Title: Shaping professional identity: a descriptive
qualitative study on Health and Rehabilitation final year students in
higher education. Abstract 175
Professional identity is
defined as
what it means to be and act as
a
professional,
as this represents
the
person’s philosophy
of
their profession (Mackey, 2007). This paper will
describe the factors that shaped the professional identity of
Occupational Therapy, Physiotherapy and Communication Sciences Disorders
students’ during their four years (2015 – 2018) of studies in the
Faculty of Health Sciences in a higher education institution. A
descriptive qualitative design was used to describe the factors that
emerged. Seven participants were purposively selected from the Faculty
of Health Sciences Campus. Individual interviews and a focus group with
participants was conducted. Data was analysed inductively. This paper
will foreground the following theme: “The curriculum and experiences
within practice and professional environments; shapes professional
identity the most.” The findings highlight how critical events in higher
education may have influenced the participants developing professional
identity as health and rehabilitation students. The curriculum played an
integral role in defining how the narrative for each participant was
played out and how professional and practice environments greatly shaped
the students developing self. Keywords: professional identity, practice
environments, curriculum,health and rehabilitation sciences
Introduction This paper will describe the factors that shaped the
professional identity of Occupational Therapy, Physiotherapy and
Communication Sciences Disorders students’ during their four years (2015
– 2018) of study in the Faculty of Health Sciences in a higher
education institution in the Western Cape. The paper will provide the
context in which the study was conducted and offers a brief review of
the literature in relation to curriculum content, professional &
practice environments and the role of professional identity in the
developing self. The methodology is briefly described, naming the data
collection and data analysis methods. The findings will be presented in a
form of a theme that will further be discussed in relation to taking a
critical lens to understanding professional identity development in
students within higher education environments. Background Professional
identity is defined as the lens to which professionals define who they
are in the way they choose act and represent themselves as defined by
the philosophy of a particular profession1. This identity is developed
and shaped by the experiences of students as they negotiate their roles
and positioning within the higher education environments. Although being
a student at a University is considered to be a prestigious
opportunity, there were many factors that impacted or influenced how
health sciences students negotiated their professional identity within a
health sciences faculty. The roles universities play in developing
countries like South Africa, are those of growth and development2 .
Universities are seen as ideological mechanisms in taking on these
roles; where government fails to do so2 . Amongst other uncertainties,
higher education in South Africa was experiencing a fees crisis where
the lack of government subsidies to universities placed pressure on
students and their families with the annual increases in student tuition
fees3. This crisis culminated in 2015 in the #feesmustfall movement,
which saw students in higher education from all over South Africa rise
up in protest against the fee increases. The current higher education
crisis, as well as other political and economic challenges in South
Africa during 2015 and 2018, have contributed to universities and the
health professions looming in a continuous state of change and
uncertainty. This continuous state of change may influence the
positionality of health professionals’ within the practice contexts they
find themselves in. In considering the continuously changing South
African higher education context, health professionals such as
Occupational therapists, Physiotherapists, Speech language pathologists
and Audiology graduates are having to reflect on who they are, and how
they choose to respond to changing practice contexts. There has been
little research around how health and rehabilitation (H&R) students
establish their professional identities within a four year degree
programme in higher education.
It was important to understand how
the development of
professional identity
occurs, and what areas are crucial to enhance their own
identity development. Identity development is critical in defining and
shaping who the graduating health professional chooses to become. The
research question How is the professional identity of final year H&R
students being shaped over the course of four years of study? was
pertinent
as it
contributed
to
unearthing
the professional identity development of
H&R
students.
Literature Review Professional identity is described as an internal
identity that reflects choices of beliefs,
characteristics
and
commitments
of the self
and is further developed or conditioned by experiences
in practice4. The professional identity will continue to develop
throughout the professional lifespan4. Personal awareness can be
identified
as a key to professional identity formation,
where the
conscious and unconscious
beliefs,
attitudes, emotions, psychological
2
and cultural background influence
the
care
the health professionals would provide for their
clients. The awareness of these factors enables the health professional
to better serve their patients and themselves4. Occupational therapists
have many potential individual and collective professional identities
that vary according to their understanding of their identity within
different historical and social environments; different situations
within these environments; and, their stakes within different events1.
Accordingly, the professional identities of occupational therapists
should reflect their changing practice context. Occupational therapy
needs to articulate its own knowledge base and that a flourishing
occupational therapists professional identity will depend on high levels
of autonomy and clinical discretion enabling them to draw on their own
skills and knowledge within given situations1. It is argued that
occupational therapists should utilise the changing professional order
that is characterised by the diversity of practice in order to negotiate
a new individual professional identity1. Historically, the professional
identities of occupational therapists were less strongly defined than
those of other professionals and based on narrow, fixed beliefs such as
holism and client-centeredness1.
This has been attributed to
a
lack of understanding of the purpose and nature of
the
role
of occupational therapists within multidisciplinary
teams. This thinking is being challenged as there are calls to redesign
occupational therapy work roles in a manner which allows skills to be
used more flexibly and which allows an opportunity for innovation and
creativity within broader, inter-clinical practices1. In a study on the
development of professional identities within the nursing community5, it
is found that professional identities continually develop. Professional
identities start to develop before entering tertiary education and then
evolve during studying, clinical experiences and subsequent careers.
However, the study highlighted the importance of education and its
effects on professional identity;
as it is during this time
period that professionals
gain the
professional
knowledge and skills
which distinguish them from other occupations.
Occupational identity was found in the literature that the individual is
at the core of their own identity formation and that society may
influence an individual’s identity6. Socially constructed identities
result from the dialect between the individual and society7 and
therefore further emphasising the importance of the consideration of the
developing self within context. Sonday explains
that there is
an explicit
link between
one’s
occupational identity and
the developing professional identity. She described how
occupational identity formed the basis to how occupational therapists
negotiated environments that impacted on their developing professional
identity8. Curriculum and professional identity Brandt discussed his
experience of professional identity formation that was achieved through
interprofessional learning and encountering patients during the early
years of study9. The curriculum and the way in which it is run enhances
the development of a student’s professional identity, through
problem-based learning, early clinical exposure, and integrated
interprofessional education9. Brandt learned significantly
through the opportunity to work with other healthcare professionals
as it allowed
the
understanding of
different perspectives
as each healthcare professionals approached the given
cases from different angles. Through the use of the experiential
learning in clinics with multidisciplinary teams, a medical student,
felt better prepared to be a health professional9. Therefore,
experiential learning in the early years of study allows a smoother
transition from theoretical studies to a working professional, where one
is better equipped to perform due to the experience gained during their
studies, as this aided in further professional identity development.
The main factors in the curriculum that were
helpful in developing
the
professional identity formation of medical students
were, the multidisciplinary healthcare settings, and
the patient contact throughout the years of study, as more skills was
learned with regards to communication and being client- centred or more
empathetic. Many differences emerged in the process of professional
identity development in graduating Physiotherapy students10. There were
three
categories of professional identity as a Physiotherapist which
were
the empowerer, the educator and the treater.
The empowerer is interprofessional, the educator is a
rehabilitation professional and the treater is uni- professional.
Studies exist that discuss how the socialisation processes amongst
students
influence the development of professional identity
and how the
students
view themselves at
the
end of their studies as health care professionals. Educators
are paying attention to educational outcomes
of professional training curricula which are intended to ensure that
graduating students are fit to practise.
However, this does not necessarily improve or facilitate the development of professional identity10.
The strength of professional identification, however, varies by profession. The
significant contributors
of baseline professional identity were:
gender; profession; previous work experience in environments;
understanding of team working; knowledge of profession; and cognitive
flexibility11. The study suggests that
students who demonstrate a particular
affinity or identification with the profession are likely to be accepted
to the course rather than those with lower levels of identification.
The strongest professional identities were
found in Physiotherapy students, while social work students had the
weakest professional identities of the professional groups.
The literature review offered an opportunity
to explore the
construct
of professional identity as
it relates to
students
studying health professions such as occupational
therapy and physiotherapy and the curriculum. Studies have shown that
context plays an integral role in influencing identity development and
that interdisciplinary practice is one example of how curricular could
encourage the development of professional identity across varying
professions. Methodology A descriptive qualitative design12 was used as
it appropriately addressed the research question in describing how
professional identity is developed and shaped by the contextual factors
and higher education environments students find themselves in. The study
was conducted at a Health Sciences Faculty at a higher education
institution in the Western Cape. The participants were final year
H&R students, including students studying Occupational Therapy,
Speech Therapy, Audiology and Physiotherapy degrees. To allow full
anonymity and confidentiality, each participant was asked to choose a
fictional name, this granted the participants full anonymity whilst
providing a personal voice.
Purposive sampling was used to
identify seven
participants
who met the
inclusion criteria. Participants
had to be final year
occupational therapy, physiotherapy,
audiology
and speech therapy students in
2018. Students who have studied at least one year in
another degree other than their current degree would be excluded from
the study. An invitation to participate in the research was sent to
class representatives and
was sent to final year students
across
the
disciplines
via
an
email
that included the information sheet and the informed
consent form. The information sheet to recruit potential participants
were also presented during a lecture slot to further attract
participants. Maximum variation aimed to provide representativeness by
including a wide range of participants. Insert Table I: Selection
criteria for participants The participants included two of each race
specified above, four of each gender, two of each discipline (apart from
Speech Language and Pathology where there was only one participant).
The participants’ disciplines were left out of Table I to further ensure
anonymity, as the class sizes are small and this would make it easy to
identify individual participants. Ethics approval (HREC 034/2018) was
granted from
Human Research Ethics Committee, Faculty of Health Sciences
at
University of Cape Town (UCT)and the
Director
of
Student Affairs at UCT first before data was collected.
Individual interviews with each participant was conducted taking 5 an
interview guide approach. They were 40 minutes long and were held at a
place that was convenient for the participants, and that was on campus. A
focus group session on the themes that emerged from the interviews was
conducted to probe further to develop emerging themes. The focus group
session contained six participants as one participant was not
available.. The participants included two OT students, one Speech
Therapy student, two Audiology students, two Physiotherapy students.
This assisted in consolidating the data that emerged from the
interviews, and served as a form of member checking. An inductive
approach was taken in order to analyse the information received from
both the interviews and the
focus group.
The
interviews were audio recorded and transcribed verbatim. The transcripts were
then
analysed
through taking a
thematic analysis
approach. The themes were used to inform the questions for the
focus group. The focus group
was
audio recorded and transcribed verbatim, the
data was then grouped into the final theme. Rigor was
ensured through the following strategies dependability, credibility and
transferability. The research
was approved by the Faculty of Health
Science
Human Research Ethics committee
and complied with the Declaration of Helsinki. Findings
The following theme emerged “The curriculum and experiences within
practice and professional environments; shapes professional identity the
most.” Insert Table II: Theme and Sub-themes This theme focuses on the
way in which undergraduate programmes’ curriculum are structured; and
the opportunities afforded to students that contribute to the
development of their professional identities. Spaces for Reflection This
subtheme directly focused on what each programme had to offer as a
space to reflect on the learning and experiences that occurs during
practice learning, as well as the personal experience each student
encounters within each site. Tutorials are one learning strategy used
over several platforms across the H&R programmes where this type of
sharing of experiences happens. Three out of the four programmes offer
these type of tutorial spaces. Only one programme in H&R has a time
scheduled for reflective space within their course curriculum. “I think
because you guys are studying occupational therapy you have something
specifically dedicated to identity whereas we don’t.” - Cami Becoming a
Rehabilitation Professional and Clinical Physiotherapy are two courses
that have influenced the professional identity of one of the
Physiotherapy participants as these courses 6 taught them how to act and
think as a professional in a practical and theoretical sense. However,
it was not a space that encourages reflection on clinical experiences
and personal identity and positioning. “...overall I feel like both
clinicals and this course allow me to at least encompass both of those
that add towards my professionalism.” - Tsholofelo Patrick shared an
example of a reflection he was able to share during a reflective space
that positively helped him make sense of the experience. This incident
occurred during practice learning with a clinician. “I had to interact
with someone who every time they saw me they saw a representation of
what was wrong with their life. So, problems they were facing like they
got burgled into and it was by criminal who were supposedly black, there
were protests at UCT and it meant that her daughter was going stay
longer in the year and she was going to get paid more. But every time
she saw me she thought, “These people”. So, I was the reminder, she
projected her problems onto me and then I was the horrible one. So yeah.
I called her racist at the end, and she cried and I was like it’s fine,
you just have to admit that you’re racist.” - Patrick This subtheme
explored the different spaces for reflection that exists in H&R
programmes. The OT division has a designated space for this type
reflection which supported some participants experiences of difference
and how these experiences influenced their developing professional
identity as a growing student. Other participants expressed that their
divisions should also have a space available similar to that of the OT
division. Practical Experience Over Theoretical Knowledge This subtheme
speaks to the experience that students acquire at practice learning as
it relates to the theory that has been taught. And the impact this
experience has on their roles as emergent health professionals. Positive
feedback from clients also helped to reassure the participants that
their roles are important and that they are making a difference to the
clients’ lives. H&R students have had reported good interactions
with their clients. “watching people be grateful when we give them
hearing aids” - Annie Participants believed that teaching theory on its
own is not enough to equip them with the necessary skills they require
to thrive in a clinical setting. They have raised concerns about the
role of theory in other professions towards developing their
professional identity. Participants also indicated that the tutorials
they have had during practice learning with their supervisors have been
helpful in guiding their interventions. “You can give a student an idea
[of their role] but they’re not going to know until they’re there” -
Alice “we do have a lot of tutorials in block where we can just come and
talk about your experiences at clinics and impact.” - Cami This
subtheme explored how positive client interactions shape professional
identity, as well as how the combination of theory and practice that is
experienced during practice learning can help students to discover their
role, and these interactions have either a significant positive or
negative impact on the participants’ professional identity. Lack of
Curricular Spaces That Allow for Intersections of Professions
Interactions amongst one's peers also may shape the professional
identity of a student through one’s time at university. The amount of
social interactions amongst one's peers varies between courses due to
schedules, physical settings and practice learning placements. The
participants felt that their professional identity was impacted due to
the lack of interactions among various health professionals. The
different professions have often been grouped together for certain
courses as well as in different venue buildings, which leaves
socialisation between the other divisions to a minimum throughout the
four years. The department are divided into Communication Sciences and
Disorders (CSD) (Audiology and Speech Language & Pathology), OT
& Physiotherapy. As the number of students in each programme varies
greatly, this results in the need for venues across the large campus,
limiting students’ interactions. This provides them with fewer
opportunities for socialisation outside of their profession and they
often experience feelings of isolation. “the physios are worse than the
medics, like we don’t really interact with the medics so they don’t
bother me at all.” - Cami “we don’t really have meridian so we don’t
really interact and we all get sent here at Old Main and then you never
see like the doctor students again” - Alice The only apparent space for
the different disciplines to interact is on the bus when taking
transport to the different practice learning sites. This is a space that
is available for social interaction amongst different professionals but
this is also dependent on practice learning placement, as students are
not guaranteed transport to certain placements and if transport is
provided, students would only be able to interact with others going to
placements in the same geographical area. “And then when your clinics
start and you like take the buses together and stuff then you can
interact more with the Physios and the OT’s “- Alice During the focus
group, whilst participants were discussing the divisions in the faculty,
an issue about hierarchy in H&R surfaced, the participants came to
the consensus that Physiotherapists were seen as and acted as if they
were at the top of the H&R food chain. “Um like the physios,
definitely, I won’t say all of them, um most of them think they better
than the rest of us. (Laughter). The OTs, Audios and Speeches are on the
same sort of level.”- Cami “I’ve heard of that hierarchy thing amongst
health and rehab. Um some OTs have come forward to me at one point in
time and told me that um or asked like why we feel as if we’re like the
next thing or the next best thing to medicine.” - Tsholofelo H&R
participants attend most of their lectures in Old Main Building whereas
the medical students are on the main Health Sciences campus. This
physical division further increases the isolation between H&R
professionals and medical students. “we all get sent here at Old Main
and then you never see like the doctor students again.” - Alice Apart
from BP and BHP course, there is no other space available for different
professions to interact with each other. In summary, this category
speaks to how the lack of interaction between the different divisions
within the FHS contributes to the dynamics on the campus, ultimately
perpetuating a hierarchy due to the lack of knowledge and disregard of
the different professional roles within the health care setting.
Discussion The model of transactionalism offers a lens to view an
individual in a way that cannot be seen as a separate entity outside of
their context15. This model aligns with the theme that professional
identity reflected their personal identities. Professional identities of
OTs have been less strongly defined due to lack of understanding of the
nature and purpose of OT1. The findings have found that the opposite of
what Mackey suggested exists in the department of H&R at UCT. OT
students appeared to have a stronger understanding
of their professional identities
in clinical practice.
The
formation
of professional identity
begins even before students enter tertiary education
and then evolves during studying, clinical experiences and subsequent
careers5, which concurred with what the participants said about their
personal identities being reflected by their professional identities.
This implies that each student’s formation of professional identity will
vary according to who they are even though they are taught the same
content throughout their university career. Individual at the core is an
assumption drawn from the occupational identity construct13,14 that
focuses on the individual is in control of itself. This is focused on
self-efficacy, personal success and self-esteem. The participants in the
study communicated that their professional identity reflected their
personal identities, namely seeing how one’s cultural and gender
identity can fit into their professional identity and how this affects
their ability to practice. This suggests that the formation of
professional identity was influenced greatly by who they are as
individuals; which is considered as one factor that contributes to the
process of developing a professional identity.
Gender was one
of
the personal identities
that
was highlighted to play a
role in the
formation
of a professional identity.
There
is a
lack
of
male representation in some departments in the FHS,
particularly OT and CSD. The effects of this include being unable to
position oneself within the profession, may deter from professional
identity as well as having concerns for his own cultural
responsibilities financially. A lack of representation was noted by a
male participant in the study who commented on how this has led to a
shortage of clinical male OTs. There is a need for more male
representatives in H&R in the form of role models, as these
professions are deemed as female dominated resulting in males being less
visible, as many male H&R professionals choose to
work in the
corporate
sector and
not
in the
health
sector
as it may be seen as more financially viable. The
inability for participants to identify themselves within the profession
in terms of their personal identity affects their self-efficacy. It was
noteworthy that no female participants brought up the lack of male
representation in their respective divisions. There is an assumption
that this lack of representation was not noted 10 by the female
participants due to the lack of direct impact on their daily
experiences, because the H&R department is female dominated.
Productivity is encompassed by the social recognition that individuals
attach to their work6 , the devaluing of H&R professionals’ roles
within the multidisciplinary team is likely to have an impact on their
productivity as it relates to occupational identity. This may occur when
H&R professionals are not recognised, respected or their roles not
acknowledged and undermined; therefore, affecting the meaning and value a
person assigns to their productivity. These negative social
transactions shape professionals’ occupational identity and contribute
to poor performance levels in the healthcare setting. According to
Phelan & Kinsella6 social dimension speaks to the way in which
society and social structures are able to influence the occupations that
individuals engage in, and therefore act to shape their occupational
identity and intern have an impact on professional identity. It was
found that the use of reflective journals brought awareness of values
that guide physicians’ interactions with patients and enhance
professional identity formation4. Many authors found that professional
identity formation is largely reliant on the combination of theoretical
knowledge and practical experience16,5,9. To a large extent the
participants of this study agreed with this as they found that learning
theory alone was not as effective if it could not be implemented
practically, in that theoretical knowledge is not solely sufficient for
the skills in their scope of practice. Structures that perpetuate the
divide The structural positioning of the FHS campus contributed to the
divide amongst the departments of MBChB and H&R through the
delegation of faculty resources and physical learning spaces. Being on
the Health Sciences campus comes with the convenience of easier access
to administration offices and faculty resources for medical students
further isolating the H&R students and potentially limiting access
to learning and further support. This could also contribute to how
H&R students position themselves in relation to medical students.
Nembhard and Edmondson17 agreed that on higher status individuals, in
this case MBChB students, receive tangible benefits that those who are
lower ranked. The second structure that perpetuates the divide amongst
healthcare professionals is curricula. Johnson5 emphasised the
importance of education and its effects on professional identity as this
is when professionals gain the professional knowledge and skills that
distinguish them from other occupations. The participants felt that what
the curriculum offered in terms of interprofessional learning was not
sufficient as it was only done in the first year of study, where they
had not yet fully understood their own role in the healthcare system.
The attempts of Becoming a Health Professional and Becoming a
Professional that were a result of Mayers18 on interprofessional
learning, were not seen to be as effective as hoped because participants
felt that they did not find these courses useful. The broad issues
discussed, offered an explanation to the factors that influence how
professional identity is shaped for health and rehabilitation students.
These factors either hindered or supported the students development in
varying ways, that then continue to perpetuate the hierarchy that
currently exists in the higher education environments. Implications for
practice This study offers insights into how curriculum can positively
shape and contribute to the developing self as an emergent health
professional. By taking into careful consideration the content we
include in occupational therapy undergraduate curricula and the practice
sites we use, this can ensure that every student finds resonance with
the experience. Conclusion This article highlighted and brought to the
fore how critical events in higher education may have influenced the
participants developing professional identity as Health and
Rehabilitation students. The curriculum played an integral role in
defining how the narrative for each participant was played out and how
professional and practice environments greatly shaped the students
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