felt that the
use of active Ieaming methods such as reflection, self-assessment, establishing
goals based on self-assessment, and devising personal action plans to
accomplish the goals were important for helping them to become a professional
that would be able to deal with their own professional development and
changes in the profession in the future. Several examples of this more active
role of the learner can be seen in the methods used in Programs 1 and 2. In
Program 1, for example, the process of completing the generic abilities
assessment and the behavioral criteria that are part of the assessment includes
many of the contemporary values discussed by participants in this study. The
behavioral abilities, for example, include such traits as responsibility, problem
solving, professionalism, commitment to Ieaming, critical thinking, and use of
constructive feedback, all of which were also described as part of the
contemporary professional ethos of physical therapy. In addition, the ability to
complete the self assessment form that is part of the generic abilities is not only
a means to socialize students into the profession and to help educators
evaluate student progress, it is also a way for students to learn to critically
assess their own strengths and weaknesses, to set goals, and to devise action
plans to achieve their goals -- an important process for independent thinking

and lifelong Ieaming, two other contemporary values of the profession.

155

Similarly, in Program 2 the use of portfolios and reflective journals is not only
an important method by which educators socialize students into the profession,
but is also a way to help students become more reflective, to be effective in self
assessment, and to be better able to articulate their values, beliefs and views
about professional, political, and legal issues. The ability to form opinions
based on knowledge of the facts leads students to be better able to make
informed decisions that are necessary to practice as an autonomous
professional, something else the profession values today. In addition, the
provision of opportunities to practice professional behaviors and to solve
professional problems through the use of active Ieaming methods such as case
study analysis, role playing, mock clinic, and clinical education helps students
in their quest to become critical thinkers and autonomous professionals.

Finally, as students are encouraged to share their opinions about themselves
and professional issues through class discussions in the professional issues
and ethics courses (Programs 1 and 2), journals and portfolios (Program 2),
generic abilities assessment (Program 1), interviews (Program 2), and clinical
education evaluations (Programs 1 and 2) throughout their education, I feel they
will be able to begin the process of creating meaning for themselves and others
in their professional world. This ability to think for one’s self and to influence the
opinions of others is another component of autonomous practice important in
today’s society.

W

This chapter describes the relationship between the core and changing
values of the profession and current methods of professional socialization in
two physical therapy programs. More specifically, both the content and the

process necessary for internalizing the contemporary professional ethos were

156

discussed. In today’s changing world, the educators in Programs 1 and 2 have
found it necessary to expand their curricula to include specific content related to
the core ethos and values (history, Code of Ethics, Standards of Practice), to the
application of these values to contemporary practice (legal, political, and
professional issues), and to the expanding image of the contemporary physical
therapist that has moved beyond the role of the clinician (research, teaching,
delegation). In addition, they have expanded their role in professional
socialization. Instead of just role modeling the behaviors they would like
students to display, faculty in these two programs apply direct and explicit
teaching methods such as articulating professional expectations, giving
students adequate opportunities to practice these expected behaviors, and
providing timely and honest feedback about student behaviors. Finally, the
values that are part of the present day ethos of the profession have resulted in
the need for teaching process as well as content. That is, if educators wish
students to internalize an ethos that includes such valued traits as autonomous
and reflective practice, lifelong active Ieaming, self assessment, and critical
thinking, they are obligated to teach them the process of engaging in these
activities effectively.

The participants in this study recognized the need to have students become
actively involved in the process of Ieaming in order to address both their own
needs and those of the profession in the future. Important contemporary values
such as lifelong Ieaming, reflection, autonomy, and diversity which are now in
the forefront of the dynamic portion of the professional ethos may someday take
a back seat to the new values that will likely develop in response to a changing
world. Although we cannot see into the future to prepare students for exactly
what these changes will be, I, along with the participants in this study, feel that

157

we can teach students a process for dealing with these changes personally and
professionally so that they are more likely to be able to respond to and even

help to create a changing ethos.

158

Chapter 7

Evolution and the Process of Professional Socialization

The purposes of this study were to describe the culture and the professional
ethos of physical therapy, to identify current methods used to help students
internalize the professional ethos, and to describe and analyze the experiences
of students and their teachers in the socialization process of physical therapists
as an example of professional socialization. Data collected through interviews
and a review of historical documents revealed that although there is a core
ethos that remains constant throughout the history of a profession, there is also
a portion of the ethos that changes across time as a result of changes within the
profession and outside of it. These three pieces of the puzzle of how a
professional ethos evolves (i.e., the core, changes occurring from within the
profession, and changes occurring as a result of outside forces) are essential to
gaining an understanding of what the profession was, is, and will be, in order to
help educators facilitate an internalization of the professional ethos in their
students. Data from Part 2 of this study suggest that faculty, clinicians, and
students are able to describe methods used to socialize students into the
profession of physical therapy and that there is consistency among the three
groups in terms of the importance of these methods for internalization of the
professional ethos. In addition, these individuals were also able to describe the
experiences of students and educators in the process of professional
socialization. As with the methods, participants provided comparable
descriptions of the experiences of students and educators in the socialization
process.

The purpose of this final chapter is to describe the importance of

159

understanding the culture and ethos of a profession as a basis for the process ,
of professional socialization. An analysis of the professional socialization
methods used in the two programs that were the focus of this study and the
experiences of students and educators in the socialization process will also be
presented. A theoretical framework for understanding this process will be
offered as a way to understand socialization in all professional programs. This
framework is based primarily on the results of this study, but also incorporates
information from the review of the literature, my experience as a physical
therapy faculty member, knowledge of physical therapy curriculums and the
documents that effect physical therapy education (is, Accreditation Standards,
The Normative Model of Physical Therapy Education), knowledge of changes in
the field, and general and adult Ieaming theories. Using information beyond
the data from this study was necessary in order to extrapolate these findings to
the process of professional socialization before and after entry to a professional
program. That is, based on the knowledge I have gained from this study and my
experiences as a physical therapy educator, I feel the process of professional
development begins prior to acceptance into a professional program and, like
other areas of development, continues throughout one’s life. Had I only used
data from this study that focused on the experiences of students while they were
actually enrolled in a program, I feel my theory would have been incomplete. In
order to justify any parts of the theory that are not directly based on the evidence
from this study I have included information about the basis for each of the
concepts and relationships I have postulated about professional development.
In the concluding sections of this chapter, implications of the results of this study
for physical therapy and professional education in general will be explored,
and limitations of this study will be discussed. Finally, suggestions for future

160

research will be offered as a way to expand the concepts that resulted from this
study.

. : manlnoo P of: ioznl , -r: :_ th B. i for Prof io.nl A i.liz-otin

Based on the remarks of participants in this study and the review of the
historical documents related to the evolution of the profession of physical
therapy, I feel it is essential to understand a profession as a culture and to
explore its evolution by reviewing its history prior to attempting to design a
curriculum that will enhance professional socialization. It is important to know
what it is we want to socialize students into in order to develop appropriate
goals and objectives for professional behavior and to devise effective methods
of facilitating the internalization of the professional ethos in students. In
addition, I feel that a professional culture must be examined from multiple
perspectives if one h0pes to design a curriculum that will help students truly
understand and internalize a professional ethos that will lead to effective and
ethical practice.
A M lti ' V' f r

As described in the review of the literature, several authors (Frost, et. al.,
1991; Martin and Meyerson, 1988, as cited in Frost, et. al., 1991) have
described a three perspective view of cultures. In the first of these, the
Integration perspective, there is little ambiguity, and consensus is thought to
exist between various factions within the culture. For those who believe in this
perspective, a lack of consensus equals a lack of culture. In the second
perspective, the Differentiation perspective, consensus occurs not at the
cultural, but rather at the subcultural level. These subcultures “may co-exist in
harmony, conflict or indifference to each other . . . subcultures are islands of

clarity; ambiguity is channeled outside their boundaries” (Frost, at. al., 1991, p.

161

8). Further, subcultures may be hierarchical in nature or may exist as equal
groups. In the Fragmentation perspective, ambiguity is always present, with
consensus and dissensus being present on a fluctuating basis depending on
the events, time, and other contextual patterns that exist in the culture.

Many scholars in the field of organizational cultures have examined a variety
of organizations from one of these perspectives (Martin, 1992). In contrast to
the objective, single perspective view of culture represented by these studies,
Martin suggests that it is far better to examine any culture from a subjective,
multiperspective view. She states that to truly understand the complexities of

any organizational culture, one must make use of the strengths of each of the

three perspectives.

At any point in time, a few fundamental aspects of an
organization’s culture will be congruent with an Integration
perspective - that is, some cultural manifestations will be
interpreted in similar ways throughout the organization, so they
appear clear and mutually consistent. At the same time, in accord
with the Differentiation perspective, other issues will surface as
inconsistencies and will generate clear subcultural differences.
Simultaneously, in congruence with the Fragmentation viewpoint,
still other issues will be seen as ambiguous, generating unclear
relationships and manifestations and only ephemeral issue-
specific coalitions that fail to coalesce in either organization-wide
or subcultural consensus. Furthermore, individuals viewing the
same cultural context will perceive, remember, and interpret things
differently. (pp. 168-169)

Any cultural context can be understood more fully if it is regarded,
at any point in time, from all three perspectives. To exclude any of
these perspectives from the domain of organizational research
would be to limit what we could try to understand. (p. 174)

Martin (1992) further explains how, although all three perspectives are
ultimately necessary to understand the complexity of any organizafional culture,
it is possible for one perspective to be most salient at one time, while the other

162

two perspectives recede into the background. Martin refers to the perspective
in the foreground as the home perspective. The two perspectives that remain in
the background are referred to as suppressed perspectives, and one of these is
usually more accessible than the other (Martin, 1992).

W. Like Martin, I feel that I was only able to
understand the complexity of the cultural ethos of physical therapy by
examining the data from this study in light of all three perspectives, as well as
within the larger context of societal change. For example, my original intent, as
described in Purpose #1, was to “describe the professional ethos of physical
therapy.” The major emphasis in carrying out this part of the project was to
identify the common beliefs, values, and norms of the profession, a purpose that
reflects the Integration perspective as the home perspective. By following a line
of questioning and data analysis guided by this perspective I was able to
identify some enduring traits of the profession, including caring and helping, a
positive attitude, hard work and dedication, and warmth and openness. In
addition, further analysis of all the data revealed other evidence of consistency
in the profession in the form of documents such as the Code of Ethics,
Standards of Practice, and Accreditation Standards. This information helped
me identify what I refer to as the Core Ethos - that part of the profession that
does not change over time. The identification of the Core Ethos as a foundation
for professional practice was enlightening and played an important role as the
basis for understanding major beliefs and values of the profession.

MW. Had I stopped at this point and not attempted
to look at the data in light of the other two perspectives, my study would have
been incomplete. It is, in fact, the changes surrounding the culture and

professional ethos that have necessitated a major shift in the education of

163

physical therapists and in the education of students in other professional
programs. For example, based on the description of changes in the profession
due to generational and cultural differences, the participants in this study
described how information about the professional ethos and its accompanying
professional behaviors must now be taught explicitly to today’s students. What
used to be an implicit curriculum related to professional values and behaviors
(e.g., “ I wouldn’t have thought it was necessary, hardly, to have started it out
with ethics . . . it was as if we just did the things we ought to do and we were
expected to do them”) has to be made explicit today in order to make it very
clear to students who hold different values what professional behaviors are
expected of them as part of being a physical therapist. The Prime Timers’
description of how the profession changed due to the entrance of males into the
profession is also an example of how a very small subculture (males), with
different expectations and values changed the profession, and subsequently
changed what we teach students about the practice of physical therapy. This
examination of different subcultures within the profession based on age,
gender, and ethnic background is one of the ways in which the Differentiation
perspective is illustrated in this study. In addition, differences within the field of
physical therapy, as in other professions, can also be seen in various special
interest groups (referred to as Sections in the American Physical Therapy
Association), in geographical differences between different regions of the
country (such as the state level Chapters of the APTA), in differences between
those who belong to the professional association and those who do not, or
between those in the field who hold different levels of degrees (physical
therapists and physical therapist assistants).

Taking the Differentiation perspective is also helpful in seeing the entire

164

profession as being a subculture within the context of a larger culture. For
example, physical therapists in the United States represent only one subculture
of the larger culture of physical therapists all over the world. On an
organizational level, this can be seen in the relationship between the American
Physical Therapy Association and the World Confederation of Physical
Therapists. In addition, physical therapy is only one of many health care
professions within the larger context of health care. Physical therapists work as
part of a team with doctors, nurses, occupational therapists, and speech
therapists. A review of the history of physical therapy revealed that physicians,
in particular, have been a major influence on the values of the profession. It
was only as physical therapists and the APTA gained freedom from the
American Medical Association with distinct and separate governance,
professional meetings, and accreditation of educational programs, that those
within the profession were able to more fully achieve professional autonomy.
Aside from individuals who are directly involved with patient care, physical
therapists must also work with those in the system who are not involved in direct
patient care, but have a profound impact on the services that clients receive.
These others include administrators, insurance company employees, and
government workers who determine how care will be provided and what types
of services will be reimbursed. As discussed by the Prime Timers, the
introduction of progress note writing, an essential part of practice today, came
about as a result of Medicare and Medicaid legislation. In addition, the advent
of special education laws helped expand the role of the physical therapist to
practice outside of the medical setting. Even individuals involved in
nonprofessional activities such as those who work in maintenance,

housekeeping, secretarial services, and food service are part of the health care

165

culture and can have a direct or indirect influence on the provision of services.
Secretarial services, for example, may be responsible for scheduling, billing,
and typing progress notes, all of which are important aspects of helping patients
to receive the best services with the greatest efficiency. The importance of
understanding these inter-relationships between physical therapists and others
speaks to the need to incorporate the Differentiation perspective into the
concept of a professional ethos.

Ultimately, the health care professions also become a subculture, embedded
in a larger societal culture. The health care system is influenced by the norms
and values of the society of which it is a part. These norms and values evolve in
relation to the history of the society, various ethnic, generational, and gender
issues within these types of cultures, and other systems or subcultures of the
society (education, business, government). While a complete evaluation of
these systems is beyond the scope of this study, a few examples from the
analysis of the interviews will help to illustrate this point. Many of the
participants discussed the impact of managed care and legislation on the
provision of health care. Others mentioned the effect of ethnic diversity and the
different values of newer generations on the professional ethos of physical
therapy. Finally, the history of our country in wars and the impact of historical
events like the Depression and the turbulent 60s were cited as important
influences on society, health care, and physical therapy. I believe that it is only
by understanding the role of the professional within this larger, more complex
world that educators can hope to design programs and implement methods
necessary to create and sustain a profession that can survive in a dynamically

changing world.

166

MW Finally. the Fragmentation perspective is
important in helping to understand the ambiguities within a profession (Martin,

1992). One prominent example of the Fragmentation perspective in physical
therapy is the current controversy over the question of what should be the entry-
level degree for PTs. Beginning in the 19403 a baccalaureate degree or a
baccalaureate degree with a certificate was established as the entry-level
degree for practice. In 1980 the entry-level degree was raised to post-
baccalaureate, with implementation of this degree in all programs set for a
target date of 1990 (this date has been moved to 2001 ). As more and more
programs are moving to the masters entry-level, there are many leaders in the
profession who are now calling for a move to a doctoral entry-level degree, and
some DPT and PhD programs have already been established. At this point,
though the majority of programs have moved to a masters entry-level, there are
still some baccalaureate degrees and certificate programs, as well as some
new doctoral programs.

The move to higher and higher levels of formal education and credentialing
has created controversy and ambiguity within the field. This controversy
becomes further convoluted in light of recent changes in health care, the
proliferation of both physical therapy and physical therapist assistant training
programs, and the recent reorganization of the American Physical Therapy
Association discussed earlier. In addition, the increasing diversity of students
and clients in health care fields coupled with the multiplicity of viewpoints and
dissensus that is part of the fragmentation perspective, as well as a reflection of
the postmodern perspective of Gergen (1991) discussed earlier, has created a
need to focus more intensely and explicitly on both the existence of diversity
and methods for dealing with it in a professional world. This creates an

167

interesting paradox in that although the multiphrenic condition described by
Gergen and reflected in the fragmentation perspective has resulted in a world
that is becoming increasing complex and ambiguous, there is a need in the
world of professional education for less ambiguity in teaching methods. That is,
methods of professional socialization must be very explicit in describing the
professional ethos and the behaviors that are reflective of internalization of the
ethos in order to make these ambiguities clear to students, to help them identify
consensus and dissensus between their personal values and those of the
profession, to help them deal with diversity in their interactions as professionals,
and to help them Ieam to deal with a professional ethos that will surely continue
to evolve.

The interplay between the use of physical therapist assistants versus
physical therapists, entry-level degree controversies, changes in health care
provisions, and increasing diversity in the profession and society are creating
multiple ambiguities within the field. Should the doctoral degree be the entry-
level degree? If so, what does this mean for the role of the physical therapist in
relation to physical therapist assistant? Should the entry-level degree of
physical therapist assistants also be raised? What is the best way to prepare
students to practice in the new millennium? And what effect will health care
changes, many of which no one can predict, have on the profession? These
are but a few of the questions that physical therapists face today, and opinions
are as abundant as are the number of physical therapists and physical therapist
assistants practicing in this country.

The Fragmentation perspective offers an avenue for beginning to understand
how these ambiguities will affect practice. The acknowledgement of the

Fragmentation perspective as an important component of professional culture

168

will help educators realize that the physical therapist of today must be well
prepared to deal with ambiguity, to be willing to take a stand for what he or she
believes in, and to adapt to changes in the field. I believe that graduates who
are prepared to do so will be more successful and may ultimately shape the
course of the evolution of the professional culture and its ethos.
Tho 2mg of meoooionol Evolotion

The results of this study support the notion that it is important to understand
the culture and ethos of the profession in order to design an effective curriculum
that will facilitate professional socialization, and that the culture and ethos are
best understood when examined from a multiperspective, historical view.
These two views, multiperspective and historical, have led me to believe that
the process by which a professional culture develops is an evolutionary one.
This evolutionary process goes beyond a mere description of historical events
by exploring how and why cultural changes have occurred, analogous to the
way species evolve. It helps explain the rational and political dynamics of the
changes that have occurred over time.
A l r f i v

Figure 2 illustrates the concept of the evolution of a professional ethos based

on a multiperspective view of culture and the importance of examining changes
in the profession in relation to societal change. This model is based primarily
on data from Part 1 of the study (individual interviews with the Fellows, the focus
group interview with the Prime Timers, Mary MacMiIlan Addresses, and
Presidential Addresses) that resulted in a view of a professional culture that
consisted of core values or enduring traits (the core ethos), and values and
roles that change throughout the history of the profession (an evolving ethos).
In addition, the multiperspective views of culture as described by Martin (1992)

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Figure 2. The Evolution of the Professional Ethos

170

and the review of the literature that described social, historical and cultural
influences on professional cultures (see pages 24-29) also served as part of the
foundation for this theoretical model.

As can be seen in Figure 2, the Core Ethos (the large double-arrowed area
in the center of the figure) is the central anchor of the profession, extends
throughout its history (the arrow in each direction indicates that the core ethos
has been present since the inception of the profession in the past and will
continue into the future), and is the basis upon which the rest of the professional
ethos (indicated by the large spiraling arrow) is built. The spiraling process
reflects the belief that each new view of the ethos is built on what has occurred
in the past, and that, while the Core Ethos remains stable, the rest of the ethos
undergoes an evolutionary process. In much the same way that man has
evolved over time in response to adaptations to internal and external
influences, a professional ethos evolves in response to intemal and external
influences on the profession over time. Changes within the profession (e.g., the
entrance of males into the field and the quest for autonomy for the profession of
physical therapy) are illustrated by the smaller arrows embedded within the
spiraling professional ethos and by newcomers to the field who may bring new
values and ideas into the profession based on their personal background and
history (illustrated by the smaller arrows outside of, but closest to, the spiraling
professional ethos).

The fact that alterations in the professional ethos occur as a result of changes
outside of the profession is also illustrated in Figure 2. The profession and its
ethos do not exist in isolation. Rather, they are embedded within the health
care system. In this way, changes in health care, such as the rise of managed

care, effect the evolution of each of the professions that comprise this system.

171

All health care professionals could certainly speak to the tremendous effect that
managed care has had on their practice. Although not depicted in Figure 2 for
simplicity’s sake, other medical professions, each with their own ethos, are part
of the health care system and affect and are affected by the practice of physical
therapy. The powerful influence of the AMA on the practice of physical therapy
is the most prominent example of this reciprocal process.

While the health care system is the umbrella for the individual health
professions, it is, in turn, part of our larger society, which includes other systems
such as education, business, and government. The health care system and the
profession are, therefore, influenced by changes in the values, norms, and
beliefs of society. For example, as described by the participants in this study,
one of the ways in which the profession has changed is that there is a more
relaxed atmosphere during direct interactions with patients Contrary to this
friendlier relationship with patients, there is also an undercurrent of litigiousness
related to alleged malpractice. This paradox within the profession parallels the
changing standards of society. As with the existence of other health professions
within the health care system that are present but not depicted in Figure 2, there
are also other systems such as education or business within society that are not
reflected in the model. These systems both affect and are affected by the health
care system within each society.

The model of professional evolution illustrated in Figure 2 reflects the
complex process by which a professional ethos develops over time. Each
generation brings new life to a professional culture and changes continually
occur within and outside the profession. Having described the process by
which the view from outside and within the profession of physical therapy have
evolved over time it is important to consider what affect all this change in

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professional ethos has had on the contemporary physical therapy practitioner.
How is this individual different from the professional of the past and why are
these differences important for educational programs?

Tho Physigl Thorooig of Tmoy

The data obtained as part of this study clearly highlight many historical
changes in the profession. Although physical therapists have maintained their
caring, helping, and positive attitude, they are very different from Mary
MacMiIlan and her colleagues from the early 1900’s. As the world around them
has evolved, so has the culture and ethos of the profession. These changes are
apparent in a variety of ways, related not so much to the core characteristics of
caring and helping as they are to the ethnic and generational backgrounds of
newcomers and to the ways in which one must practice today in order to be
viewed as effective and successful to those within and those outside of the
profession.

In contrast to the technician role of the reconstruction aides, physical
therapists today are more autonomous, more diverse, more educated, more
involved in delegation, and more scholarly. In addition, the world of health care
has caused a huge shift in practice. In the beginning years of the profession, for
example, the issue of who would pay for services was not an important
consideration for the practitioner. There was money to pay for all services and
as many services as were needed for as long as they were needed. The Prime
Timers discussed how they never even thought about how much services cost
and who would pay for them. They simply sent their patients to the payment
department of the hospital, and didn’t give it a second thought. Today, with a
shrinking health care dollar and the advent of managed care, it has become

necessary for all health care practitioners to be wiser about reimbursement.

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They must now demonstrate that their services are, in fact, helping their clients
in order to prove their effectiveness to those who are providing reimbursement.
The shrinking health care dollar, coupled with increased litigation in our
country, has also caused health care workers to be more accountable. This, in
tum, has led to an increasing number of outcomes effectiveness studies,
pressing physical therapists to become research consumers, if not producers of
research, in order to understand how they can truly be effective in helping their
patients. In addition, because there is less money to go around in every field,
professionals must be better able to influence those in power, both within their
work setting (supervisors, administrators, physicians), and outside it. It is now
important to be able to influence legislators who hold many of the strings tied to
reimbursement money and the policy makers who make decisions about who
will provide services. The physical therapist today is also practicing in a wider
variety of settings than did the pioneers in the field. In contrast to the first
physical therapists who treated injured war veterans in hospital settings or
children with polio, students today must be educated to practice not just in
hospitals, but also in private practice, outpatient clinics, rehabilitation centers,
cardiac rehabilitation programs, public schools, nursing homes, home care, etc.
Each of these settings not only has different types of patients, but also different
forms of administration, rules, and reimbursement and legislative issues. This
increased variety in treatment settings is another change that demands a more
complex educational process. Finally, as the role of the physical therapist as a
delegator has expanded it has become increasingly important for them to gain
skills in teaching, consulting, and empowering patients to care for themselves.
All of these changes have had an impact on the culture and ethos of the
profession. While the core of helping and caring, dedication and hard work,

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warmth and openness, and a positive attitude continues to be at the heart of the
professional ethos, the changes described in this study have resulted in a new
view of the physical therapist. This new physical therapist, the one who must
teach, delegate, manage, keep up with rapid changes in health care and
technology, worry about reimbursement, conduct outcomes effectiveness
studies (or at least be able to read and understand them), and be able to treat a
variety of patients in many different settings has added new dimensions to the
core of the ethos of the profession. The contemporary physical therapist is not
just a clinician who can be involved in helping patients. Therefore, the old
ethos, consisting of a small handful of core values, is no longer enough. New
roles, an ever evolving technological society, and changes in educational
theory have added new values to the ethos. In addition to valuing helping
patients and hard work, physical therapists today also value reflection, self-
assessment, critical thinking, problem solving, and lifelong learning. They put a
premium on understanding and accepting diversity in their patients and in their
colleagues. As autonomous practitioners, they embrace advances in health
care and proactively respond to changes in reimbursement and practice
patterns that affect patient treatment even when it means changing the ways
they practice.

In spite of this changing ethos, some educational programs in physical
therapy continue to function as if they are preparing students to function only as
clinicians. But just as students and society have changed, so must educational
programs. Educators need to be aware of the changes in the ethos in order to
successfully socialize students into the profession, and students should
carefully consider the changed roles and ethos of physical therapy in order to
be sure they have chosen the profession that is right for them. Within the

175

educational setting, the methods used by both faculty and clinicians to help
students attain the professional ethos need to reflect the new world in which the
physical therapist must now live and work. Part 2 of this study, to which I now

turn, illustrates some of the ways in which this can be accomplished.

F'l" lntrnlitinfthPf inIE i f inl
W

Prior to beginning this study, I was often confused by comments from my
colleagues that it was not possible to “teach” affective behavior and that this
type of Ieaming could not be measured. I felt that there had to be something
that could be done to help students attain the professional skills and behaviors
that would indicate that they had, indeed, internalized the ethos of the
profession. At the very least, I felt, faculty needed to make attempts to do so. To
do nothing seemed unwise for educators and unfair to students.

Having been fortunate enough to conduct this study, I can say with some
conviction that my pessimistic colleagues were wrong. It is, in fact, very
possible to describe some of the ways in which educators attempt to help
students become part of the professional culture and display the behaviors that
indicate that they have internalized the professional ethos. The participants in
this study described a number of ways in which students are socialized into the
profession. Beyond the fact that everyone was able to describe some of the
ways in which educators facilitated the socialization process, it is most
interesting to note that the perceptions of students matched those of faculty and
clinicians. Students could describe the methods educators used to help them
internalize the ethos of the profession as well as their teachers. For example,
like the educators in Program 1, students in Program 1 clearly identified the

generic abilities and the professional issues courses as two of the most

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important ways in which they were socialized into the profession.

Beyond the generic abilities and these courses, however, they also cited
such methods as receiving consistent and regular feedback about their display
of professionalism, having clear goals and expectations for professional
behavior, being given opportunities to practice professional behaviors, being
responsible for their own Ieaming, having appropriate and consistent role
models, and attempting to practice in as realistic a setting as possible. While
students recognized that it is important to practice techniques on each other
initially, the opportunities they were provided to interact with clinicians and
patients in the academic setting, to visit clinical sites, and finally and most
realistically, to treat and interact with patients and professionals during clinical
internships were cited as especially important parts of the socialization process.
Likewise, students from Program 2 consistently cited the use of reflective
journals, portfolios, mock clinic, a strong emphasis on ethics through the
separate ethics courses, the use of regional clinical coordinators, and the
professional issues courses as important aspects of their professional
socialization. Like the students in Program 1, they were also able to describe
other methods of socialization that were described by their faculty. Based on
this information, it can be seen that students are aware of the ways in which
they are initiated into the culture of physical therapy, at least in these two
programs.

In addition to the educator-student match between perceptions of methods of
socialization, faculty described other ways in which they felt that students had
become aware of the methods and felt they were successful in their
socialization attempts. This evidence included information obtained primarily

from the students in journals, exit interviews, and in conversations following

177

graduation when graduates were looking for ways to handle difficult students
now that they (the graduates) were functioning as clinical instructors. In
addition, faculty from Program 1 talked about the improvement in their students
since the advent of the generic abilities and faculty from Program 2 discussed
how students cited the professional issues seminars and reflective journals as
effective means of socialization during exit interviews. Clinicians, although not
as familiar with the curriculum of the programs, were also able to talk about how
students in Program 1 had changed since the generic abilities had been
instituted, and students-in Program 2 were articulate in reflecting on their growth
and applying their newly attained knowledge of professional issues in the clinic.

While I would like to think that the methods applied by these programs
provide at least part of the answer to effective socialization, I also interpret these
remarks with some caution since there are many other factors that affect the
behavior, professional and otherwise, of individuals in all professions. First,
physical therapy students are often described by university administrators and
faculty as one of the best groups of students on campus, a fact that certainly
would contribute to their high standards once they enter the program. Even
those students who start out with lower or unarticulated standards when they
first enter college quickly realize that they must change their presentation of
themselves in order to be accepted into these very competitive programs.
Secondly, as suggested by other authors (Abbott, 1988; Stroot and Williamson,
1993), students may self select into professions that match traits that they
already possess, another confounding factor. Finally, the lack of controlled
studies and the small number of participants in this study speaks to the need for
more evidence in this regard.

The question remains, what methods were used in these two programs that

178

caused students to perceive that they had been successfully socialized into the
profession? One answer, I believe, lies in the more active and process oriented
methods used by educators in these two programs which reflect a changing
world and a changed profession. Faculty and students described the
importance of active Ieaming for the process of professional development in
these two programs. In contrast, my experience in educating physical therapy
students, conversations with experts in the field of physical therapy education,
and knowledge of physical therapy curriculums in other programs indicate that
other professional educators have not responded as readily to changes in the
world and the professional ethos and continue to use old methods to try to help
students intemalize the new ethos. For example, although role modeling
continues to be an important aspect of socialization, it is not enough in and of
itself to effectively help students become part of the ever more complex
professional culture and to prepare them to be able to cope with future changes.
Changes in the world and resulting changes in the professional ethos
necessitate that methods of professional socialization be very explicit and that
they be expanded to reflect the values of this new ethos. That is, changes in
student diversity, changes in society, and changes within the profession have
resulted in a new professional ethos that cannot be successfully facilitated by
doing the things that were done when the world was a much less complex and

more local place, and when students held basically the same values as their

teachers.
I 3113.".-.2 hon fth P ofmzinvl __ . 0 ah I .t: t a! tit: r. "
WW? Based on the integration of the knowledge I

have gained from my past experiences as a physical therapy educator,

conversations with colleagues and experts in the field, and the results of this

179

study, I feel that in order for students to be successfully socialized into a
profession, they must be able to combine the personal values they hold prior to
admission with the core or stable values of the professional ethos, and with the
dynamic or changing values of the profession that continue to influence the
evolution of the professional culture and ethos over time. Several authors cited
in the literature review (Myers, 1982; Abbott, 1988; Stroot & Williamson, 1993)
discussed how personal values affect the student’s initial decision to enter the
field and how willing they are to change in response to new Ieaming
experiences in the professional program. As previously discussed, students
may be able to compare their personal values to some of the core values of the
profession prior to admission based on their observations and interactions with
practitioners. This comparison is possible because the core values (which are
the basis of the Core Ethos as discussed earlier in this chapter) do not change
over time and thus are reflected in the words and deeds of most practitioners
with whom students come into contact. For example, every applicant to physical
therapy programs, without exception, when asked why he or she wants to be a
physical therapist responds, “I want to help people”, the number one core value
identified by the participants in this study. Because the core values are
universal and easy to identify, I feel that these are the primary values students
use to compare with their own values when self selecting into a profession.

In contrast, the changing values of the profession are ones with which
students are not as familiar. Students, in fact, described how they were not
familiar with many of the changed roles and contemporary issues of the
profession and discussed how they first became aware of these changed roles
and issues in the professional issues courses once they were admitted into the

program. This lack of familiarity with evolving values, changes roles, and

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contemporary issues occurs for two reasons. The first is that some of these
changes are not directly observable. That is, students may not know that
physical therapists are now more autonomous because they do have not a
previous history to compare the practitioners of today with those of yesterday.
One faculty member in Program 2, for example, stated,

I think that the thing that students don’t often understand is . . .
how we got to where we are. They . . . walk into the curriculum
and they are . . . professionally socialized today . . . . They don’t
understand where we have been and why we are progressing in
the direction we are progressing and what sacrifices or efforts
people have put out to get there. (P2F3, p. 12)

In addition, depending on where in the evolutionary process the culture and
ethos are, there may be many practitioners who are unaware of major changes
because they have not been exposed to them or because they refuse to change
their practice and, therefore, continue to operate using the values and skills of
the past, values which may have worked for them, but will not prepare future
practitioners to function effectively. For example, it is no longer enough for
physical therapists to be simply clinicians who want to help people without
dealing with the cost and documented effectiveness of their services, problems
with reimbursement and management, or the politics of power in the workplace
and outside of it. Several factu members and students identified this problem,
stating that while role models in the academic and clinical settings were
basically consistent at the core level (caring and helping), there were
practitioners who were functioning as technicians and were not keeping up with
changes in the profession. These individuals, as well as those few practitioners
who students felt were not as professional as they could be, were described as
negative role models whose values were not consistent with those of the faculty

or the profession. Students discussed how they would not want to practice in

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the same manner as these negative role models.

The process by which students become part of a community of practitioners
by melding their personal values with the core of the ethos and the changing
values of the ethos I call “value negotiation.” It is how I conceptualize the
process by which students come to internalize the professional ethos
throughout their education and how they continue do so throughout their
professional careers. More specifically, value negotiation can be defined by
looking more closely at the definitions of the two words, value and negotiation.
A value is defined as “a standard or principle regarded as desirable or
worthwhile . . . worth in importance or usefulness to the possessor” (Riverside
Webster’s ll Dictionary, 1996, p. 746). Negotiation is defined as the process by
which one is able “to meet and discuss with another in order to reach an
agreement, . . . to settle by meeting and discussing, . . . to accomplish or cope
with successfully” (Riverside Webster’s ll Dictionary, 1996, p. 546). Combining
these definitions, value negotiation can be more specifically defined as the
process by which students in professional programs meet and discuss
fundamental beliefs and rules of behavior that are based on desirable
standards and principles of the profession in order to successfully become a
member of the professional community of practitioners, to internalize the ethos
of the profession, and to be able to cope with the responsibilities inherent in the
profession.

MW. I feel that both educators and
students are important entities in value negotiation. The primary responsibility
of educators is to provide an environment that will facilitate the internalization of
the professional ethos in their students. This socialization is accomplished by

making students aware of what is expected of them and allowing them

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opportunities to engage in and receive feedback about their level of
understanding and application of professional values and behaviors. These
roles for the educator parallel those in other teacher-leamer scenarios. As
described by the participants in this study, these explicit and systematic
methods have become a necessity in the area of professional socialization due
to increasing student diversity and changes in society. In addition, faculty must
apply good teaching methods to the process of professional socialization.
These include methods such as establishing appropriate goals and objectives
for professional socialization, providing opportunities for practice and feedback,
motivating students to want to internalize the professional ethos, facilitating
transfer of professional behaviors to all settings, and assessing professional
behavior. Both students and educators described these methods as helpful in
the socialization process.

Although an in depth discussion of principles of teaching and Ieaming is
beyond the scope of this study, it is necessary to at least mention their
importance in professional education for several reasons. First, in contrast to
professionals trained in the fields of education or educational psychology,
professionals in other fields are not familiar with these principles and methods.
Physical therapy is a good example of this lack of preparation in principles of
teaching and Ieaming. The ever present need for physical therapists
throughout the history of the profession coupled with the proliferation of physical
therapy education programs has resulted in a corresponding shortage of
faculty. In contrast to being hired for their pedagogical beliefs or their expertise
in teaching and research, physical therapy faculty were hired more for their
clinical expertise in various content areas. In essence, the paucity of physical

therapy faculty led many universities to hire practitioners for their license, their

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content knowledge, and their desire to become part of the academic world.

Many factu knew little about teaching or Ieaming. They felt that because they - '-

had an interest in teaching and content expertise, and had been successful in
one-on-one clinical instruction of students, they would like to try teaching. In
addition, new faculty often were hired without any thought to training or
mentoring them in order to help them Ieam the basic principles of teaching and
Ieaming. My personal experience reflects this scenario as I began my teaching
career in a program that had two new full-time faculty and many clinicians who
taught part-time. Although I am not familiar with all other professional education
programs, I have had conversations with faculty from other fields who have
found themselves in similar situations as they began their teaching careers.

A second reason for describing explicit socialization methods used by these
two programs related to principles of good teaching is that many educators may
not think that these issues are applicable to or important for the process of
professional socialization. Instead, many physical therapy educators with
whom I am familiar are operating on the assumption that, like in the past, role
modeling is enough to help students Ieam and internalize the values and
behaviors reflective of the professional ethos. In contrast to this view, experts in
the field (i.e., Fellows and Prime Timers), students and educators supported the
notion that role modeling is simply not enough in today’s complex world for
successful socialization into a profession. Today’s educators, like the
participants in this study, must go beyond role modeling if they hope to graduate
competent and ethical professionals.

Today there are more educators within the field of physical therapy, and I
imagine in other fields as well, who are familiar with principles of teaching and

Ieaming through formal education, continuing education, or mentoring

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programs within their university than there have been in the past. Unfortunately,
there are still many educators in professional programs who know little or
nothing about teaching, Ieaming, or the process of professional socialization.
This situation has implications for professional education, which will be
discussed later in this chapter.

Crootim moonim in mmmonitioo of orggioo. Although the application of
principles of teaching and Ieaming are important to the process of professional
socialization, they are only one small part of a much more complex process.
More importantly, I feel that educators need to create meaningful interactions
within the environment in order to motivate students to become full participants
in the professional arena or the community of practice. A community of practice
is defined by Lave and Wenger (1991) as “a set of relations among persons,
activities, and the world, over time and in relation to other tangential and
overlapping communities of practice” (p. 98). Newcomers are drawn into the
community through a process that Lave and Wenger (1991) have termed
legitimate peripheral participation. Legitimate peripheral participation is
defined as “the process by which newcomers become part of a community of
practice. A person’s intentions to Ieam are engaged and the meaning of
Ieaming is configured through the process of becoming a full participant in a
sociocultural practice. This process includes, indeed it subsumes, the Ieaming
of knowledgeable skills” (Lave & Wenger, 1991, p. 29). As students progress
through professional programs, they are afforded more and more Opportunities
in the community of practice, until, in their final apprenticeships they are
afforded the opportunity to function as independent professionals. Through
these opportunities, they Ieam what is expected of them as a member of the
profession. Because these opportunities are the primary ways in which

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students are exposed to and subsume the identity of a professional, at least
according to Lave and Wenger (1991), the ability of educators to create early
opportunities that are meaningful, appropriate, and effective is crucial to helping
newcomers become true members of the community who have internalized the
ethos of the profession.

Students described the importance of creating meaning for themselves, as
well as how they assumed more responsibility and interacted more in the
clinics, as they progressed through the program. They cited the use of
discussions with classmates and practitioners in the professional seminar
courses (Programs 1 and 2), reflection in the journals and portfolios (Program 2)
and the self-assessment process that is incorporated into the generic abilities
(Program 1) as ways in which they were able to “get a sense of” and “a better
understanding of” how they felt about an issue in order to create meaning for
themselves. In addition, they described how input from faculty, clinicians, and
leaders in the field regarding new developments in health care and the
profession helped give them a better understanding of “what the profession
stands for". Faculty discussed how they felt students were becoming part of the
community based on feedback they received from the students during exit
interviews, journal entries, and course assignments. Students also discussed
how increased responsibility during their clinical internships helped them begin
to make the transition from students to professionals and to feel more like
contributing members of the professional community. This was particularly true
of the students in Program 2, where students did longer 14 week internships.
Faculty from Program 2 also discussed how these longer internships allowed
students more time to “really get involved in the ethos of the clinic”. Overall,
reflection, discussion, and involvement with practitioners seemed to be the

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primary ways in which students begin the process of sense making and creating
meaning for themselves and others in the community of practice.

The process of providing such opportunities early in the educational process
has become even more crucial as the world has become more global and fast-
paced. In the past, the process of legitimate peripheral participation during the
educational program was a much slower one. Graduates of physical therapy
programs had the luxury of a more gradual transition from the culture of a
student to that of a professional. Students were often protected from difficult
patients, demanding physicians, and worry about reimbursement for services.
They could take their time, even after graduation, Ieaming to evaluate and treat
patients who stayed in the medical system for much longer periods of time.

New graduates of the past could slowly build up their case load as they spent
time observing other therapists and getting used to handling the demands of
being a professional. Today, this is not the case as patients are being
discharged sooner due to limits on insurance coverage and practitioners are
under pressure to provide intense, short-term services. Graduates, therefore,
must be able to step into their professional roles quickly; they must Ieam to both
evaluate and treat patients during the initial therapy session; and they must
know how to react in a timely manner to political and professional issues.
Educators, therefore, must prepare students for these roles earlier in the f
educational process. Just as the world has become more fast-paced, so must
the process of legitimate peripheral participation. This is the reason cited by
educators in Program 2 for longer clinical internships. That is, Program 2 faculty
felt that a full academic year of apprenticeships would give students time to
function more effectively as a clinician, and would also prepare them to move

beyond the role of the clinician and to begin to create meaning for themselves

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and others in their community of practice -- to begin the process of legitimate
peripheral participation in a more timely fashion so that students are well
prepared to function as professionals upon graduation. In addition, as
discussed earlier, the use of reflection and discussion also helped students to
become familiar with and begin to make sense of issues important to the
profession early in their education so they were better prepared for practice
upon graduation.

Tho mlo of tho gooont in voloo nogotiotion. Although the educator provides
an appropriate learning environment that facilitates legitimate peripheral
participation and professional socialization, this is only the first step in value
negotiation. Ultimately, the Ieamer is responsible for “deciding” to become an
actively contributing member of the community of practitioners. As stated by
one of the faculty members interviewed for this study, “the faculty will do
everything possible for you to develop these behaviors. It is up to you to
develop them” (P1F3). Students, therefore, play the major role in professional
socialization.

Educators acknowledged the importance of providing active Ieaming
environments through case studies, outside readings, and teaching methods
that made the students responsible for their own Ieaming. Students also
acknowledged the importance of developing active Ieaming skills since they
will have to “figure things out for themselves” once they graduate. They readily
accepted responsibility for their own Ieaming and development and felt that this
was one of the ways in which they were able to internalize the ethos of the
profession. Based on the data from this study, theories of adult Ieaming, and
my experience in teaching physical therapy students, I feel that active Ieaming
is accomplished through students being open to identifying and exploring their

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own values and behaviors in relation to those of the profession; actively
participating in class discussions, lab sessions, and clinical internships; being
open and honest with oneself and others around issues related to professional
socialization (e.g., reflection and self-assessment, critical discussions, and peer
and mentoring conversations); displaying behaviors consistent with the values
and beliefs of the profession; and contributing to creating meaning within the
community of physical therapy. Because the data from this study supports the
premise that students who are actively involved in the socialization process
perceive themselves as being successful in internalizing the professional ethos,
primary emphasis in descriptions of the student’s role will be related to how he
or she functions as an active participant in a community of practitioners during
professional education.

Wm The process of value
negotiation can be divided into three phases: Awareness of Values and
Expectations, Active Learning, and Artistry. Ideally, students progress through
the stages successfully, and have entered the Artistry phase by the time they
graduate. Value negotiation, however, is a developmental process. As such, it
is important to keep in mind that, just as children do not always follow the same
trajectory of development, neither do students in professional programs.
Rather, students will progress through the phases at their own rate, may go
back and forth between phases or stages, and may not reach the final stage by
the time they graduate. The phases, then, should be interpreted merely as
guidelines and not rigid stages that all students must pass through in the exact
order at the same time. In general, the closer the student’s values are to the
ethos of the profession to begin with, the quicker and more easily he or she will
progress through the phases. Lastly, the reader should keep in mind that the

189

process of internalizing the professional ethos is never really complete, in the
same manner that human development is never complete. That is, the ethos of
a profession is a moving target that evolves in response to changes in society,
to newcomers to the profession, and to changes from within the profession.
Professionals who do not, or cannot, change in response will lose their sense of
professional ethos over time.

Figure 3 illustrates the process of value negotiation from the time the student
becomes interested in and applies for entry to the professional education
program and continues beyond graduation. As with the process of the evolution
of a professional ethos depicted in Figure 2, the large double-arrowed area in
the center of the figure represents the Core Ethos of the profession. This Core
remains the same throughout the student’s time in the program just as it
remains constant in the evolution of the professional ethos. A second important
concept depicted in Figure 3 is reflected in the smaller arrow labeled “student’s
personal values.” This arrow represents the personal values (which may or
may not overlap with the values of the profession) that students bring with them
to the program based on their family background, ethnic origin, gender, ago,
religion, peer group, and other life experiences. As discussed by participants in
this study, students do not come into professional programs as blank slates.
Rather, they have a lifetime of experiences that determine who they are at the
time of entry into the professional program, what personal values they possess,
and what behaviors they display as a result of the values and experiences they
bring with them. While some of their personal values may be the same as those
of the program and the profession (often at the core level) some may differ and
may need to be altered if students are to be successful in the program and

ultimately in the profession.

190

PHASE "I
Artistry

PHASE II
Active
Learning

PHASE I
Awareness of
Expectations
and

Values

 

Figure 3. The Process of Value Negotiation

191

The ascending spiraling anew that winds around the Core Ethos represents
the ethos that students possess as they progress through the program and
through the three phases of value negotiation. As can be seen from Figure 3,
students enter the program with only the ethos of the student. This idea is
similar to and reflective of the work of Becker, et. al. (1961) who in their classic
work, Boos in Whito, described the world of medical students as a “student
culture.” According to Becker and his colleagues, students are never “young
doctors” (or in this case “young physical therapists”). They participate in the
community not as members of the professional culture, but as members of the
student culture. Students, therefore, display behaviors that reflect their efforts to
deal with the reality of being a student (e.g., successfully completing classes,
pleasing faculty). This idea is reflected in Figure 3 by the large portion of the
spiraling arrow. representing the student ethos and culture at the beginning of
the program. As the student progresses through the program, the student
culture begins to be replaced by the culture and ethos of the professional until,
at the time of graduation, they ideally have internalized the professional ethos
and have become part of the professional culture. The spiraling process itself
indicates that each level of professional socialization is continuous with and
builds upon the previous level. The arrow at the end of the spiral indicates that
professional socialization continues throughout one’s career. Finally, the small
arrows embedded within the spiraling process of the student/professional ethos
represent changes that are occurring within the ethos itself.

On the following pages each phase and the accompanying stages are
described in greater detail. A table describing the role of the educator, the role
of the student, and the result of successfully completing the phase accompanies

each description.

192

Ph : Aw n f V l n Ex ti n

Phase I, Awareness of Values and Expectations, occurs prior to and at the
beginning of the professional program. It consists of two stages, Awareness
of Program and Professional Expectations and Identification and
Comparison of Personal and Professional Values and establishes the
base upon which the other phases are built. An overview of Phase I can be
found in Table 6.

WW3. During Stage 1, Awareness of Program
and Professional Expectations, students are made aware of program and
professional expectations related to the professional culture and the
professional ethos. Providing information, on a very general level, even to
students who are considering applying to the professional program is one way
to prepare students for the process of professional socialization. While all
faculty and students endorsed the provision of explicit goals and objectives for
professional behavior for students already admitted into the program, one
faculty member also described how professional socialization “is something you
have to give students over a period of time to develop . . . starting with pre-
admission” (P1F3, p. 5). Raising awareness of professional expectations for
individuals who have not yet been formally admitted to a program can be
accomplished informally through brochures and other program information that
describes the philosophy of the program and the profession, through
informational meetings, and by encouraging program applicants to observe and
have conversations with practitioners. Because students may only be familiar
with the helping role, or core ethos of the profession, this provision of additional
information about the changing role of the professional will, I believe, help them

make a more informed decision about their career choice. As discussed by the

193

Table 6. The Role of Educators and Students During Phase I

PHA E I: AW R NE F XPE TATI N AND VAL

 

Role of Educators: Academic Faculty

1. Informal Introduction prior to application and acceptance to program.

2. Formal introduction of expectations of the program and the profession upon
admission.

3. Presentation of documents outlining expectations and values of the professional
culture.

4. History of the profession.

5. Encouragement to join and become involved in professional organization.

Role of Student
1. Listen to lectures, videos, interviews, etc.
2. Participate in class discussions.
3. Become aware of values and expectations through participation in class discussions
and assignments.
4. Join the professional organization and attend meetings.

0-]. ;0|.‘|o 0“”: _e|o ’-‘TOI. .|o'o-1.o.: ; -j.

Role of Faculty
1. Structure Ieaming environment to help students become aware of personal values.
2. Assist students in comparing personal and profession values through guided self-
assessment

Role of Student
1. Become aware of and articulate personal values.
2. Compare and contrast personal values with those of the profession.
3. Guided self-assessment

Resuns
1. Understanding of the evolution of the ethos of the profession.
2. Beginning intemallzation of the professional ethos
3. Ability to converse in the language of professional practice and intellectualllze about
the profession.

194

participants in this study, as well as by a number of authors (Abbott, 1988;
Stroot and Williamson, 1993), many students self select into professions whose
values and beliefs match their own. For this reason, it is important for students
to know where they stand in comparison to the professional ethos, since
students who discover that they have a view of the profession that is not realistic
or reflective of its fundamental values and beliefs may choose another career,
saving themselves much time and money.

Once enrolled in the professional program, more specific information can be
provided to students in this regard. The first step for educators is deciding
exactly what it is they want to teach students about professional behavior and
the professional ethos, followed by writing appropriate goals and behavioral
objectives that reflect the mission, philosophy, and goals of the program and the
profession. Following the establishment of program goals and objectives,
faculty explicitly explain these goals to students so that there is no confusion
about what is expected, no matter how difficult the expectations may seem to
someone just beginning a professional program. In this study, for example,
educators in Program 1 make students aware of their expectations during their
orientation through the introduction of the generic abilities. Similarly,
participants from Program 2 discussed how expectations for student behavior
were made clear during the orientation process. Students from both programs
testified that goals and objectives were made very explicit throughout the
program, that they were realistic, and that they were consistent with the goals of
the clinical sites at which they completed site visits or clinical internships. In
addition, students stated that knowing what was expected of them was helpful in
the socialization process.

In addition to an orientation to the specific expectations of the program, both

195

groups of educators introduce students to professional documents such as the
Code of Ethics, Standards of Practice, and licensure laws very early in the
program and encourage students to join and become actively involved in the
meetings and activities of the professional association. Finally, although not
specifically cited as something that is definitely done in either program, several
faculty members discussed how it is important for students to understand where
in the history of physical therapy they are entering the profession so that they
can begin to understand how it is that physical therapists evolved to their
present status and why the ethos is the way it is. This is another source of
information, then, that may prove helpful to students at the beginning of their
professional education.

.. . : 2: lo rn' -ttin-z. . army ri .on of 9.: .onzl =_no crofiril:m~o:. vl : .
Just as the heterogeneity of the student population has made it necessary for
educators to be very explicit about their expectations for student behavior,
heterogeneity has also made it important for faculty to make the implicit
curriculum about professional values and professional behaviors explicit. This
assertion was supported by the educators in Part 2, and also by the Fellows and
Prime Timers, as a recommendation to help facilitate the intemallzation of the
professional ethos. The process of identifying and comparing personal and
professional values occurs during the second stage of Phase I, Identification
and Comparison of Personal and Professional Values.

All participants in this study felt that newcomers to the field today generally
possess the same core values of helping and caring, hard work and dedication,
warmth and Openness, and a positive attitude as their predecessors. Fellows
and Prime Timers alike discussed how these core values are basically

unchanged. In contrast, participants felt that people entering the field today may

196

also have some different standards and values than those individuals who
entered the field in the past due to generational differences, differences in
society, ethnic differences, and family backgrounds. The metaer of America
as a melting pot with everyone having the same beliefs and values is no longer
useful. Instead, this metaphor has been replaced by a postmodern view (i.e., as
reflected in the work of Gergen and Martin discussed earlier) of the world in
which individual differences and constant cultural change are the norm. For this
reason, educators can no longer assume that students share their beliefs and
values. As one Prime Timer explained, “we can’t just assume that their
backgrounds are going to be like our backgrounds” (Prime Timer 8, p. 3).

The implications of this change for educators are twofold. First, we can no
longer expect students to just “do the right thing” since their definition of “the
right thing” and ours may be very different. Also, because of the complexity of
the world today, there is rarely only one right thing to do. I feel that one of the
first steps in helping students to become a true member of the community of
practitioners, therefore, is to help them identify what their personal values are
and how they are similar to or different from those reflected in the core or
evolving ethos of the profession . Students may need to participate in values
clarification sessions or general discussions of what their own values are and
how they have developed. One Prime Timer, for example, discussed haw
educators need to be much more overt in trying to get students to talk about
their backgrounds and how they developed the personal ideals and values they
have.

Once students have identified and articulated their values and compared
them to those of the profession, faculty may then move on to other methods of
exploring and expanding student values to meld with those of the profession,

197

co-creating meaning with students through classroom discourse that is relevant
and timely in regard to the values of the profession. The professional issues
courses offered in the two programs chosen for this study were described as the
primary process by which students initially become familiar with and practice
talking about the issues and values that are important for a practitioner in
today’s world. Within these courses, faculty and clinicians discussed current
issues in the field and invited students to join in the conversation through small
group sessions, class discussions, and writing reflective journals. Students
described how the process of sharing ideas and thoughts about values and
contemporary issues during the professional seminar series facilitated the
process of professional socialization. The use of practicing clinicians as
speakers in these courses helped students begin to see positive role models
beyond the faculty, another method that was felt to contribute positively to
socialization of students in these two programs. In addition, the presence of
practicing clinicians in the classroom was felt to reinforce the fact that
professional behavior and understanding professional issues are important to
all members of the profession, not just to faculty.

Throughout the process of identifying and exploring values, students can be
encouraged to compare and contrast their ideas with those of their peers and
full-fledged members of the profession (i.e., faculty and clinicians). Although
faculty are, at first, very involved in leading these discussions and facilitating the
identification of important issues, the primary purpose of these discussions is to
help students identify areas of consensus and dissensus between their values
and those of the profession as a beginning step toward professional
socialization. Because faculty are so involved at this stage of professional

socialization the term “guided self assessment,” as opposed to independent self

198

assessment, seems a more appropriate term to describe this process.

W. During Phase I, students are exposed to the
expectations of the program and the profession in the area of professional
behavior. In addition, they begin to become more acutely aware of their values
through methods such as discussion, exposure to role models, and reflective
journals. They are encouraged to compare their values to those of the
profession in order to begin to understand what they must do to continue down
the path of professional development. Guided self assessment, with faculty
providing a lot of structure regarding relevant issues in the field and class
discussions is a hallmark of this phase. Students, at this point, will ask more
questions than in the later phases of the program as they attempt to understand
the profession better.

Because students have just begun the journey toward professional
socialization during Phase I, they may only be able to intellectualize about the
ethos. That is, they can list or describe the values of the profession and
compare them to their own. They can discuss the history, the Code of Ethics
and Standards of Practice of the profession, but they cannot “feel” or apply
them. The professional ethos has not become a part of their personality. At this
point, it is rare that any student has internalized the ethos of the profession.

P ll: 'v in '

While there is no set time for passage from one phase of value negotiation to
the next, Phase II, Active Learning, begins at about the time students complete
their initial semester in the professional program and have become familiar with
the profession, its history, and its culture (T able 7). It is during this second
phase of value negotiation, when students do most of the work of internalizing

the professional ethos. This phase is characterized by more student

199

Table 7. The Role of Educators and Students During Phase II

PHA E II: TIVE LEA NIN

Role of Educator: Academic and Clinical Faculty

1. Provide an educational environment that facilitates professional socialization.

a. Opportunities to prawce professional behavior In as realistic a manner as
possible.

b. Consistent, timely, and regular feedback regarding professional behavior.
c. Multiple role models from a variety of settings.
(I. Use of adult Ieaming strategies .

2. Emphasize active Ieaming rather than passive reception of presented material.

3. Encourage students to join and become increasingly Involved In professional

organizations.

Role of Student
1. Active participation In the socialization process.

a. Practice professional behaviors.

b. Share thoughts, opinions, and feelings honestly and openly.

c. Give honest feedback to peers in group projects, study groups, discussions,
conversations, etc.

d. Be open to constructive feedback from peers and educators.

e. Apply values to specific situations.

f. Create meaning within the classroom settings.
2. Independent Self-assessment

a. Periodic, personal, case-grounded self assessment

b. Identify areas of strength and those needing Improvement or development

c. Set goals and objectives, devise and carry out action plans for continued
professional development

3. Value Negotiation

a. Continuetocompareandcontrastpersonaland professionalvaluesasnew

issues surface.

b. Compare and contrast views of different professionals.

c. Be open to changing opinions, values, and behaviors based on case
grounded self-assessment and feedback from others and conflicts between
personal and professional values and feelings.

4. Creating Meaning for Self

a. Compare and contrast role models.

b. Incorporate values and professional behaviors of role models into personal
view of the Ideal professional.

Resuus
1. Increased awarenessof professional values/issuesand possibleconfllctswlth
personal values.
Case Grounded self-assessment
Resolution of specific value conflicts or ethical dilemmas through case grounded self-
assessrnent and value negotiation.
Personal and professional values begin to meld.
Increasing lntemalization of professional ethos.

9’.”

9’9”

200

involvement than in Phase I when students were first becoming familiar with the
profession and faculty provided more structure in terms of presentation of
material, greater involvement in leading discussions, and guided self
assessment. In contrast, the role of the faculty during Phase II begins to
diminish. While faculty are obviously still a very important part of the
socialization process, their role is altered as they begin to question students
more about their futures in the profession and what they might do in different
situations.

More specifically, the faculty role during Phase II is to provide adequate
opportunities for practicing professional behaviors in as realistic a manner as
possible; provide consistent, constructive, and regular feedback regarding
student progress in the area of professional socialization; expose students to as
many role models as possible; and provide opportunities for the use of adult
Ieaming strategies such as active Ieaming, problem solving, critical thinking,
reflection and independent self assessment. In addition, the role of clinical
educators becomes more prominent as students begin to make visits to clinical
sites to practice newly Ieamed skills and complete short-term apprenticeships.
Consistency in expectations and professional behaviors on the part of
academic and clinical educators, therefore, becomes increasingly important.
Finally, educators in both the academic and apprenticeship settings continue to
encourage students to join and become active in professional organizations as
a beginning step in making a contribution to creating meaning within the
community of practice. Faculty stated that they used these methods as an
avenue for professional socialization and students perceived all of these

methods as helpful for them in the socialization process.

201

itinlt hin mth : Pr i nf k. Theuseofregular
practice is generally believed to be important for all types of Ieaming
(Sorcinelli, 1995; Yelon, 1996) as can be seen in the often used phrase,
“practice makes perfect.” Unfortunately, little attention is usually paid to Ieaming
things about professional behavior through practice. In contrast to the norm, the
faculty in the two Programs included in this study made a concerted effort to
include opportunities to practice all skills associated with being professional,
including those related to professional values. This practice went a long way
toward helping students, with one student explaining that they practiced
situations in class so many times that it just became natural once they were out
in the clinics with real patients. In addition to a sufficient number of
opportunities for practice, both programs made practice sessions as realistic as
possible through the use of case studies, role playing, and whenever possible,
practice with the types of real people that they will eventually be serving
(patients, students, other professionals). During the academic portion of the
students’ education, Program 2 was especially effective in providing
opportunities to practice in as realistic manner as possible through the use of
Mock Clinic.

In conjunction with practice, effective educators regularly offer both positive
and critical feedback to students when appropriate (Yelon, 1996). This
feedback should be consistent, supportive, and provided at the earliest
reasonable opportunity in order to motivate students to want to continue to Ieam
by building confidence in their professional skills and helping them identify
unprofessional behavior so that it can be corrected in a timely manner.

Students who practice without feedback are less likely to make improvements in
Ieaming (Sorcinelli, 1995). Faculty and clinicians from both programs echoed

202

this sentiment. All participants were able to provide specific examples of when
they had offered immediate feedback that resulted in immediate improvement
when students displayed unprofessional behaviors. Feedback provided
through the use of the generic abilities in Program 1 was the most consistent
and regular form of feedback offered to students in that program, while the use
of portfolios and review of the portfolios with faculty advisors was described as a
very effective means of receiving feedback for Program 2. Students in both
programs emphasized that while the generic abilities or portfolios (for their
respective programs) were formal ways in which they received feedback, they
also received consistent, regular, constructive feedback from academic and
clinical faculty throughout the program on a more informal basis. All students
described faculty feedback as helpful in the socialization process.

In addition to feedback from educators, students in these programs also
received feedback from peers during class discussions, while working on group
projects, and during lab practice sessions. Cooperative Ieaming in the form of
group projects, study groups, or student discussion sessions were also felt to
enhance intemallzation of values as students were exposed to the variety of
Ieaming styles, beliefs, and values in their peers. Discussion sessions in the
continuing professional issues series, in particular, were cited as an important
contributor to internalization of the professional ethos. In Program 2, the Ethics
course was also felt to be beneficial in facilitating discussions of ethical and
professional issues that would help students develop confidence in their

professional choices.

Th rot: ft : -tt: 0 ' r 01:. .: II' Vl:__: "Hitt'izlt'l i . -21:
W. According to Value Negotiation Theory, the primary

role of the student during Phase II is to become an active participant in the

203

socialization process. I feel this can be accomplished in several ways. First,
students must take advantage of all opportunities for practice. This would
include such activities as using time wisely during lab sessions (e.g., mock
clinic or similar lab courses), participating in class discussions (e.g., in the
professional issues courses or similar courses), sharing thoughts and feelings
honestly and openly in reflective journals and discussions, giving honest and
constructive feedback to peers, asking questions of individual faculty when
necessary, and being open to constructive feedback from educators and peers.
As described by students, it is by practicing all aspects of professional
development that the professional ethos becomes a “natural” part of who the
students are as a people and professionals, and how they will ultimately be
able to become a member of the community of practice. In addition, I feel that it
is only through active participation that students will discover what they know or
don’t know; where they need improvement; and most importantly for this study,
where conflicts in values, beliefs, or professional behaviors exist. As part of the
Theory of Value Negotiation, I am proposing that the discovery of conflict occurs
as students become aware of dissensus or confusion both within the profession
and between their personal values and those of the profession. In other
instances, students may run across situations that involve value conflicts, ethical
dilemmas, or professional issues (e.g., entry level education) that they have
never encountered or thought about before. In these cases students have to
decide what stand they think is best for the profession and for themselves as a
future professional.

The real work of value negotiation, then, occurs as students become aware
of conflicts or confusion. Although they have been exposed to the big picture

regarding professional values and beliefs during Phase I, they now have the

204

responsibility to apply these values to specific situations. Because awareness
is the first step in resolving conflicts or confusion, I believe that offering students
timely feedback about unprofessional behavior is very important. If students are
unaware of the conflicts their values or behaviors are creating for themselves or
others, it is difficult to resolve the issues on which these conflicts are based. As
a result, professional development can stagnate. Faculty, in particular,
supported this notion of feedback regarding professional behavior. In the
examples of unprofessional behavior provided by faculty, students were often
unaware that the behavior they exhibited was unprofessional. As a result,
students most often thought about the behavior, apologized, and resolved the
conflict Interestingly, students were also able to describe instances of
unprofessional behavior in both their classmates and, sometimes in the
behavior of practicing professionals. In some instances, they described how
they and their classmates had approached another student about behaviors
that reflected badly on the class or on the program. Although, because of their
position as students, they were unable or unwilling to provide this same type of
feedback to practicing clinicians, awareness of the conflict helped them to form
a better picture of themselves as an ethical, effective practitioner as they
decided that these types of physical therapists were negative role models who
exhibited behaviors that they would not exhibit in the fiJture.

The importance of raising awareness of value issues is also. why I believe
that the use of many case studies grounded in professional ethics across the
curriculum is an important component of value negotiation and professional
socialization. Participants in both Parts 1 and 2 of this study stressed the
importance of integrating issues related to professional socialization throughout

the curriculum rather than simply presenting them in a separate course during

205

one semester in the program. Students, faculty, and clinicians from both
programs described how professional behavior is ingrained into students from
the moment they enter the program. One way in which Programs 1 and 2
accomplish this is through the professional issues seminar series which extend
over the academic portion of the program. In addition, Program 2 uses Mock
Clinic to present cases to students, and both programs use case studies
throughout the program to help students develop problem solving skills. The
extent to which these case studies incorporate issues related to professional
development rather than just evaluation and treatment issues, however, is not
clear from the interview data.

Based on my knowledge of physical therapy curriculums and accreditation
standards of the American Physical Therapy Association, I believe that the
addition of this component to case studies would be an easy and worthwhile
one. For this reason, I have incorporated the integration of professional issues
into case studies into my conceptualization of how it is that students come to
internalize a professional issues. For example, rather than just providing
students with a list of signs and symptoms from which they are to use their
problem solving skills to decide what is wrong with the patient and how they
would treat the problem, these scenarios could also include problems related to
value judgments or ethical dilemmas. This would accomplish two things. First,
students would be asked to consider their own values in relation to those
depicted in the case and would have to consider how they would apply their
own values and those of the profession to the problem. This type of informal
self assessment of values based on specific cases would be beneficial in
helping students internalize the professional ethos as they weighed the pros

and cons of their decisions. Because faculty and classmates would be

206

available, students could also discuss their decisions for solving the dilemma
with input from others around them helping students to create meaning for
themselves and others within the community of practice. Students described
how they used discussions in the professional issues course and other courses
as a venue for being exposed to and sharing ideas with those of others as part
of their quest to become a contributing member of the professional community.
A second thing that would be accomplished by incorporating issues related to
professional development into all case studies throughout the curriculum would
be that students would realize that there is no one faculty member who is the
expert on professional values and culture. Rather, as suggested by theories of
situated Ieaming, students would realize that knowledge regarding professional
socialization (as well as other areas) is distributed among the entire community
of practitioners (Hutchins, 1993). Although one faculty member may be
responsible for a course on ethics or the professional seminar series, each
faculty member and clinician would be viewed as having expertise in the area
of professional development and professional socialization.

Once students become aware that a value or ethical problem exists, the next
step in value negotiation is to begin to try to resolve the issue by comparing and
contrasting ideas. This can be accomplished through class discussions; private
discussions with faculty, peers, or clinicians; gathering more information about
the topic either in class or through outside sources (i.e., library, professional
journals, attending professional meetings on the topic); or reflective journals. In
general, these methods reflect the process of active Ieaming that was perceived
by students as making significant contributions to the process of professional
socialization. Ultimately, it is the student alone who must resolve issues for him

or herself by deciding where he or she stands on an issue. I feel that it is the

207

resolution of the conflict through case grounded self assessment that moves the
student along the road to an intemallzation of the professional ethos.
WM. On a more formal basis, self
assessment can be incorporated into the curriculum in order to help students
assess how they have grown in all areas. This formal type of self assessment is
accomplished in Program 1 through the semester review of the generic abilities
and in Program 2 through the portfolio review and interviews and is felt by the
participants in Part 2 of this study to be a useful tool for helping students
internalize the ethos of the profession. Although the term self assessment is
used to describe this process, the actual completion of generic abilities or
portfolio reviews also encompasses many other principles of adult Ieaming,
another factor which I and the participants in this study thought to be helpful in
the professional socialization of students. First, the student is an active
participant in the assessment process. After reflecting on the expectafions of
the program and the definition of a professional that they have created
throughout their education, students decide where they feel they are in the
process of internalizing the ethos of profession by identifying strengths and
areas in need of improvement. In addition, students set goals for themselves
and devise action plans that will help them achieve their goals. Although
students receive feedback from faculty regarding their assessment and plan, it
is only after they have established for themselves where they are in the process
of professional socialization that this feedback is received. As a result, students
stated that this process was helpful in establishing a pattern of setting goals and
devising plans for themselves that they felt would be helpful to them upon
graduation when they would encounter situations where there would be no one

available to tell them what to do. This type of self assessment and goal setting

208

may be helpful, for example, in planning lifelong Ieaming opportunities.
Students also felt that because formal self assessment was completed several
times throughout the program, they could look back on previous assessments
and see how they had grown since that time. The opportunity to see growth
was thought to be a motivating factor in their ability to continue to remain
dedicated to and complete the program successfully.
WWW During Phase II OI
value negotiation students have more opportunities to become involved in the
professional association and have increased exposure to physical therapy role
models as more clinicians are brought into the program to assist in classes and
as students begin to visit apprenticeship sites in order to begin to use their new
skills in real situations. Their community of practice begins to expand to include
others outside the classroom setting. The community begins to welcome them
more. For example, in most programs several weeks of clinical experience at
apprenticeship sites are integrated into the academic portion of the program. In
addition, local professional association meetings often make special efforts to
include students in the community by personally inviting them to meetings or
sponsoring special activities for students. On a local and national level,
students are invited to attend student conclaves. In all of these real situations, I
feel that students have the same opportunities and responsibilities to examine
their values and behaviors that they had when they applied the process of value
negotiation to case studies, theoretical situations, or professional issues. In
addition, in this study, students perceived the exposure to an increasing number
and variety of role models as contributing to their continuing professional
development as they observed professionals in action, and decided for

themselves which behaviors and attitudes they would incorporate into their own

209 '

view of the ideal professional. Participants in this study felt that students who
had adequate opportunities to become aware of and apply ideas to case
studies and issues related to the professional ethos, would be more prepared to
interact with patients and with others in the community and would be better able
to make good decisions about professional behavior and professional practice.

W391. During Phase II, students begin the active process of
internalizing the professional ethos. While educators provide opportunities to
be socialized into the profession, it is students who must actively participate,
reflect on their progress, and assess where they are and where they need to do
to in order to become a professional. Initially during this phase students are
provided with case studies and theoretical or professional issues in the
classroom. In these instances, there are no real consequences or rewards for
any decisions students make in regard to these “paper-pencil” scenarios.
Faculty and peers are very available to help students explore ideas and
thoughts related to professional values. In contrast, as students progress
through the program, faculty input is decreased and students are afforded
increasing opportunities to interact with real patients and practicing clinicians.
The consequences and rewards in these situations are also real. A patient may
get hurt or a future colleague may think a student is irresponsible or
unprofessional if these situations are not handled appropriately. Based on the
data from this study, students, faculty, and clinicians feel that if students are
adequately prepared in the academic setting through the methods described
above, the likelihood of unwanted results in the clinical setting is reduced since,
as stated by one student, these skills, beliefs, and behaviors just become a
“natural part of who you are.”

At this point in the process of professional socialization, most students are

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well on their way to internalizing the ethos of the profession. Although they are
not totally independent in their professional role, they are being given
increasing opportunities to develop independence. In addition, as they enter
the clinics, they are given more opportunities to interact and receive feedback
from clinicians, rather than just from faculty. As they observe practice in action,
they can begin to see connections between what they have Ieamed about
professional behavior, how it can be applied, and how it can impact them as a
practitioner. In addition, as described by several students, they can also
examine the growth they have made as they review their portfolios, journals, or
their generic abilities assessments. As a result, not only can they intellectualize
about the ethos, but they are beginning to be able to apply the ethical and
professional principles inherent in the ethos to practice. Their personal and
professional values are beginning to meld and being a physical therapist is
becoming a part of who they are.
PM3o Ill - Artim

Artistry, the final phase of value negotiation, begins as students enter their
final apprenticeships and approach graduation (Table 8). This Phase is divided
into three stages -- Approaching Graduation, After Graduation, and the Epitome.
While the conceptualization of the first phase is based primarily on the data from
this study, it also incorporates theoretical perspectives of educational
researchers that have become reflective of contemporary views of teaching and
Ieaming (e.g., Schon, 1983; 1987). The last two stages are extrapolated from
the data and literature review and are based more on my experience in the field
of physical therapy education, my knowledge of the profession of physical
therapy, and my belief that the process of professional socialization is a

developmental one that must continue throughout one’s career. While the data

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Table 8. The Role of Educators and Students During Phase III

PHA E III: R" TRY
WWW

Role of Educators: Clinical Faculty Role Increases
1. Provide opportunities for an active role in the apprenticeship site.
2. Provide opportunities to practice professional roles outside that of the clinician.
3. Continued practice and feedback regarding professional behavior.
4. Prepare students for surprise and sense-making.
5. Provide increasing opportunities for legitimate peripheral parficipation/creating
meaning for community.
Role of Student
Active participation in professional development.
Practice reflection-in-action through problem setting and solving, and critical thinking.
Continue value negotiation.
Independent self-assessment
Review of growth through GAs, self-assessment, portfolios, journals, interviews.
Beginning to create meaning within the clinical community.
Resun
Increased identification with practicing professionals rather than peers or faculty.
Diminished student culture and ethos.
See world through the eyes of a professional.
Final process of lntemalization of the professional ethos.
Image of self as a professional emerges.
Personal and professional selves become one.
Increasing participation In professional organization and community of practice.

NEPS’IPSr’Nf’P’S’IPWNT“

 

Role of Graduate

1. Continued growth through self-assessment, goal setting and lifelong Ieaming

2. Full participation in professional organization and community of practice.

3. Seek mentors and others for advice.

4. Continued independent value negotiation as new dilemmas and issues arise.

5. Movefromtheroleof”theeducated” to”educator'asbegintoworkwithstudents
Role of Educator '

1. Availability to serve as advisers, mentors, and role models for graduates

2. Offer lifelong Ieaming opportunities through continuing and post-entry level education
Resuns

1. lntemalization of the professional ethos as a dynamic entity.

2. Independent and Life Long Learning.

3. Successful practice in indeterminate zones of practice.

4. Full acceptance into community of practice.

 

1. Deflne the professional ethos and culture.
2. Mentor future leaders.

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from this study does not specifically support the conceptualization of continued
professional development described in stages 2 and 3 of the Artistry Phase, I
felt it was important to include this information in order to create a theory that
would offer a complete developmental picture. Doing otherwise, I felt, might
lead readers of this study to conclude that the process of professional
socialization is complete at the time of graduation.
WM. Stage 1, Approaching Graduation, begins
as students are completing their final apprenticeships and nearing graduation.
Although they are still technically students, they are beginning to function more
and more as professionals as they are given increased responsibility in
professional duties. As students become more immersed in the professional
setting, while at the same time becoming further removed from the classroom,
they begin to identify more with the clinicians who surround them rather than the
classmates with whom they had spent much of their academic lives (Sabari,
1985). As part of the Theory of Value Negotiation, I feel that as this shift occurs,
students become better able to see the world through the eyes of a professional
rather than the eyes of the students. This helps them meld their professional
with their personal views. In contrast to Phase II, where students continue to go
back and forth between the student and professional worlds, comparing and
contrasting the two views, students in phase III begin to solidify their ’
professional views, and consequently, their professional values and ethos. The
ethos and culture of the student recedes farther and farther into the background
until it eventually diminishes to nothing. Although some students may not
complete this transition by the time they graduate most will have melded their
personal and professional values with the core values of the profession and the

current dynamic values, at least to some extent, by the time they graduate.

213

Once students have let go of their student culture and student views and have
established a sense of what it means to be a professional, I feel they are well on
their way to internalizing the professional ethos, at least at the core and at the
most obvious of the dynamic levels. That is, their personal values, the core
values and beliefs of the profession, and concerns about current issues in the
profession that are affecting the roles, responsibilities, and ethos of the
profession become fused as one and become part of who the person is.

One of the ways in which I believe that students are able to make this final
transition is by being given increasingly active roles in the apprenticeship
setting. Those students who are protected from difficult patients, demanding
physicians and administrators, or the hassles of fighting for reimbursement of
patient services with insurance companies will not be able to internalize the
ethos of the new physical therapist and will not reach the stage of true
professional socialization. Students who are merely given opportunities to
function as clinicians, an important role, but only one part of the new
professional ethos, will continue to function as clinicians when they graduate.
While they may become extremely effective in this area, they will not be
adequately prepared for the real world. The faculty in Program 2 supported this
notion and offered this as an explanation for why they felt that longer clinical
internships were necessary and helpful for their students. Because student
placements extended over an entire semester, they were able to move beyond
beyond basic patient care and become involved in working with more complex
patients and participating in other aspects of the work of physical therapists.
Students from this program also said they felt they were able to get more
involved in their work as a result of the longer internships. Clinicians felt that

the longer internships were perhaps unnecessary since they seemed to “run out

214

of things to teach the students” toward the end of the fourteen weeks. As
discussed earlier, however, this may be because students had acquired many
of the basic skills and were moving onto developing other aspects of their
professional roles, such as dealing with insurance companies and physicians,
becoming a part of the professional staff, and creating meaning within the
community of practice, some of which is not “taught” in the same manner that
one teaches a student how to apply a certain evaluation or treatment technique.
My conceptualization of the process by which students continue along the
road to professional socialization during Phase III is similar to that of the earlier
phases. For example, practice and feedback, this time from practicing
clinicians, remain methods that are useful to students. More importantly,
students continue to be active participants in their own development. In
Programs 1 and 2, for example, students continue to go through the process of
reflection and self assessment as they set goals for themselves in the clinical
setting. They interact with other students, practicing therapists, and other
professionals within the clinical setting, taking in what they see and continuing
to build their view of the ideal physical therapist by comparing and contrasting
what they see others doing with what they would do in similar situations.
Roflogion. As students continue to be given more and more responsibility,
their ability to reflect on their actions becomes increasingly important. While
others may be available to offer advice at a later time, students interacting with
patients and other professionals can not always stop what they are doing to find
a colleague to help them solve a problem. Instead, students must develop a
new kind of reflection -- one that allows them to think on their feet and solve
problems as they occur. Donald Schon (1983; 1987) has coined the term

“reflection-in action” to describe this process. Reflection-in-action is the process

215

by which professionals reflect on what they do during professional practice and
how they change their actions when the usual ways of doing things do not work
(Schon, 1983; 1987). This may occur, for example, when making a decision to
delegate tasks to a paraprofessional results in other problems for the
department, or when a patient has a complex set of problems that do not reflect
any cases that have been seen before. Reflection-in-action is the process by
which successful practitioners are able to reframe a situation that defies the
usual into a problem that can be solved (Schon, 1983; 1987). It is a process
that goes beyond the realm of the technical know-how that is necessary to solve
simple, mundane, or everyday problems, to knowing how to frame problems
that are unique, uncertain or laden with value conflicts (Schon, 1987). Schon
refers to this process as practicing within the “indeterminate zone of practice.”

These indeterminate zones of practice - uncertainty, uniqueness,
and value conflict -- escape the canons of technical rationality.
When a problematic situation is uncertain, technical problem
solving depends on the prior construction of a well-formed
problem -- which is not itself a technical task. When a practitioner
recognizes a situation as unique, she cannot handle it solely by
applying theories or techniques derived from her store of
professional knowledge. And in situations of value conflict, there
are not clear and self-consistent ends to guide the technical
selection of means. (Schon, 1987, p. 6)

The ability to think on one’s feet, to reflect-in-action, is only accomplished after
many months of reflection and problem solving. The ability to blend knowledge,
technical skills, and values in order to reflect-in-action and be able to solve the
complex and sometimes ambiguous problems that exist in today’s professional
world has become an important part of the ethos of many professions. It is not,
however, a skill that is easily or readily Ieamed. its precursors - exposure to a

variety of problems and solutions, the ability to frame situations in such a way

216

that they become a problem to be solved, the ability to reflect, and the
willingness to not only take action, but be willing to take responsibility for that
action- are necessary components of developing this skill. These precursors
are also the skills that have been described as an important part of professional
socialization in Phases l and ll of value negotiation and are supported by the
participants in this study as a means of facilitating the lntemalization of the
professional ethos. Reflection-in-action, therefore, is the culmination of

academic and apprenticeship preparation that incorporates these skills.

 

graduation, most students have some sense of who they are as a professional,
another sign that they have lntemalized the professional ethos. At this point
students may be able to look back over their behaviors and beliefs during their
professional program and see how they have changed their views and how
they have grown. This was true of several of the students in this study, who
discussed how they could now see ethical and professional matters more
clearly and could now understand what educators were trying to help them see
in the area of professional socialization. Students in Program 1 were able to
see their progress as they reviewed their generic abilities self assessments,
while those in Program 2 were able to review their portfolios and participated in
exit interviews as a means of seeing how far they had come since entering the
program. Finally, students discussed how they had become more involved and
felt welcome in the professional world as they completed their final internships.
Mom. As mentioned earlier not all students reach the
point of successful internalization of the professional ethos by the time they
graduate. For these students, especially, the process of value negotiation does

not stop upon graduation. Even for those who have successfully internalized

217

the professional ethos, value negotiation continues throughout their careers.
Some of this occurs as a result of making the transition from student to
professional. Other authors (Brief, et. al., 1979; Chao, 1988; Bradby, 1990)
have described this period as one of surprise or reality shock. During this
period there may be disappointment or surprise at how the real world functions.
Students recognized this period of transition and one student very explicitly
stated that this transition process is “going to happen no matter what.” Students
also thought that educators helped them make this transition in several ways,
including realistic practice, longer clinical internships (in Program 2), the
generic abilities (in Program 1), fostering independent thinking and
responsibility for Ieaming, and emphasizing the need to continue to grow
through continuing education, mentor programs, reading, and asking for
support from coworkers as needed. Educators can help graduates make this
transition from student to professional more smoothly by letting them know that
they may experience these feelings as they make the final transition from new
graduate to professional and by providing a realistic picture of the professional
world as possible (Brief, Van Sell, Aldag, and Malone, 1979; Bradby, 1990;
Lurie, 1981). Ultimately, however, it is students who must take this final step
toward independence.

A second reason for continued value negotiation and development is that, as
described in Part 1, the culture and ethos of the profession are constantly
changing in response to changes in society, to incorporating newcomers into
the profession, and in response to changes within the profession. New
generations of professionals bring their own set of personal values that will
contribute to changes within the profession. The increasing pace of change in

our society is producing ethical and political problems that did not exist before.

218

Those who choose not to keep up with these changes and deal with

contemporary problems will, I feel, become stagnant. As a result, they may lose ‘ 3

their sense of professional ethos as the profession continues to evolve without
them.

One of the most important transitions that occurs during this stage is that the
graduate becomes responsible for his or her own Ieaming and professional
growth. The formal role of educators has diminished to nothing in terms of their
responsibility for providing the specific Ieaming opportunities for professional
socialization that are necessary for entry into the field. There is no longer
someone telling the graduate what he or she must do to continue to grow with
the profession. Rather, practicing professionals identify their own needs and
seek appropriate resources to fulfill those needs. They may identify a mentor,
attend continuing education conferences, become more active in professional
organizations, form study groups or journal clubs to seek answers to specific
questions within their work setting, or return to the university setting to pursue
an advanced degree. All of these methods were discussed by students as ways
that faculty encouraged them to continue Ieaming after graduation. They
realized that that they would be responsible for their own growth as they
continue along the path of professional development through lifelong Ieaming.

This responsibility for one’s own Ieaming does not mean that graduates
cannot turn to their former educators for advice in determining which direction to
take in terms of deciding if they should specialize in a certain area of treatment,
how they can become more involved in professional organizations, discussing
employment opportunities, or identifying courses or activities that might help
them further their professional growth. On the contrary, it has been my

experience that many graduates seek advice regarding the best mechanisms

219

for continued professional growth from educators, including faculty and former
clinical instructors. The responsibility of educators to provide this advice is one
of the informal ways in which they continue to become involved in the
professional socialization of their graduates. Continuing to role model
professional behavior is another mechanism by which educators may continue
to influence the intemallzation of the professional ethos in new graduates. On a
more formal basis many universities, including the one in which I currently
teach, also offer continuing education courses, post-entry level degrees, and
opportunities to interact with students in the classroom as ways for graduates to
continue to Ieam. Continuing education opportunities may also be provided by
area hospitals and clinics through formal courses or inservice education. On
more of a one-to-one basis some departments have a mentor or buddy system
in which new graduates are assigned to work with someone who has been in
the field for some time and who is willing to help the graduate make the final
transition to the professional world. One student interviewed for this study
described this experience as being “similar to a clinical internship, but not as
strict.” Finally, graduates may seek a mentor in a former faculty member that
they feel could provide them with counsel regarding the type of professional
they would ultimately like to become.

Graduates make the final transition from student to professional by moving
beyond the reality shock that often occurs during initial employment after
graduation. They begin to gain more confidence in the independent application
of both technical skills and the professional values that have been instilled
throughout their education. They are faced with a variety of professional
problems that will eventually lead to the development of independent reflection-
in-action. For those who have had the opportunity to engage in reflection and

220

self-assessment, as the students in the Mo programs in this study have, I feel
the ability to independently identify problems and reflect-in-action will develop
quickly. Similarly, as graduates gain more experience in the profession and
interact with others in the work environment, they become full participants in the
community of practice. As with the development of reflection-in-action, I feel that
these professionals who have been given opportunities as students to be
meaningfully involved in the community through exposure to professional and
political issues, discussion of ethical problems, and value negotiation will reach
this goal sooner than those who have not been provided these same
opportunities. These sentiments were also expressed by the educators and
students intenriewed in Part 2 of this study.

Once graduates have made this final transition from the world of the student
to the that of the professional as they begin to make sense of the professional
world, I contend that they have taken the final step toward the internalization of
the ethos of the profession. As this occurs, the graduate takes on new
responsibilities related to teaching and Ieaming, including the responsibility for
lifelong learning discussed above. Just as important for this study, they also
move from the role of the educated to that of the educator as they become the
professionals who provide opportunities for others to Ieam and to create
meaning with the community.

W. Although one is never quite finished internalizing the
professional ethos since it is always changing, there does come a time for some
individuals when they reach the epitome of professional socialization. I say
only some individuals because most people never reach this point. It is
reserved only for those who have become acknowledged leaders or experts in
the field. Those who reach this point become the individuals who actually help

221

define the professional ethos. This is not to imply that one simply needs many
years of practice or to be elected to a position of power within the professional
organization to reach the epitome. In fact, I feel that very few people reach the
epitome of value negotiation. Not all professionals who practice for many years
become experts and not all people elected to office are truly leaders. One of the
Fellows interviewed for Part 1 of this study discussed this issue. She talked
about how some people are true leaders who are very dedicated and have
worked hard to achieve their status as a leader. In addition, these types of
leaders were created by followers who recognized leadership ability, good
ideas, and dedication. In contrast, there are some people who may appear to
be leaders on the surface, but in reality they are only people who happened to
be in the right place at the right time. These are people who are in leadership
positions, but who are not truly good leaders.

In my interactions with individuals who I, along with a number of the
participants in this study, feel have reached the epitome of value negotiation
and have become true leaders in the field a number of characteristics stand out.
First, these are people who are humble. While they recognize that they stand at
the pinnacle of the profession, they also recognize that there is always room for
growth and that they can Ieam from others in the profession, just as others can
learn from them. Several of these individuals said that they could not believe
they are so well respected and loved by others in the profession because they
“were just doing their job.” Finally, in relation to this study, I have found an
interesting paradox in that although these individuals help define the
professional ethos, some of them have more difficulty in describing it than the
students, who simply rattle off a list of what they think a physical therapist should
be like. Perhaps this is because these leaders realize the complexity of the

222

situation or perhaps it is because the view from the top is so overwhelming.
5])me of tho §tooy

This study identified methods used to socialize students into the profession of
physical therapy as a specific example of professional socialization. Because it
is necessary to know what it is that faculty wish to socialize students into, Part 1
of this study focused on examining data obtained through historical documents
(Mary MacMiIlan Lectures and Presidential Addresses) and interviews with
individuals who had been in the profession for a fairly long period of time (i.e.,
Fellows and Prime Timers). This data revealed that there are some traits and
values that form the core of the ethos of the profession (e.g., caring for and
helping others) that have not changed since the inception of the profession and
are unlikely to change, at least in the foreseeable future. There are also a
number of factors that influence the cultural ethos of a profession that result in
changes in values and beliefs. These factors can be divided into those that
occur as a result of changes from within the profession itself (e.g., a new
generation of individuals enters the profession who are different than their
predecessors) or from outside the profession (e.g., societal changes in values
or new legislation). These changes have, in turn, created a new professional
culture and professional ethos, resulting in a different type of practitioner who
not only needs a new set of skills, but also has different values and beliefs. It is
this latter finding (i.e., continual changes in values and beliefs) that has the most
important implications for educators in professional programs. The evolution of
the professional ethos has resulted in a need for new methods of professional
socialization.

Part 2 of the study, then, was an attempt to describe exemplary methods of

professional socialization based on interviews with 6 students, 6 clinical

223

educators, and 6 faculty members from two university programs (3 students, 3
clinical educators and 3 faculty members from each program). These two
professional preparation programs were identified by myself and other physical
therapy educators as making a conscious effort to utilize methods that would
facilitate the intemallzation of the professional ethos of physical therapy and
professional behaviors that reflect that ethos. Analysis of this data revealed that
faculty, clinicians, and students are able to identify methods used by faculty and
clinical educators to socialize students into the profession, and that students’
perceptions of these methods are similar to those of their teachers. These
methods are not only good teaching practice applied to professional
socialization, but more importantly, are a reflection of the changes in the
profession and society identified in Part 1. Further, there is some evidence
provided by faculty and clinical educators that the methods employed by these
two programs are effective in facilitating the internalization of the professional
ethos of physical therapy and the professional behaviors that would accompany
this intemallzation. All participants, both in Part 1 and Part 2, however,
acknowledged that no method is entirely effective and that some students will “
never get it.” In addition, because of other influences on students’ values and
beliefs (e.g., family, peers, the media), the extent of the contribution of these
methods to professional socialization remains tentative at this time.

Chapter 6 offered a look at the relationship between the data obtained from
the two parts of this study. The historical account of the evolution of the
professional ethos served as the basis for knowing what educators wish
students to Ieam through the process of professional socialization. The use of
methods, in turn, reflected the values related to the evolution of the professional
ethos. While each set of data could stand alone, their real strength was found to

224

lie in their relationship to one another.

Finally, “value negotiation” was offered as a model for understanding the
process of socialization in professional education programs. Consisting of
three phases of development, Awareness of Values and Expectations, Active
Learning, and Artistry, this theoretical model outlined the roles and
responsibilities of educators and students in the process of professional
socialization. While the role of educators is important in that they provide
opportunities within the academic and clinical environments that facilitate the
process of lntemalization of the professional ethos, it is ultimately the students’
responsibility to take advantage of these opportunities by becoming active
participants in the socialization process.

Imolimoo' n3 for Phfiigl Thorooy

The results of this study have specific implications for physical therapy
education in several ways. First, it has described physical therapy culture as a
foundation for the establishment of a professional ethos. Establishing a clear
yet dynamic picture of who physical therapists are, particularly as compared to
who they have been, has implications for physical therapy education. If one of
the goals of physical therapy education is for students to assimilate the culture
and ethos of the profession, it is necessary for students and for physical therapy
educators to have clear definitions of these two terms within the profession, as
well as some of the factors that have contributed to these definitions. For
example, in Part 1 of this study factors that have contributed to the evolution of
physical therapists from technicians beginning with its inception in 1917 to the
more autonomous individuals they are today have been described.

Based on the description of the professional ethos and the process of

professional socialization described in this study, physical therapy educators

225

can begin to incorporate methods for facilitating the intemallzation of the
professional ethos into their curriculums. As a first step, physical therapy
educators need to become familiar with both traditional and contemporary
principles of teaching and Ieaming and the process of professional
socialization. Many physical therapy educators have no background in
education, possessing only their content knowledge and their desire to help
students Ieam, as they enter the world of academia. While these two
possessions are important, they are not enough to facilitate Ieaming of any kind,
including the type of Ieaming involved in professional socialization. While
understanding such things as how to write goals and objectives so that students
will know what is expected of them in terms of professional behavior is one
component of teaching, it is more important for faculty to recognize the need for
educating reflective practitioners who are responsible and active learners. As
outlined in the model of Value Negotiation, this is the type of Ieaming that
ultimately results in successful socialization into the profession. Fortunately,
this problem has been recognized by the American Physical Therapy
Association and the Section for Education has initiated training programs
through continuing education to address this need.
lmlitinfrPrf inl in

From a broader perspective, I feel this study has implications for professional
education in general. Just as physical therapy educators must define their
professional ethos and the many factors that have influenced it, so must other
professions seek to do so. The identification of the factors that facilitated
professional development and socialization in the students in this study may aid
other professional educators in the process of socializing students into their

respective professions. In addition, the acknowledgement of change in

226

professional identity across time may assist educators in realizing that they
cannot expect students to have the same values and beliefs as they (the
educators) have. Each new cohort of students has grown up in a different time
with new sets of norms and expectations for behaviors. These students,
therefore, may not be able to simply absorb the values and beliefs of those
around them. Rather, faculty and other practitioners in the professions must
take an active role in helping students successfully complete the journey to
obtaining a professional ethos that will help them function as competent and
ethical practitioners in today’s changing world. The recognition of this
difference between the new and the old will, I hope, help other educators to
facilitate the intemallzation of a professional ethos in their students. It will
speak to the need for all professions to explicitly articulate a clear, yet dynamic,
sense of their values and beliefs so that they will know what it is that they would
like students to become. I feel that many students today are floundering as a
result of unclear and unrealistic expectations for professional practice. While
educators do not want, and cannot expect, students to be carbon copies of
themselves, there are some professional ideals that need to be passed on from
one generation to the next in order to maintain the core identity of the
profession.

Because of the many ambiguities in choices that today’s students must make
as compared to the professionals of yesterday, we can no longer expect
students to instantaneously function with a clear sense of professional identity
as soon as they receive their diploma, particularty if we do not offer them any
guidance during their professional education. Because of the dynamic,
reciprocal, and situational nature of professional socialization, however, a static

instructional design with prescribed ways of teaching students exactly how to

227

behave and what to think as they enter the professional world is unrealistic.

The process of value negotiation, described in this study, I believe, offers a way
to give students some direction, yet allow them a sense of autonomy, agency,
and decision making that will ultimately make them responsible for the
internalization of a professional ethos that is consistent with that of their chosen
profession. Overall, educators in professional programs need to be guides,
rather than masters. There is a need to provide students with information about
the cultural norms, beliefs, and values of the profession (i.e., content) while
giving them the ability to recognize when to apply them and how to make their
own choices about appropriate professional behaviors (i.e., process).

Any plan for professional socialization should provide enough flexibility to
allow for changes in the professional ethos over time as new generations of
students enter the profession and the rest of the world around us continues to
change. As described earlier, one faculty member interviewed for this study
discussed how we must acknowledge generational differences and be careful
as educators not to simply create students in our own image, since this image
may not be appropriate to function in a changing world.

Finally, faculty need to recognize that the process of professional
socialization is a developmental one that takes time. Further, as described
earlier, some students may be late bloomers who do not demonstrate a true
internalization of the professional ethos until some time after graduation. More
disheartening, there are some students, who in the words of several of the
individuals interviewed for this study, “will never get it.” This does not mean that
educators have not done a good job, particularly if most of students are
successful. I feel that acknowledging developmental issues and the fact that not
every student will be successful, just as not all students are successful in the

228

academic or psychomotor areas, will go a long way in helping educators
continue on the road to trying to socialize students into the profession without
excess frustration or feelings of failure. Because of the many changes that are
occurring in the world today, educators cannot expect students to internalize the
professional ethos by osmosis. Rather it is through art of good teaching and the
science of using good teaching practices such as making students aware of
expectations, allowing opportunities for practicing these expectations, and
encouraging active Ieaming in all phases of professional socialization that
educators will ultimately be successful in socializing students into a profession.
Lim"nsn 'nfrF rt

As with all qualitative studies, the small number of programs and individuals
involved in this study limits its generalizability. This limit to generalizability is a
criticism often leveled at qualitative research, and most qualitative researchers
would agree that “generalizability is clearly not the strength of qualitative
research” (Firestone, 1993, p. 16). Part of the problem related to the
generalizability stems from the fact that “the strongest argument for generalizing
is usually thought to be extrapolation from sample to population” (Firestone,
1993, p. 16). In qualitative research, where small sample size and purposive
sampling is used instead of random sampling with large number of subjects, the
use of this type of sample to population generalizing clearly limits the use of
qualitative research in applying research results to other setting. In addition, the
results of qualitative research may not be applicable to other settings ”because
qualitative research is inductive and because it focuses primarily on
understanding particulars rather than generalizing to universals” (Maxwell,
1992,p.296)

Qualitative researchers readily acknowledge this limitation in sample to

229

population generalizability and offer alternative forms of generalizability for
qualitative research. Firestone (1993) and Maxwell (1992), for example,
describe applicable methods for generalizing qualitative research from data to
theory, rather than to populations or other settings. The purposes of
generalizing to theory, as described by Firestone and Maxwell, are to use the
theory to make predictions, to confirm the predictions, and to identify the scope
or limitations of the theory. According to Firestone, qualitative researchers
increase confidence in a theory when similar results are obtained from a
replication of a study. Confidence in a theory can also be increased, however,
when different results from similar, but not replication, studies differ in
predictable ways (Firestone, 1993; Maxwell, 1992). That is, the theory can
predict and explain what will happen in similar, as well as different, instances of
the same phenomenon. Maxwell summarizes the use of qualitative research to
generalize to theory as follows:

Generalization in qualitative research usually takes place through
the development of a theory that not only makes sense of the
particular persons or situations studied, but also shows how the
same process, in different situations, can lead to different results.
Generalizability is normally based on the assumption that this
theory may be useful in making sense of similar persons or
situations, rather than on an explicit sampling process and
drawing conclusions about a specified population through
statistical inference. (p. 293)

Maxwell (1992) and Firestone (1993) offer several avenues for generalizing
to theory that will help define its scope and, thus, its ability to explain concepts
and relationships between concepts in predictable ways. These methods
include the use of purposive sampling to identify critical or ideal cases, the use
of deviant cases, and multicase studies. “Critical and deviant cases can be

used to explore or extend existing theories. Multicase studies can use the logic

230

of replication and comparison to strengthen conclusions drawn in single sites
and provide evidence for both their broader utility and the conditions under
which they hold (Firestone, 1993, p. 22)

In addition to the limits to generalizability just discussed, the many variables
that influence the professional behaviors of students outside the educational
setting confound the ability to accurately assess the effectiveness of the
methods of professional socialization outlined in this study. Rather than being
an answer to the question of how to effectively socialize students into a
profession, I offer the results and my conclusions based on the results as a
beginning answer to this question and as a challenge to professional
colleagues in physical therapy and other fields to explore this area further.

In regard to future studies, professionals and students in other fields could
participate in similar qualitative studies to describe and analyze methods used
in other programs. Or, other individuals within the field of physical therapy
could be interviewed to compare and contrast methods of socialization of today
compared to those of the past. Individuals from several different programs,
some of whose students feel they were well socialized and others whose
students feel that they were not, could participate in future studies to compare
methods of socialization used by these programs. Observations of faculty and
students as they progress through a program could be used to describe what
actually happens compared to what educators and students report to have
happened, as was done in this study.

Other questions to be answered in relation to professional socialization might
expand on the issues raised in this study. How, for example, can we assess the
effectiveness of professional programs in successfully socializing students into

our various professions? If we can assess effectiveness, are some methods

231

more useful than others? Are some socialization methods more effective for
one type of profession than another? Are the methods outlined in the model of
value negotiation proposed in this study useful or effective? Is there a
difference in the process for students of different genders, ages, or cultures?
How important are the professional Code of Ethics and Standards of Practice
for professional socialization?

I feel that my work has provided me with a good beginning look at the
process of professional socialization, specifically within the field of physical
therapy, but also as an example to other professionals. I hope that others will
also appreciate this beginning insight into professional socialization and that it
will encourage them to continue to explore this area in order to answer the
questions posed above as well as their own pressing practical and theoretical

questions.

232

 

APPENDIX A

233

APPENDIX A
EXPLANATORY LETTERS AND CONSENT FORMS

EXPLANATORY LETTER FQR PILQT §TQDI - IRB # 35-333

Dear Colleague,

I am a physical therapy educator and a doctoral student in the Educational
Psychology Program at Michigan State University. As part of a research
practicum requirement, I am conducting a pilot study for my dissertation. The
purposes of this study are to explore explore the relationship between the
identity of the individual practitioner and the identity of the profession; to
describe the impact that society, culture and history have had on both of these
constructs; to describe the influence of these factors on the values of our
profession; and to identify methods for teaching these values to our students. In
order to gather this information, I am planning to conduct a series of
semistructured interviews. You have been identified as a person who is a
leader in this area and who might be interested in participating. The purpose of
this letter, therefore, is to inquire about your willingness and availability to be
interviewed.

The interview will take approximately one hour and will be tape recorded for
later analysis. ,I will arrange the interview at a time of greatest convenience for
you. I have enclosed a copy of sample questions for the interview for your
review in order to allow adequate time for you to think about your answers.
Your participation in this study is, of course, completely voluntary, and can be
terminated at any time, either before or during the interview. The names of all
participants in the study will remain confidential and tapes and transcripts will
be reviewed only by myself and my practicum and dissertation committees.

If you would be willing to participate in this pilot project, please complete and
return the attached form by fax [(810) 3704287)] or in the stamped, self-
addressed envelope as soon as possible. After receiving your reply, I will
contact you by phone to setup a time for the interview. In the meantime, if you
have any questions about the project you can contact me at work [(810) 370-
4047] or at home [(810) 641-5313]. You can also contact my advisor, Dr.
Christopher Clark, by phone at Michigan State University [(517) 355-8502] or in
writing at College of Education, Michigan State University, East Lansing,
Michigan 48824-1034.

Thank you for your consideration of this request. i look forward to hearing
from you.

Sincerely,

Chris Stiller-Senna, M.A., P.T.

Enclosures: 2
234

QQNSENT TQ PARTIQIPATE IN PIQT T DY-IRB #

I give my consent to participate in the study, “Values in Physical Therapy
Education: Merging Personal and Professional Identity” and am willing to be
contacted to arrange a time and place to be interviewed. I understand that I will
be interviewed by the investigator at a time convenient to both of us. I also
understand that the interview will take approximately one hour, will be tape
recorded for future analysis by the investigator, and will be confidential. I further
understand that I may terminate my participation in this project at any time.

 

 

 

 

 

 

 

 

Name
Address
Phone (work) (home)
(fax) (e-mail)
Signature of participant Date

Return to: Chris Stiller-Senna, M. A., P. T
1891 Farmbrook
Troy, Michigan 48098

Fax: (810) 370-4287

235

EXPAAT Y E'ITRFRDI ERTATIN T Y

Dear Colleague,

I am a physical therapy educator and a doctoral student in the Educational
Psychology Program at Michigan State University. In the past, as part of a pilot
study I was conducting for my dissertation, you participated in an interview on
“Values in Physical Therapy Education: Merging Personal and Professional
Identity”. l have completed my pilot study and am now in the process of
expanding it to include other data, such as a focus group interview with the
Prime Timers and a review of historical documents, for my dissertation, which is
entitled “Students’ Perceptions of Socialization in Professional Education
Programs: The Example of Physical Therapy". As part of my dissertation, I
would like to include the analysis of the data obtained in the previous
interviews. I am, therefore, writing to request your permission to include the
data obtained when I last interviewed you and to be able to contact you in the
future for clarification of previous responses and for follow-up questions. As in
the previous request for participation, all information will be kept confidential
and will be available only to myself and my dissertation committee, as
explained in the attached consent form. You may withdraw your consent to
participate at any time.

If you would be willing to have the information from the pilot study included in
my dissertation, please complete and return the attached form by fax [(810)
370—4287] or in the stamped, self-addressed envelope as soon as possible. If
you have any questions about the project you can contact me at work [(810)
370-4047] or at home [(810) 641-5313]. You can also contact my advisor, Dr.
Christopher Clark, by phone at Michigan State University [(517) 355-8502] or in
writing at College of Education, Michigan State University, East Lansing,
Michigan 48824-1034.

Thank you for your consideration of this request. I look forward to hearing
from you.

Sincerely,

Chris Stiller-Senna, M.A., P.T.

Enclosure: ( 1)

236

N ENT F R DI ERTATI N T DY

I give my consent to have my previous interview data from the practicum study
on “Values in Physical Therapy Education: Merging Personal and Professional
Identity” included in the present dissertation study on “Students’ Perceptions of
Socialization in Professional Education Programs: The Example of Physical
Therapy”, and to be contacted in the future for clarification of previous
responses and for follow-up questions. I understand that, as in the pilot study,
all results will remain confidential, that I can terminate my participation in the
project at any time, and that I can request that any statement I have made not be
used in this study. I also understand that because of the limited number of
individuals who are possible subjects for this study, there is a possibility that
someone may recognize an idea that l have shared, in spite of the fact that
every attempt will be made to protect my identity.

 

 

 

 

 

 

 

 

Name
Address
Phone (work) (home)
(fax) (e—mail)
Signature of participant Date

Return to: Chris Stiller-Sermo, M. A., P. T
1891 Farmbrook
Troy, Michigan 48098

Fax: (810)370-4287

237

APPENDIX B

238

APPENDIX B
INTERVIEW QUESTIONS FOR PILOT STUDY

INTR TI N

As a leader in the profession of physical therapy, you have experienced
many changes in practice over the years. These changes in practice resulted
from the impact of influential people both within and outside of the profession,
as well as social, political, economic, cultural, and historical events that have
occurred over the years. As a doctoral student in educational psychology, I am
interested in finding out how these people and events have shaped the values
that serve as the foundation for our Code of Ethics and Standards of Practice.
The following questions are my attempt toget your thoughts on how our
professional values developed and how we can best pass these values on to
the students that we teach in physical therapy education.

Because this Interview is part of a pilot study, I am interested in your opinion
and feedback about this experience in order to improve my ability to gather
similar data for my dissertation. For example, are there ways in which you think
this project can be improved; do you have any suggestions for other people to
interview; did the interview questions adequately address the issues of
professional values, and if not do you have any suggestions for improvement?
Please feel free to add any information that you feel is important to my topic, but
is not adequately addressed in my questions. In addition, keep in mind that we
can stop the interview at any time if you decide you no longer want to
participate.

AJ A EA F NTER T AND IDIN E T N
I. Autobiography
How did you become a physical therapist? What was it like for you personally
and for the profession at the time? What draw you to where you are today?
What do you think causes others to become physical therapists? How did you
come to be recognized as a leader in the field?

_ II. ldealsNalues

What were your ideals and values as you entered the profession? How have
they evolved and changed over the years? How and why do you think the
ideals and values of the profession have evolved and changed over the years?
Are there any personality traits of physical therapists that you think have
remained constant throughout the history of our profession? If so, what and
why? Which have changed and why?

Ill. Influential people and events

What social, cultural, or historical events do you think have impacted the
profession/you personally the most and why? What people have done so and
why?

239

IV. Educating students
What advice would you give to someone like me who is completing a doctorate
in the field of educational psychology about teaching professional values to

students?

240

APPENDIX C

241

APPENDIX C
EXPLANATORY LETTER/CONSENT FORM - PRIME TIMERS FOCUS
GROUP

Dear Colleague,

I am a physical therapy educator and a doctoral student in the Educational
Psychology Program at Michigan State University. As part of my dissertation, I
am conducting a study to identify values held by physical therapy practitioners
and the profession. The purposes of this study are to explore explore the
relationship between the identity of the individual practitioner and the identity of
the profession; to describe the impact that society, culture and history have had
on both of these constructs; to describe the influence of these factors on the
values of our profession; and to identify methods for teaching these values to
our students. In order to gather this information, I am planning to conduct a
focus group interview with members of the Prime Timers. As a member of this
group, I feel you would have some insight into the development of the
profession. The purpose of this letter, therefore, is to inquire about your
willingness and availability to participate in the focus group interview and to be
contacted in the future for clarification of interview responses and follow-up
questions as needed.

The session will take approximately two hours and will be videotaped for
later analysis. I will arrange the group meeting at a time of greatest
convenience for all those that will be involved. I have enclosed a copy of
sample questions for the interview for your review in order to allow adequate
time for you to think about your answers. Your participation in this study is, of
course, completely voluntary, and can be terminated at any time, either before
or during the focus group interview. The names of all participants in the study
will remain confidential and tapes and transcripts will be reviewed only by
myself and my dissertation committee. Because of the limited number of
possible subjects for this study, however, please keep in mind that it is not
100% guaranteed that I can completely conceal your identity in all instances
(particularly if there is an idea that you feel strongly about and have shared with
many other people).

If you would be willing to participate in this study, please complete and return
the attached form by fax [(810) 3704287)] or in the stamped, self-addressed
envelope as soon as possible. After receiving your reply, I will contact you by
phone to set up a time for the focus group interview. In the meantime, if you
have any questions about the project you can contact me at work [(810) 370-
4047] or at home [(810) 641-5313]. You can also contact my advisor, Dr.
Christopher Clark, by phone at Michigan State University [(517) 355-8502] or in
writing at College of Education, Michigan State University, East Lansing,
Michigan 48824-1034.

242

Thank you for your consideration of this request. I look forward to hearing
from you.

Sincerely,

Chris Stiller-Senna, M.A., P.T.

Enclosures: 2

243

QQNEENT TQ PARTIQIPATE IN PRIME TIMER§ EQQLIE QBQUE

I give my consent to participate in the study, “Values in Physical Therapy
Education: Merging Personal and Professional Identity”. I am willing to be
contacted to arrange a time and place to be participate in the focus group and to
be contacted for clarification of any of my responses and for follow-up
questions. I understand that the group session will be arranged at a time
convenient to the investigator and other Prime Timers who give their consent to
participate in this study. I also understand that the group session will take
approximately two hours, will be videotaped for future analysis by the
investigator, and will be confidential. Confidentiality will be maintained within
the limits of the study: that is, because of the small number of possible subjects
for this study, I understand that someone may recognize an individual idea I
have shared, in spite of all attempts by the researcher to conceal my identity. I
further understand that I may terminate my participation in this project at any
time, that I can refuse to answer any questions, and that I can request that the
video recorder be turned off at any time or that I any response I have given not
be used in this study.

 

 

 

 

 

 

 

 

Name
Address
Phone (work) (home)
(fax) (e-mail)
Signature of participant Date

Return to: Chris Stiller-Senna, M. A., P. T
1891 Farmbrook
Troy, Michigan 48098

Fax: (810) 370-4287

244

APPENDIX D

245

APPENDIX D
QUESTIONS FOR FOCUS GROUP

INTR D TI N

As a member of the Prime Timers, you have experienced many changes in
practice over the years. These changes in practice resulted from the impact of
influential people both within and outside of the profession, as well as social,
political, economic, cultural, and historical events that have occurred over the
years. As a doctoral student in educational psychology, I am interested in
finding out how these people and events have shaped the values that serve as
the foundation for our Code of Ethics and Standards of Practice. The following
questions are my attempt to get your thoughts on how our professional values
developed and how we can best pass these values onto the students that we
teach in physical therapy education.

MA R AREA F INTERE T AN I TI N
l. Autobiography of the profession

How do you think the profession has changed over the years? Do you think
the reasons for people wanting to become a physical therapist have changed?
What do you think Mary MacMiIlan might say if she saw what was happening in
physical therapy today?

II. ldealsNalues

What were the ideals and values of the profession when you first began
practicing? How have they evolved and changed over the years? How and
why do you think the ideals and values of the profession have evolved and
changed over the years? Are there any personality traits of physical therapists
that you think have remained constant throughout the history of our profession?
It so, what and why? Which have changed and why?

III. Influential people and events

What social, cultural, or historical events do you think have impacted the
profession/you personally the most and why? What people have done so and
why?
As someone who has been practicing for a long time, how do you think you
have impacted the profession? How has the Prime Timers influenced others in
the profession?

IV. Educating students

What advice would you give to someone like me who is completing a doctorate
in the field of educational psychology about teaching professional values to
students?

246

APPENDIX E

247

APPENDIX E
EXPLANATORY LETTER/CONSENT FORM FOR PROGRAM
INTERVIEWS

Dear Colleague,

I am a physical therapy educator and a doctoral student in the Educational
Psychology Program at Michigan State University, and am currently in the
process of completing my dissertation research. The purposes of my study are
to describe the culture and professional ethos of physical therapy and to identify
methods for helping our students to internalize a professional ethos that is
consistent with the beliefs of practicing clinicians and the APTA. In order to
gather this information, I am planning to conduct a series of semistructured
interviews. You have been identified as someone who might be interested in
participating in this study. The purpose of this letter, therefore, is to inquire
about your willingness and availability to be interviewed.

The interview will take approximately one to and and one half hours and will
be tape recorded for later analysis. I will arrange the interview at a time of
greatest convenience for you. I have enclosed a copy of sample questions for
the interview for your review in order to allow adequate time for you to think
about your answers. Your participation in this study is, of course, completely
voluntary, and can be terminated at any time, either before or during the
interview. The names of all participants in the study will remain confidential and
tapes and transcripts will be reviewed only by myself and my dissertation
committee.

If you would be willing to participate in this study, please complete and return
the attached form by fax [(810) 952-5273)] or in the stamped, self-addressed
envelope as soon as possible. After receiving your reply, I will contact you by
phone to setup a time for the interview. In the meantime, if you have any
questions about the project you can contact me at work [(810) 370-4047] or at
home [(810) 641 -5313]. You can also contact my advisor, Dr. Christopher
Clark, by phone at Michigan State University [(517) 355-8502] or in writing at
College of Education, Michigan State University, East Lansing, Michigan
48824-1034.

Thank you for your consideration of this request. I look forward to hearing
from you.

Sincerely,

Chris Stiller-Sermo, M.A., P.T.
Enclosures: 2

248

WT T9 PARTIQIPATE IN PRQQRAM INTERVIEWE

I give my consent to participate in the study, “Students’ Perceptions of
Socialization in Professional Education Programs: The Example of Physical
Therapy” and am willing to be contacted to arrange a time and place to be
interviewed. I understand that I will be interviewed by the investigator at a time
convenient to both of us. I also understand that the interview will take
approximately one to one and one half hours, will be tape recorded for future
analysis by the investigator, and will be confidential. I further understand that I
may terminate my participation in this project at any time.

 

 

 

 

 

 

 

 

 

Name
Address
Phone (work) (home)
(fax) (e-mail)
Signature Date

Return to: Chris Stiller Serrno, M.A., P.T.
1891 Farmbrook
Troy, Michigan 48098

Fax: (810)370-4287

249

APPENDIX F

250

APPENDIX F
INTERVIEW QUESTIONS FOR PROGRAM INTERVIEWS

INTR D Tl N

One of the goals of professional education in physical therapy is to help
students attain a professional identity that is consistent with the values and
beliefs of practitioners and the American Physical Therapy Association. As a
student in a physical therapy program, I am interested in your experiences in
being socialized into the profession. The following areas of interest and guiding
questions are my attempt to obtain your thoughts on this topic. Please feel free
to add any information that you feel is important to the topic, but is not
adequately addressed in my questions. In addition, keep in mind that we can
stop the interview at any time if you decide you no longer want to participate.

MAJOR AREAS OF INTEREST AND GUIDING QUESTIONS -
STUDENTS

I. Definition of the Professional Ethos of Physical Therapy
What do you think are the core beliefs, values, and characteristics of

physical therapy (i.e. the professional ethos)? Can you give me an example of
how you think physical therapists portray an image of this professional ethos to
their colleagues, patients, other health care team members, and the general
public? Can you give me a specific example of how you have portrayed this
image to others either while you were in the academic setting or while you were
on your clinical affiliations?

ll. Personal Experience

What are some of the ways that you think the faculty and clinical educators in
your program attempt to socialize students into the profession? Can you give
specific examples? Can you describe an incident that stands out in your mind
as “the” example of professional socialization based on your experience as a
physical therapy student in your program? Are there any times when you feel
you may have acted unprofessionally or have questioned the professional
behavior of others? If so, can you describe these incidents? Do you feel your
faculty and clinical instructors are in touch with current changes in the field in
terms of the professional culture of physical therapy? Why or why not? Are you
aware of what other programs do to help students become part of the
professional culture of physical therapy? If so, what do they do?

Ill. Experience with Program “X”

Do you feel students in your program are made aware of the program goals
for professional behavior and the attainment of a professional ethos? If so,
how? Do you think these goals are realistic for professional practice?

251

Are you aware of anything program “X” does to help students to lntemalize
the professional ethos of physical therapy? If so, what and how do you feel this
contributes to the professionalization of the students?

Do you feel your program prepares students to be active and reflective
Ieamers who are responsible for their own Ieaming? If so, how? Do you feel
this contributes to students’ lntemalization of a professional ethos? If so, how?

Do you think the role models in the academic and clinical settings in which
you participate are consistent? Why or why not?

Do you think your program does anything to help students make the
transition from student to professional? If so, what?

Compared to other programs, how effective do you think your program is in
helping students intemalize the professional ethos of physical therapy? What
evidence can you provide at its effectiveness?

Do you think the faculty and clinical instructors in your program are aware of
your experiences in becoming socialized into the profession? Why? Can you
give a specific example to support your answer?

IV. The Ideal

If you could design an ideal situation to help students attain a sense of
profession identity, what would that look like? How could this be accomplished
and what obstacles might you have to overcome in order to set up your ideal
situation? How close does program “X” come to this ideal situation?

V. The Future
What, if any, changes can you foresee in our professional ethos and culture
in the future as a result of social, political, historical, or cultural changes? How
do you think faculty and clinical educators can best prepare students to be able
to deal with these changes? Do you think your program has prepared you to
deal with these changes?

VI. As part of this study I conducted interviews with Fellows and Prime Timers in
order to define the contemporary professional ethos and any changes that have
occurred over time. I will read a short synopsis “* of what they said and I’d like
to know whether you agree or disagree with this and why you feel the way you
do?

"Summary Statement of Values and Identity

Physical therapists are generally good people who ware glad to
be in a helping profession. They value hard work, dedication, and
seeing others get better. They are concerned about maintaining
high standards of care and professional ethics. They are warm
hearted and caring and enjoy having fun. On the negative side,
some younger therapists and some students today have become
more interested in self-fulfillment and making money rather than
providing good patient care.

252

 

MAJOR AREAS OF INTEREST AND GUIDING QUESTIONS -
FACULTY AND CLINICAL EDUCATORS

I. Definition of the Professional Ethos of Physical Therapy
What do you think are the core beliefs, values, and characteristics (i.e.
professional ethos) of physical therapy? Can you give me an example of how
you think physical therapists portray an image of this professional ethos to their
colleagues, patients, other health care team members, and the general public?
Can you give me a specific example of how you help students to attain this
professional ethos?

ll. Personal Experience

In your present position, or in previous positions you have held, what are
some of the ways in which you, personally, have helped students to attain a
sense of professional ethos? Does the institution in which you currently work,
or those in which you have worked in the past have specific policies or
procedures for helping students attain a professional ethos? If so, what are
they? Do any courses specifically address this issue? If so, what are they?
How effective do you think the methods or courses are in helping students
internalize the professional ethos of physical therapy? Why? Can you give me
a specific example of a student that you have witnessed acting
unprofessionally? Very professional? What did you do in each situation?
Why?

Ill. Experience with Program “X”

In regard to the physical therapy program at “X”, do you feel students are
made aware of the program goals for professional behavior and the attainment
of a professional ethos? If so, how? Do you think these goals are realistic for
professional practice?

Are you aware of anything program “X” does to help students to internalize
the professional ethos of physical therapy? If so, what and how do you feel this
contributes to the professionalization of the students?

Do you feel program “X” prepares students to be active and reflective
Ieamers who are responsible for their own Ieaming? If so, how? Do you feel
this contributes to students’ lntemalization of a professional ethos? If so, how?

Do you think the role models in the academic and clinical settings in which
students from program X” participate are consistent? Why or why not?

Do you think program “X” does anything to help students make the transition
from student to professional? If so, what?

Compared to other programs, how effective do you think program “X” is in
helping students internalize the professional ethos of physical therapy? What
evidence can you provide of its effectiveness?

Are you aware of how the students feel about the process of professional
socialization at program “X”? Do you think their views are consistent with those
of the faculty and clinical educators? Can you give me a specific example of

253

how you know this?

IV. The Ideal

If you could design an ideal situation to help students attain a sense of
profession identity, what would that look like? How could this be accomplished
and what obstacles might you have to overcome in order to set up your ideal
situation? How close does program “X” come to this ideal situation?

V. The Future
What, if any, changes can you foresee in our professional identity in the
future as a result of social, political, historical, or cultural changes? How do you
think we can best prepare students to be able to deal with these changes? Do
you think program “X” has prepared students to deal with these changes? How
have they done so?

VI. As part of this study I conducted interviews with Fellows and Prime Timers in
order to define the contemporary professional ethos and any changes that have
occurred over time. I will read a short synopsis “* of what they said and I’d like
to know whether you agree or disagree with this and why you feel the way you
do?

"Summary Statement of Values and Identity

Physical therapists are generally good people who ware glad to
be in a helping profession. They value hard work, dedication, and
seeing others get better. They are concerned about maintaining
high standards of care and professional ethics. They are warm
hearted and caring and enjoy having fun. On the negative side,
some younger therapists and some students today have become
more interested in self-fulfillment and making money rather than
providing good patient care.

254

APPENDIX G

255

APPENDIX G
DESCRIPTION OF SUBJECTS

EM
1: 85 year old female; 65 years of experience in PT; certificate in PT in 1930;

has several honorary doctorates; has been a Fellow since 1986; currently
lectures and writes about musculoskeletal problems

2: 62 year old male; 39 years of experience in PT; BSPT in 1956; MA
Rehabilitation Counseling in 1964; PhD in Rehabilitation Counseling in 1971;
has been a Fellow since 1991; currently teaching in a physical therapy program

3: 52 year old female; 28 years of experience in PT; BSPT in 1967; MA in
Human Development; PhD in Higher Education Administration; has been a
Fellow since 1995; currently is the Dean of Graduate Studies at a university in a
large urban setting and also teaches in the PT program at the same university

P T r
1: 76 year old female; 52 years of experience in PT; BS in 1943; Certificate in
PT in 1944; MA in 1961; currently is working as an independent contractor

2= 75 year old female; 52 years of experience in PT; BS in Education in 1943;
Certificate in PT in 1944; MEd in 1970; Licensed Nursing Home Administrator in
1974; founded and is currently employed in a multidisciplinary rehabilitation
agency; is a consultant to an archdiocese in a large city; is a PT instructor for a
State Department of Public Health

3: 73 year old female; 50 years of experience in PT; BS in 1945; Certificate in
PT in 1946; MSPT in 1952; retired

4= 60 year old female; 39 years of experience in PT; BSPT in 1957; currently
working in an acute care hospital

5: 70 year old female; 45 years of experience in PT; BSPT in 1951 ;‘ Graduate
work in geriatrics; retired

6= 74 year old female; 46 years of experience in PT; BSPT in 1950; retired

7= 77 year old female; 52 years of experience in PT; BS in 1942; Secondary
Teaching Certificate in 1943; Certificate in PT in 1944; currently retired, but
does volunteer work with patients with Huntington’s Disease

8: 63 year old female; 38 years of experience in PT; BS in Ed. in 1955;
Certificate in PT in 1958; MS in 1971; PhD in 1981; Currently Chair and
Distinguished Professor in a PT Program

256

9= 52 year old female; 28 years of experience in PT; BA in 1966; MS in 1968;
PhD in 1980; currently self-employed

10: 67 year old female; 43 years of experience in PT; BS in 1952; Certificate in
PT in 1953; Master’s in 1966; currently employed in home health care

11: 73 year old female; 50 years of experience in PT; BA in 1945; Certificate in
PT in 1946; MA in 1947; currently employed in home health care

Progrom 1
Faculty 1: 49 year old female; 26 years of experience in PT; BSPT in 1971 ; also

has MEd in 1980; PhD in Physiology in 1988; three year post-doc in physiology
1988-1991; clinical area of interest is acute care, orthopedics, and
rehabilitation; has been teaching in Program 1 for 6 years; no previous teaching
expenence

Faculty 2: 36 year old male; 14 years of experience in PT; BSPT in 1983; MA in
Higher Education in 1995; clinical area of interest is orthopedics; is a certified
Feldenkrais Practitioner; has been teaching in Program 1 for 5 years; no
previous teaching experience

Faculty 3: 59 year old male; 35 years of experience in PT; BS in PE and
Certificate in PT in 1962; MPH in 1968; clinical area of interest is orthopedics;
has been teaching in Program 1 for 9 years; no previous teaching experience

Clinician 1= 28 year old male; 5 years of experience in PT; BSPT in 1992;
clinical area of interest Is neurorehabilitation; currently employed as the
Director of Rehabilitation and the Center Coordinator of Clinical Education in a
small rural hospital

Clinician 2= 48 year old female; 24 years of experience in PT; BSPT in 1973;
clinical area of interest is neurorehabilitation; currently employed as a clinical
specialist in a large hospital system

Clinician 3= 43 year old female; 20 years of experience in PT; BSPT in 1977;
clinical area of interest is neurorehabilitation; currently employed as the
Rehabilitation Medicine Supervisor and Center Coordinator of Clinical
Education in a Veterans Hospital

Student 1: 39 year old male; 88 in PE; completing final clinical internships;
expected to graduate in four months

Student 2: 23 year old female; completing final clinical internships; expected to
graduate in four months

257

Student 3: 27 year old female; BS in Anthropology; completing final clinical
internships; expected to graduate in four months

Progrom g

Foculty 1= 28 year old female; 6 years of experience in PT; B8. in Fine Arts in
1981; MPT in 1991; Clinical area of practice is in neurorehabilitation; is certified
as a Neuro Clinical Specialist by the APTA and has completed a 6 month
residency in neurorehabilitation; has been teaching in Program 2 for one year;
no previous academic teaching experience prior to Program 2

Faculty 2: 41 year old male; 19 years of experience in PT; 88. in PT in 1978;
MS. in Anatomy in 1982; PhD in Anatomy in 1986; Clinical area of practice is
orthopedics and sports medicine; is also an certified athletic trainer; has been
teaching in Program 2 for four years; has previous and concurrent academic

teaching experience at two other universities; has been teaching for 14 years

Faculty 3: 48 year old male; 22 years of experience in PT; BS. in 1971; MS in
PT in 1975; PhD in Higher Adult and Lifelong Learning in 1992; clinical area of
practice is pediatrics; has been teaching at Program 2 for 5 years; has previous
teaching experience at two other universities; has been teaching since 1980.

Clinician 1= 39 year old female; 17 years of experience in PT; BSPT in 1980;
MS in Cardiopulmonary PT in 1987; is certified as a Cardiopulmonary
Specialist by the APTA; clinical area of interest is cardiopulmonary PT; is
currently a clinical specialist in a large hospital setting

Clinician 2= 30 year old female; 6 years of experience in PT; BSHS/MPT in
1991; clinical area of interest is orthopedics; currently employed by a large
hospital working in an outpatient orthopedic clinic

Clinician 3= 33 year old female; 11 years of experience in PT; BSPT in 1986;
clinical area of interest is in general practice; currently employed as a
supervisor and Center Coordinator of Clinical Education in a large hospital

system

Student 1: 27 year old female; BS in Physiology in 1992; new graduate of MPT
program; working in acute care in a large hospital setting

Student 2: 26 year old female; new graduate of MPT program; working in a
large hospital setting

Student 3: age not provided by participant (estimated to be in early to mid

twenties); female; in the process of completing her first of two fourteen week
internships; expected date of graduation is one year

258

APPENDIX H

259

APPENDIX H
GENERIC ABILITIES

Qenorio Aoilgy' Dofinition
. Commitment to Learning The ability to self-assess, self-correct, and self-

direct; to identify needs and sources of
Ieaming; and to continually seek new
knowledge and understanding

. Interpersonal Skills The ability to interact effectively with patients,
families, colleagues, other health
professionals, and the community and to deal
effectively with cultural and ethnic diversity
issues.

. Communication Skills The ability to communicate effectively
(i.e., speaking, body language, reading,
writing, listening) for varied audiences and

purposes.
. Effective Use of Time The ability to obtain the maximum benefit from
and Resources a minimum investment of time and resources.
. Use of Constructive The ability to identify sources of and seek out
Feedback feedback and to effectively use and provide

feedback for improving personal interaction.

. Problem-Solving The ability to recognize and define
problems, analyze data, develop and
mplement solutions, and evaluate outcomes.

. Professional The ability to exhibit appropriate professional
conduct and to represent the profession
effectively.

. Responsibility The ability to fulfill commitments and to be

accountable for actions and outcomes.

. Critical Thinking The ability to question logically; to identify,
generate, and evaluate elements of logical
argument; to recognize and differentiate facts,
illusions, assumptions, and hidden
assumptions; and to distinguish the relevant
from the irrelevant.

260

10. Stress Management The ability to identify sources of stress and to
develop effective coping behaviors. '

ml hvirlritrifr mmitmnt rnin

Beginning Level
-ldentifies problems
-Formulates appropriate questions
-Demonstrates a positive attitude (motivation) toward Ieaming
-Offers own thoughts and ideas
-Identifies need for further information

Developing Level (builds on preceding level)
-Prioritlzes information needs
-Analyzes and subdivides larger questions into components
-Seeks out professional literature
-Sets personal and professional goals
-identifies own Ieaming needs based on previous experiences
-Plans and presents and in-service, or research or case studies
-Welcomes and/or seeks new Ieaming opportunities

Entry Level (builds on preceding level)
-Applies new information and reevaluates performance
-Accepts that there may be more than one answer to a problem
-Recognizes the need to and is able to verify solutions to problems
-Reads articles critically and understand limits of application to
professional practice
-Researches and studies areas where knowledge is lacking

Post-Entry Level (builds on preceding level)
-Ouestions conventional wisdom .
-Formulates and reevaluates position based on available evidence
-Demonstrates confidence in sharing new knowledge with all staff levels
-Modifies programs and treatments based on newly-Ieamed skills and
considerations
-Consults with other allied health professionals and physical therapists
for treatment ideas
-Acts as a mentor in area of specialty for other staff

261

ml hvirlriteri rPrf inlim

Beginning Level
-Abides by APTA Code of Ethics
-Demonstrates awareness of state licensure regulations
-Abides by facility policies and procedures
-Projects professional image
-Attends professional meetings
-Demonstrates honesty, compassion, courage, and continuous regard for
all

Developing Level (builds on previous level)
-Identifies positive professional role models
- Discusses societal expectations of profession
-Acts on moral commitment
-Involves other health care professionals in decision-making
-Seeks informed consent from patients

Entry Level (builds on previous levels)
Demonstrates accountability for professional decisions
-Treats patients within scope of practice
-Discusses role of physical therapy in health care
-Keeps patient as a priority

Post-Entry Level (builds on previous levels)
-Participates actively in professional organization
-Attends workshops
-Actively promotes the profession
-Acts in leadership role when needed
-Supports research

262

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