Abstract
Background The physical therapy profession has adopted professional core values, which define expected values for its members, and developed a self-assessment tool with sample behaviors for each of the 7 core values. However, evidence related to the integration of these core values into practice is limited.
Objectives The aims of this study were: (1) to gain insight into physical therapists' development of professional core values and (2) to gain insight into participants' integration of professional core values into clinical practice.
Design A qualitative design permitted in-depth exploration of the development and integration of the American Physical Therapy Association's professional core values into physical therapist practice.
Methods Twenty practicing physical therapists were purposefully selected to explore the role of varied professional, postprofessional, and continuing education experiences related to exposure to professional values. The Core Values Self-Assessment and résumé sort served as prompts for reflection via semistructured interviews.
Results Three themes were identified: (1) personal values were the foundation for developing professional values, which were further shaped by academic and clinical experiences, (2) core values were integrated into practice independent of practice setting and varied career paths, and (3) participants described the following professional core values as well integrated into their practice: integrity, compassion/caring, and accountability. Social responsibility was an area consistently identified as not being integrated into their practice.
Limitations The Core Values Self-Assessment tool is a consensus-based document developed through a Delphi process. Future studies to establish reliability and construct validity of the tool may be warranted.
Conclusions Gaining an in-depth understanding of how practicing clinicians incorporate professional core values into clinical practice may shed light on the relationship between core values mastery and its impact on patient care. Findings may help shape educators' decisions for professional (entry-level), postprofessional, and continuing education.
Professionalism encompasses standards for values, behaviors, and practice within a profession. The term “profession” has descriptive and normative meanings.1 As a descriptive term, it describes occupations possessing a defined body of knowledge that is applied to practice. The normative component refers to established quality standards and ethical codes applied to practice. Both descriptive and normative components provide the foundation for professionalism.
The formation of professional identity, including development of professional values, actions, and aspirations, has been recognized as an essential element of education in the health professions.2–5 The essential elements of professionalism within practice must be defined for students to ensure appropriate education6 and opportunity for identity formation,7 with continued development throughout a person's career.
Expectations for integration of professionalism into curricula exist in accreditation standards for a number of health professions, including medicine, nursing, occupational therapy, and pharmacy.8–11 Medicine defines professionalism as demonstrating a commitment to carrying out professional responsibilities and adherence to ethical principles.12 The Commission on Accreditation in Physical Therapy Education (CAPTE) specifies requirements related to professionalism as part of standards for curriculum content.13 In practice, the physical therapy profession has articulated expectations for professionalism with the core values and Code of Ethics.
Values are important beliefs or ideals that guide or influence a person's decisions or actions.14 Values represent a judgment of what is important to an individual or group of individuals. Members of a profession are socialized into the values of that profession, which is likely to influence their future behaviors as practicing professionals.15 Professional socialization is an interactive process of acquiring a professional identity based on values and meanings—the development of a professional voice.16 Professional socialization may be broadly defined as acquisition of the knowledge, skills, values, roles, and attitudes associated with the practice of a particular profession.
An important dimension of professionalism is the core values espoused. The World Health Organization (WHO) identifies 4 primary health care values: equity, people centeredness, community participation, and self-determination.17,18 Each discipline within the health professions embraces values and behaviors in practice that mirror WHO values. Nursing has identified professional behaviors associated with professionalism: adherence to a code of ethics, theory development use and evaluation, an orientation to community service, continuing education competence, research development use and evaluation, self-regulatory autonomy, professional organization participation, and scholarly dissemination.4
Principles are fundamental truths or assumptions, often associated with expected standards of behavior. In medicine, professionalism is built on principles of excellence, humanism, accountability, and altruism and is demonstrated through clinical competence, communication, and ethical understanding.19 These values and behaviors function within a social context and social trust,8 requiring physicians to serve the individual in concert with serving the profession's broader social responsibilities.20,21 Sociological theories underlie developing professionalism within the social context. Specifically, the functionalist perspective22 provides a framework for considering the meaningfulness of community of practice and a valuing of the social contract between the profession and the members of society whom they strive to serve. The benefits of situating this study of professionalism from this sociological perspective include consideration of professionalism from varied individual and societal viewpoints while attending to the opportunities, constraints, challenges, and assumptions.23 In this respect, professionalism implies a contract between members of a profession and society and describes attitudes, interactions, obligations, and behaviors.24
Professionalism is a multidimensional construct that has been addressed through numerous American Physical Therapy Association (APTA) documents. Professionalism was defined in APTA's Vision 2020 statement:
Physical therapists and physical therapist assistants consistently demonstrate core values by aspiring to and wisely applying principles of altruism, excellence, caring, ethics, respect, communication and accountability, and by working together with other professionals to achieve optimal health and wellness in individuals and communities.25
The development of professional core values in physical therapy parallels the evolution of physical therapists from “allied health professionals” providing care under the direction of a physician to that of a doctoring profession in which care is delivered autonomously.26 Initially, a consensus-based document on professionalism was integrated into the Normative Model of Physical Therapist Professional Education.3 Subsequently, the 7 professional core values (accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility) were adopted within a key document in physical therapy titled “Professionalism in Physical Therapy: Core Values Self-Assessment.”27 The APTA's 2006 Education Strategic Plan articulated the imperative to integrate these core values into physical therapy education and practice.28 The APTA approved a new Vision Statement in 2013: “Transforming society by optimizing movement to improve the human experience.”29
The profession of physical therapy has begun to study the relationship among values, behaviors, and practice. Gersh30 identified 3 themes in a study of professionalism in physical therapist practice from clients' perspectives: compassion and caring, trust, and empowerment. Specifically, clients described physical therapist professionalism as behaviors that demonstrated: reflective listening and responding, caring, respect for individual differences, trust, excellence, and the empowerment of clients as equals in all care-related activities.30 Schafer et al studied professionalism within the realms of clinical practice and professional (entry-level) education, stating that “professionalism provides the contextual background for all physical therapist practice while administration and management skills…provide the content necessary for optimal physical therapist practice.”31(p262)
Although the physical therapy profession has articulated the components of professionalism, the best way to measure how practitioners actualize these values through behaviors in practice remains a challenge. The Physical Therapist Clinical Performance Instrument (CPI) for Students (APTA, 2006) examines students' ability to “demonstrate professional behavior in all situations.”32(p16) Specifically, the CPI links specific core values to student behaviors. The list of sample behaviors includes demonstrating integrity in all interactions, exhibiting caring and compassion while providing service to patients. The CPI also examines accountability, described as “practices in a manner consistent with established legal and professional standards and ethical guidelines.”32(p17)
Recognizing that the core values are the foundation for development of professional behaviors in practice, previous authors utilized sample indicators of the Core Values Self-Assessment (CVSA) as inclusion criteria for their longitudinal studies of professional learning and development of novice physical therapists.33,34 The CVSA was used to explore how professionalism is exemplified in practice in our study as well.
Schafer and colleagues31,35 articulated expectations for integration of Leadership, Administration, Management, and Professionalism (LAMP) skills into the physical therapy profession, identifying skills for inclusion in professional education and those for development during a person's career. The Health Policy and Administration (HPA) section of APTA has developed continuing education programs incorporating these expectations (including CVSA) to promote achievement of Vision 2020.36 These LAMP concepts also have been incorporated into entry-level doctor of physical therapy (DPT) curricula.37
Acknowledging the linkage among values, behaviors, and practice, the professional core values have been linked to the 8 principles in APTA's revised Code of Ethics.38 The revised Code of Ethics also expanded its “social contract” beyond the individual treatment encounter to include broader social and ethical issues.18 Furthermore, this revised Code of Ethics integrated ethical guidelines for all of the roles that physical therapists fill beyond patient/client treatment.28 The new Vision Statement represents a shift that expands beyond the internal focus on individual patients to more external responsibilities emphasizing behaviors related to social responsibility and advocacy for patients and society. Consistent with WHO values, the APTA Educational Strategic Plan28 makes explicit an evolved role for collaboration with other health care professionals to enhance the provision of health care services and advocate at individual patient and society levels and supports Gersh's suggestion that physical therapists “model the ideals associated with professionalism and ethical leadership and practice” expected of today's physical therapists.26(p12)
Inherent in professionalism is taking on the values, actions, and aspirations of a person's chosen profession. Students are introduced to guiding documents of a profession (such as the Code of Ethics and APTA core values) to set expectations for behavior of members.15 Self-assessment and reflection are critical elements in the formation of professional identity. Educators and mentors should work to develop the skills of self-assessment39 in order to facilitate physical therapists' awareness of the importance of professionalism. Although the core values are commonly introduced in entry-level education, the opportunity for the continued development of core values should extend beyond this introduction through effective mentorship, as demonstrated through previous study of caring.40 Development of professional identity and professionalism has been shown to extend beyond novice practice.41,42
Despite the evolution of defined knowledge and skills expected of physical therapists and development of the CVSA document, there is limited evidence that the core values have been integrated into physical therapist practice at the entry level and beyond. The aims of this study were: (1) to gain insight into physical therapists' development of professional core values and (2) to gain insight into participants' integration of professional core values into clinical practice.
Method
A qualitative design using thematic content analysis with general inductive technique43–45 permitted in-depth exploration of participants' perceptions of the development and integration of APTA's professional core values into physical therapist practice. Institutional review board approval included informed consent of participants and measures to protect confidentiality.
Participants
A purposeful sample (N=20) of practicing physical therapists across clinical settings was selected to explore the role that varied professional, postprofessional, and continuing education experiences related to exposure to professional core value concepts have in influencing physical therapist practice. One of the investigators (L.A.G.) is the Director of Clinical Education at Stockton University with access to a database of practicing clinicians in the Mid-Atlantic region (New Jersey, Pennsylvania, New York, and Delaware). Participants were selected from the geographic area within driving distance of investigators to conduct face-to-face interviews. To explore varied professional and postprofessional education experiences, participants included: graduates of entry-level DPT programs, postprofessional DPT graduates, and those who had not pursued a postprofessional DPT degree. In addition, practicing clinicians with primary roles as administrators were sought. As previously discussed, the LAMP continuing education offerings include exposure to the core values and the concept of professionalism in practice.36 Snowball sampling was used to recruit participants from the region who had attended a LAMP workshop. Snowball sampling, or chain sampling, utilizes knowledgeable informants to identify subsequent participants to serve as information-rich cases.44
Data Collection Procedures
We used purposeful sampling to recruit participants who met the inclusion criteria via telephone.46 Recruitment of participants with varied professional and postprofessional experiences helped guard against potential bias of recruitment from any one academic or clinical institution.
Prior to participating in audiotaped semistructured interviews, each participant signed an informed consent form and completed a demographic questionnaire and the APTA CVSA (eAppendix). The CVSA served as a prompt and provided context for several of the semistructured interview questions (Appendix) to explore this multidimensional concept. This tool consists of the 7 core values (accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility) and 68 sample indicators. Individuals self-assess how frequently they demonstrate behaviors associated with each of the core values using a 5-point Likert scale rating of “always” (5) to “never” (1).27 We developed the semistructured interview questions from existing literature related to professional development, clinical reasoning, and professional core values. Each participant's résumé was used to complete a résumé sort47–50 whereby participants were asked to reflect on the impact of their experiences in developing professional core values through a series of interview questions (Appendix). For example, during the interview, participants identified specific work or education experiences from their résumé that they considered to be most or least influential in developing professional core values. This mechanism provided insight into participants' perspectives regarding the importance of varied professional experiences.
Interview sessions lasted approximately 60 minutes and were conducted at a time and location convenient to the participants. Interviews were conducted by 3 researchers (P.Q.M., L.A.G., and S.F.W.): 2 experienced qualitative researchers and 1 less experienced researcher. To ensure consistency across the researchers, the initial interview was conducted by pairing one experienced qualitative researcher with the researcher with less qualitative experience. The pair then coded the interview transcript separately, followed by comparison and discussion. An iterative comparative process of data collection and preliminary data analysis continued until data saturation or redundancy was achieved.46
Data Analysis
Data sources included audiotaped interview transcripts, résumés, the CVSA, field notes, and reflective memos. Exploration and analysis of multiple data sources permitted more complete understanding and qualitative description of participant perceptions of factors influencing development and integration of professional core values. Interview transcripts were read and reread by the researchers in order to gain a deep understanding of participants' perspectives. Initial descriptive categories were independently derived from the data by the investigators using inductive content analysis. Through an iterative process of coding and discussion among the researchers, an exhaustive and mutually exclusive coding scheme was developed to classify the data into categories.43–46 QSR NVIVO8 software (QSR International [Americas] Inc, Burlington, Massachusetts) was then utilized for qualitative descriptive content analysis (coding) and interpretation to find meaningful patterns to identify prominent categories (themes). During the iterative comparative process of data collection and data analysis, we noted significant similarities in participant responses to interview questions regarding professional core values. The emerging pattern of participant interview responses led to post hoc exploration and analysis of the CVSA artifact data (Figure).
Sequence of recruitment, collection of artifact and interview data, and data analysis.
Trustworthiness Consistent With Qualitative Rigor
Throughout data collection and analysis, several strategies were utilized to ensure rigor and enhance trustworthiness. Credibility of findings was established by triangulation among participants and data sources. Use of multiple investigators fostered reflexive dialogue during data collection and analysis. Additional strategies to reduce researcher bias included maintaining field notes and reflective memos to document researcher impressions and significant phrases in the transcripts. These notes and memos served as an audit trail of researcher decisions and emerging themes.
Reliability of the coding scheme was determined to be 82.3% agreement, with kappa statistic=.78 representing substantial agreement51 among multiple investigators. Verification of coding scheme and categories with an external consultant with expertise in qualitative research methods was completed. Finally, a peer-checking strategy was used to establish trustworthiness of the findings.44 Member check46 comprised a written interview summary, including data and the researchers' preliminary interpretations, which was sent to each participant for review and confirmation.
Role of the Funding Source
The authors acknowledge funding support from the APTA Health Policy and Administration Section Research Grant. They also acknowledge the following sources of support from Stockton University: School of Health Sciences grant, Research and Professional Development grant, and graduate assistantships from the Office of Graduate and Continuing Studies.
Results
Participants
The participants had a mean age of 39.4 years (SD=13.4, range=24–57) and a mean of 11.86 (SD=12.7, range=17–36) years of experience in a variety of practice settings (Tab. 1). Fourteen participants were female, and 3 reported minority group ethnicity. Entry-level education included 8 DPT degrees, 6 master of physical therapy degrees, 5 bachelor of science in physical therapy degrees, and 1 certificate in physical therapy from 9 different academic institutions. Seven individuals from 4 different academic institutions subsequently earned a postprofessional DPT degree. Participants from entry-level DPT programs reported variable levels of exposure to professional core values content. Five participants had attended LAMP workshops. Six participants held administrative or supervisory positions. Six participants were American Board of Physical Therapy Specialties (ABPTS)-certified specialists, and 6 participants held other certifications.
Demographic Characteristics of Participantsa
Factors Influencing Development
A résumé sort was utilized as an interview prompt (Appendix) to explore participant perspectives of factors influencing development of professional core values (aim 1). The categories or themes that emerged are described in the following sections.
Theme 1: Personal values are the foundation for professional core values.
Compassion/caring, integrity, and accountability were strong attributes described and valued by those who entered the profession. These behaviors and attributes were demonstrated across participant experience levels. When asked to describe the relationship of professional core values and patient care, participant 12 responded: “Some of them are just innate, they're part of me as a person. They just come into play when treating people.”
These professional core values were described as an internal compass to guide clinical decisions in order to do the right thing for their patients. Participants indicated that personal values became interlinked with the professional values of compassion/caring, integrity, and accountability early on in the process of identity formation, as illustrated by participant 13: “My personal values are my professional values.” In particular, the core value of compassion/caring was identified by most of the participants (n=15) as what led them to enter the profession. This core value remained paramount, guiding day-to-day patient care decisions.
Upon reflection, participants identified several experiences that contributed to development of professional core values. Entering the profession with personal values of compassion/caring and accountability provided a foundation for easy transition to integrate them into the context of professional values:
I learned from my parents, 12 years of Catholic school. My parents were salt-of-the-earth kind of people. My mother would drive people around to doctors' appointments. They put a roof on somebody's house because they had back problems. They were very powerful role models from an early age. (Participant 12)
I think a lot of it was in place before I was introduced to the core values from my upbringing and my parents. Just kind of the way, it was drilled into me. I think my parents' overall goal was to raise someone who could be a positive influence on society. (Participant 17)
All participants indicated that entry-level physical therapy education blended the professional core values into an existing set of personal values.
Theme 2: Professional core values are further shaped by experiences.
There was a layering of professional core values throughout the academic and clinical careers of participants. For example, 18 participants identified that they entered the profession with integrity as a personal attribute and that both education and clinical experience helped them apply it to professional practice. The following participant described how professional values evolved from personal values and prior experiences in the development of professional identity:
When I was in the corporate environment,…I had integrity, I was trustworthy. Looking back, they were more like my personal values, and when I came to this career (physical therapy), I think that the professional values were more fully explained and defined for me, how they impacted my behavior. I think they evolved, but I do not think they changed so much. I realized that they were also a reflection of my personal values. (Participant 1)
Novice participants in their early career were more likely to identify entry-level education and mentors as most influential in developing their professional core values. More experienced participants identified several facilitating factors in developing and integrating professional core values into practice: serving as a mentor, participation in clinical or academic teaching, and pursuit of clinical specialization or postprofessional degrees.
Clinical experiences provided opportunity for development of the professional core values for all participants. Positive and negative experiences had significant impact. For some participants, early career experiences provided vivid examples of “what not to do” in their careers, as illustrated in the quote below:
I can still remember that administrator today, and lack of integrity is what comes to mind. Sometimes, you think about who serves as your role models, and this is where I don't want to be. (Participant 3)
Alternatively, several participants described the importance of positive mentors and role models during their careers who they wanted to emulate. A novice clinician described a clinical instructor:
One of my instructors was a great mentor. I still look up to him and keep in touch with him. My mentor really worked on getting my clinical skills good…. You need to, as a professional, take it to the next level. I look at it like a combination, that it needs to be both the clinical and the professional…. You need to develop in all these areas. (Participant 19)
Additional factors that subsequently facilitated positive development and integration of professional core values in clinical practice included pursuit of excellence, as exemplified by attainment of advanced credentials and engagement in leadership activities. Likewise, participants identified factors related to their practice setting, such as practicing in an environment that provided mentoring opportunities, articulated explicit expectations and dedicated resources for professional development, and supported clinical decisions based on best practice versus “profit motive.”
In addition to the presence of mentors and role models who embodied professional values, working in organizations with clearly articulated expectations for excellence strongly influenced participants. The impact of these factors was articulated by the following quote:
I was a clinician who wasn't always on top of his game, honestly. I came to (this organization), and that was a life-changing event…because I started getting exposed to people who took therapy really seriously and were striving to be excellent. I said (to myself), “Okay, this is sink or swim time.” That's what got me started on the path of excellence. (Participant 3)
Only 4 participants identified professional association membership as most important when reflecting on the résumé sort. Conversely, factors perceived as barriers to development and integration of the professional core values included the absence of mentors, time constraints, and a focus on productivity expectations that were perceived to be at odds with patient-centered care in clinical practice.
Theme 3: Integration of core values into practice is independent of varied career paths and practice setting.
Although it was evident that the community of practice influenced development of professional core values, there was no one clear path or practice setting that led to their integration into clinical practice. Participants described various paths of positive and negative experiences that shaped their development. For example, when describing prior clinical experience, 5 participants reported that they left employment situations that were not congruent with their professional core values. Negative clinical experiences were described as powerful and meaningful in shaping their professional core values in subsequent positive experiences. Other participants intentionally selected practice settings that provided a community of practice consistent with their values and views of professionalism. The following participant described how her work environment supported her core value of excellence:
As far as excellence, that is something in my company. It is something I always strive for, but my company provides me the ability to go above and beyond…it is our very core of what we do. (Participant 7)
Similarly, 2 novice clinicians specifically sought a practice setting that espoused excellence, as defined by an emphasis on evidence-based practice. Participant 14 identified excellence as a strength and noted: “Excellence is something that really never ends. I think it has to do with always learning new evidence and keeping up with everything that's going on.” He described how this value was manifested in his chosen practice setting:
We have a lot of resources, we keep up on the evidence, we get email blasts on a couple of really key articles on specific diagnoses that we treat all the time. They take the clinical bottom line from all of the articles published in 1 or 2 geriatric journals. Between the mentoring, every resource we have, and experience, that's how my clinical decision making is evolving. (Participant 14)
Participants embarking on a second career path in physical therapy or those pursuing a mid-career change in practice setting relied on their prior professional experience and strongly developed and articulated professional values to select a clinical practice site congruent with their values, or to leave a practice when they perceived a mismatch. Furthermore, participants with prior experience reported that exposure to positive role models and expectations for continuing professional development was essential to their pursuit of advanced certification activities and engagement in professional association activities. Participant 3 described how he embarked on the pathway to specialist certification:
For me, excellence really started when I joined (this organization), because I was exposed to different people and the standard of practice (he) expected. Excellence of care, evidence-based practice, how we are with our patients. (Participant 3)
Some participants demonstrated a consistent commitment to learning throughout their careers, as evidenced by engagement in the professional association, serving as teachers and mentors, and pursuit of advanced credentials. These participants set the bar for excellence at their respective institutions. They were internally driven to continually pursue new knowledge while communicating excellence to others through advanced credentialing and certifications. Valuing this external validation of their clinical excellence seemed to be a component of their developing professional identity. In addition, these participants reported sustained membership in professional associations. The most established participants valued serving as a mentor and working with others to facilitate their growth and excellence.
Interestingly, several participants (n=8) specifically noted the impact of completing the CVSA, as shown in the following feedback:
My advice would be to keep a list of the core values and really look at them every now and then, and reassess yourself. Because until I looked at this, it didn't occur to me these areas are missing, and I know I need to make a change and make some of these areas right. (Participant 7)
Participants situated their view of their professional identity in their personal values. This was evidenced by the following quote from participant 13: “I got into this profession to try and help individuals and to be a good therapist.”
Integration of Core Values Into Practice
Key findings from participant interviews related to aim 2 are presented in the following sections and provide insight into participant perspectives about integration of professional core values into practice.
Participants' reflections, when discussing their responses to the CVSA, highlighted to what extent the core values were integrated into practice. During interviews, participants identified areas of current strength and areas to strengthen further. A pattern of similarities in responses emerged, where participants described these strengths: integrity (n=18), compassion/caring (n=15), and accountability (n=13) (Tab. 2). Social responsibility was overwhelmingly identified as an area to strengthen further (n=19).
Participants' Perceived Areas of Strength for Professional Core Values as Identified During Interviews
In addition to serving as an interview prompt, the CVSA provided artifact data to triangulate interview findings. Specifically, participants described entering the profession with personal attributes that became interwoven into professional behaviors for those core values identified as strengths. Exemplars for these areas of strength within the context of sample indicators are included below:
Integrity
You can't separate the person from the profession. I think that's why I am as good as I am. I believe in what I do, and this is who I am. I am caring and compassionate. Integrity—that's who I am. You're not going to get deception from me. (Participant 7)
Integrity, I think you have to adhere to high ethical principles and standards; you have to be trustworthy. (Participant 15)
How do you view yourself? What are your values? Do your values correspond with not only the industry you are in but also how you act and how you treat other people? Are you trustworthy and honest? So, I think in each of these,…I am incredibly accountable and am very responsible. I have a high level of integrity. (Participant 1)
Compassion/Caring
Compassion and caring, I think that is one of the reasons that I got into physical therapy. (Participant 2)
I think it would be very difficult for someone to have different personal values from professional values…for someone not to have a natural sense of compassion and understanding. (Participant 18)
Accountability
Taking control because you are responsible and are held accountable for your actions, you have to be straightforward, you don't hide from things, and it is a way of being professional. It is a way one should conduct oneself, not only in the profession but also in life. (Participant 5)
I've just come to realize that if you are going to do the job the right way here, you have to take your own personal responsibility. (Participant 18)
All but one of the participants identified social responsibility as an area to strengthen. Only 3 participants provided interview examples of the sample indicators “participating in political activism” and “advocating for changes in laws, regulations affecting physical therapist services.” Across the group, participants reported during interviews that they rarely or occasionally engaged in the sample behaviors “participating in achievement of societal health goals” (n=17) and “promoting community volunteerism” (n=16). Participants' perspectives of these sample indicators were exemplified by the following quotes:
It concerned me…that I had the lowest score on social responsibility. Some of it is built into my job. I do community projects and so forth, but it is related to work, not on my own. I am not taking on anything additional beyond that. I haven't done things that I have been asked to do outside of work. That may be an excuse, because we find time for things we want to do. (Participant 2)
Social responsibility, the thing that got me is that it says leadership in the community, and political activism, and that is like, eh…(shrugs). I have never been too politically active. After taking a class (in postprofessional DPT program), it may be time to pay more attention, to see what is going on politically with health care. (Participant 1)
Participants identified barriers to engaging in the sample indicators of social responsibility, such as time constraints, or not knowing what to do. Other participants lacked awareness of the sample indicators or did not view the sample behaviors as their individual responsibility. When participants reflected on the CVSA, they identified sample indicators as areas for potential growth. For example, participants noted that they were meeting all of the sample indicators for the core value of altruism with the exception of providing pro bono services (n=4) and care to underserved populations (n=6).52 Likewise, as a group, participants reported that they were meeting all of the sample indicators for professional duty, except for 9 participants who reported involvement in professional activities beyond the practice setting only occasionally or rarely. Conversely, 5 participants who identified professional duty as an area of strength were actively involved in the professional association in various roles.
Discussion
Three themes emerged from the data related to the development and integration of professional core values. First, personal values were the foundation for developing professional core values. Second, beyond these innate attributes, professional core values were further shaped by experiences. Third, participants demonstrated development and integration of core values into practice independent of practice setting and varied career paths.
Our findings affirm prior literature on experiences that shape professional development and expertise.47 Although experience was instrumental in shaping professional core values, participants' rankings on the CVSA were not directly linked to length of clinical experience. We expected to see a developmental process in the expression of professional core values, but we were intrigued by “outliers” who were novices in terms of years of experience yet provided examples of meeting the sample behaviors at a level more consistent with some of the more experienced participants. In examining the data closely for alternative explanations, 2 factors appeared to be most influential in the expression of the core values. The first factor was clearly articulated expectations of and definitions for excellence in the workplace. The second factor was the presence of mentors and role models who embodied the professional core values in clinical practice. These 2 factors are elements that are consistent with a community of practice,7 and they fostered collective excellence by addressing individual professional development needs and goals. These findings are consistent with the work of Black et al33 and Hayward et al34 where “promising novice” practitioners developing professional identity was influenced by the context of the clinical community of practice. In particular, the second year of practice was identified as a critical point for professional role formation, as promising novices continued learning but relied less on mentors and began contributing to the community of practice by sharing their experience, assuming leadership roles, and considering future participation in clinical specialty training.34 There also were examples of the critical influence of community of practice for more experienced practitioners who changed jobs at mid-career. Some participants described working in communities of practice that fostered or developed the core values of professional duty and social responsibility. The importance of mentors has previously been identified in the literature describing clinical decision making of novice and experienced practitioners.47
Our findings raise the question of experience versus attributes, or the interrelationship of internal attributes and external experiences. Affective attributes have not been articulated in the expertise literature, as the primary focus has been on development of clinical decision-making skills.47,49,50 Our results indicate that the path to professional growth and actualization of professional identity includes not only the acquisition of clinical content knowledge and skills across the cognitive and psychomotor domains of learning but also development of the attributes of professionalism and core values in the affective domain. The “novice outliers” in this study specifically sought experiences and work environments that fostered development of core values and clinical content knowledge.
Lifelong learning was seen as an essential component of professional development and professionalism among the participants studied, similar to the findings of Hayward et al.34 This view has been exemplified in nurses completing master's programs who reported increased confidence, evidence-based practice development, and enhanced professionalism.41 In a survey of American nurses, professionalism was significantly related to years of experience, higher educational degrees in nursing, membership in professional organizations, and specialty certification.42 We were intentional in recruitment of participants with varied professional, postprofessional, and continuing education exposure to professional core values content. Based on our results, those distinctions were not the defining experiences for development and integration of professional core values into clinical practice, and we were unable to group participant findings based solely on those factors. For example, participants who had attended continuing education via the LAMP program described having mixed views on the influence of that activity. Two experienced participants described it as an influential mid-career professional development experience. Other experienced participants reported limited impact, which they attributed to the fact they were already actively engaged in leadership roles in their professional association.
Does Clinical Practice Reflect Espoused Expectations for Professionalism?
Our professional documents continue to evolve and provide a framework for discussion of the findings specific to aim 2. Recent revisions of the APTA Code of Ethics specifically address the societal obligations of the profession.18,38 The core value of social responsibility is explicitly linked with Code of Ethics principle 8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally.38(p821) Sullivan et al called for the physical therapy profession to move beyond our “historical roots within the medical model of health service delivery,”53(p1666) noting that one of the fundamental expectations of a health care profession is that health and health improvements are primary elements of our social contract with society. Several authors18,38,54 have described 3 successive and overlapping periods in the evolution of physical therapy ethics: self-identity, patient-focused identity, and an “emerging” period of societal identity. These concepts are consistent with changes in the revised APTA Vision Statement, focused outward beyond individuals to include communities and populations.29
As participants reflected on the CVSA, they acknowledged the need to strengthen the behaviors consistent with social responsibility. Also of interest were 2 sample behaviors listed for the core value of altruism27 that participants identified as not being met: providing pro bono services and care to underserved populations. We suggest that these specific sample behaviors and the core value of social responsibility are similar in that collectively they could be considered examples of evolution of the profession's “societal identity.” The majority of sample behaviors of professional core values that participants identified were integrated into clinical practice, particularly with respect to a “patient focused identity.” In clinical practice, this was evidenced by participants who described examples of providing excellent care within their practice setting for their specific patients. However, the majority of participants had not fully actualized all of the sample behaviors for professional duty and social responsibility. These participants grounded their view of their professional identity in their personal values. Edwards et al18 suggested that the broadening of focus from concern for well-being of individual patients to include societal concerns represents maturation of the profession's sense of “moral agency.”
Three participants who reported that they were meeting many of the sample indicators of professional duty and social responsibility shared the following common characteristics: high standards of performance for their practice, leadership within and service to the profession, motivation to participate in lifelong learning (as evidenced by post–entry-level credentialing), and, most significantly, sustained engagement in professional activities beyond the practice setting over the course of their careers. These 3 participants exemplified a broadening of perspective presented in the definitions of professional duty and social responsibility. Their shift in focus from individual patients to also encompass wider concerns for society was consistent with the maturation of the profession's sense of moral agency.18
Participant reflections about the CVSA provided a “snapshot” of where we are as a profession. The importance of compassion/caring is consistent with previous research.30 Our findings may be an indication that in our professional evolution, we have not yet evolved to fully embrace the sample indicators described for social responsibility. Edwards et al18 suggested a “disconnect” between the societal obligations expressed in the revised codes and the individual frameworks. We believe that limited integration of the core value of social responsibility into practice described by participants may be evidence of this disconnect between the espoused values and ethics of the profession's documents and clinical practice. It is important to note that physical therapists do not necessarily move through Purtilo's stages of identity54 based on individual years of experience. Rather, these findings may be applied to the evolution of the profession at large during this period of emerging societal identity.
Recommendations for Practice
The CVSA was intended to increase awareness of the core values and serve as a mechanism for examining the frequency of demonstrating the core values in practice.27 Instructions encourage individuals to establish goals for “increasing the frequency with which you demonstrate specific sample behaviors with specific core value(s).” Although frequency of behavior is relatively easy to measure, the question remains whether it is important to have high frequency in all areas. Focusing on frequency does not take into account the appropriateness of context. We turn to participants' perspectives during interviews in this regard. One of the sample indicators for the core value of integrity is “confronting harassment and bias among ourselves and others.”27 Participants noted they did not encounter such situations frequently but responded appropriately in those few situations. In this example, even one such action would be an embodiment of the core value in context. Similarly, when engaging in political activism (a sample behavior for social responsibility), is it the quantity of actions or the quality of engagement that matters? We suggest that, as members of the profession, we look beyond frequency and consider both context and impact of the actions. Reliance on numerical frequency ratings alone does not provide the in-depth qualitative reflective feedback needed to facilitate professional growth.
Previous authors have noted the importance of reflection for professional growth.33,34,47,49 A strength of the methods for this study was using CVSA as a prompt for reflection and discussion. We recommend periodic review, using the CVSA tool to provide structure for deliberate reflection. Identifying areas for professional growth through narrative writing can guide continuing professional development throughout a person's career. This recommendation is consistent with previous authors'40 acknowledgment of the importance of continued development of core values. Individual reflection may engender thoughtful discussion within a person's community of practice. Organizations seeking to integrate professional values into clinical practice may choose to build expectations into career ladders that encompass professional roles and responsibilities within society, in addition to individual interactions with patients. Raising awareness of the profession's core values espoused in the “Professionalism in Physical Therapy: Core Values Self-Assessment” document27 will enhance integration into clinical practice. In turn, this may help individuals move forward toward embracing societal identity as part of professional values and behaviors. With the recent adoption of a new Vision Statement for the physical therapist profession,29 further exploration of the guiding principles and elements of professional values is certainly warranted and absolutely essential if the new vision is to be achieved.
Novice learners would benefit from mentorship and feedback throughout all phases of their professional development. Clinical educators have unique opportunities to discuss and provide feedback about observed behaviors to facilitate the development of professionalism.55,56 For example, within one entry-level curriculum, international service learning activities have been shown to develop social responsibility in DPT students.57 Effective teaching in professionalism should incorporate a 3-stage process with respect to student learning and performance: set expectations, provide experiences, and evaluate outcomes.58 Specifically, we recommend that professional development provide explicit experiences to develop both clinical skill competencies and professional behaviors and values.
Limitations
“Professionalism in Physical Therapy: Core Values Self-Assessment”27 is a consensus-based document developed through a Delphi process, which establishes content validity. However, other psychometric properties of this tool have not been established. In particular, we would recommend future studies to establish reliability and construct validity of the current tool. For example, there is overlap of sample behaviors among the core values. Providing pro bono care and care to underserved populations are designated as sample behaviors for the core value of altruism, but they might be framed with either compassion/caring or social responsibility as well. We also recommend longitudinal study of the tool, particularly with respect to sensitivity to change over time. From a research perspective, there are inherent limitations in utilizing self-assessment tools, including the potential for bias or inaccuracy of recall.51 There may be a tendency for respondents to provide what is perceived to be the expected, or more favorable, response. However, self-report is the only direct way to ascertain perceptions, attitudes, and underlying values. Participants' interview responses were quite candid about positive and negative experiences and, in many cases, revealed situations that were less than ideal. Using the current document as an interview prompt helped frame the participants' reflection and discussion of perspectives regarding the professional core values and highlighted areas for future consideration.
Qualitative research explores small samples in greater depth, so findings are not generalizable in a statistical sense. The sample was drawn from the Mid-Atlantic region of the United States and may not reflect perspectives from other regions. Although participants were not selected to be a representative sample of practicing clinicians, they were similar to the APTA member demographic profile59 with respect to age, sex distribution, and range of years in clinical practice. Finally, 17 participants in this study were members of APTA; their experiences and values may not reflect those of practicing clinicians who are not members of the professional association. The high representation of APTA members was unexpected and was not discovered until after analysis of the demographic forms. We do not believe this characteristic unduly influenced our findings due to the fact that only 4 participants identified professional association membership as “most influential” in discussion of the résumé sort.
In conclusion, participants described professional core values that were integrated into their practice, as well as identified areas for further growth. The perspectives gained from individual participants provide insight into our profession's evolution from a patient-focused identity to the aspirations for societal identity espoused in our new vision. Gaining an in-depth understanding of how practicing clinicians develop and incorporate the professional core values into clinical practice can shed light on the relationship among core values mastery, its impact on patient/client management, and the importance of community of practice in the realization of the new vision. Periodic review using the CVSA tool could guide deliberate reflection and ongoing professional development throughout a person's career. Additionally, these findings may be used by educators and managers to facilitate the professional development of the students and clinicians with whom they work.
Appendix.
Interview Questions and Résumé Sort
Footnotes
Dr McGinnis and Dr Guenther provided concept/idea/research design and fund procurement. All authors provided writing, data collection and analysis, and participants. Dr McGinnis provided project management and facilities/equipment. Dr Wainwright provided administrative support. The authors thank the participants for sharing their perspectives and insights.
The study was approved by the Institutional Review Board of Stockton University.
Some of the content in this article was presented at the APTA Combined Sections Meeting; February 8–11, 2012; Chicago, Illinois.
The authors acknowledge funding support from the APTA Health Policy and Administration Section Research Grant. They also acknowledge the following sources of support from Stockton University: School of Health Sciences grant, Research and Professional Development grant, and graduate assistantships from the Office of Graduate and Continuing Studies.
- Received April 1, 2015.
- Accepted February 13, 2016.
- © 2016 American Physical Therapy Association
References
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