Professionalism as a core value of postgraduate physiotherapy students of Ahmedabad: a cross sectional survey

INTRODUCTION

The Merriam Webster dictionary defines professionalism as “the conduct, aims, or qualities that characterize or mark a profession or a professional person.” Professional codes are designed and implemented by the profession’s regulatory body; hence they differ according to different health care professionals and countries. The chief two ethical perspectives for health care practice and education are: principlism and virtue ethics. Principlism refers to the four principles: Autonomy, Beneficence, Non-maleficence, Justice. Autonomy is patient’s right to decide the course of action, so long as they have the capacity to act on it and relates to informed consent. Beneficence comprises of the health care professionals’ positive attitude of giving benefit and weighing the risks and benefits for optimum outcome. Non-maleficence refers to doing no harm intentionally or unintentionally. Justice addresses the conflict between the distributions of scarce healthcare resources, respect for people’s rights and for morally acceptable laws. Virtue ethics is a person-based approach where the moral character of individual’s action is considered.¹

In APTA’s Vision 2020 statement, professionalism was one of the important elements described. The 7 core values described are: accountability, altruism, compassion/caring, excellence, integrity, professional duty, social responsibility. Accountability has been described as the active acceptance of various roles by the therapist for self, the society, patient/client needs and the profession. Altruism is the primary regard of placing the patient needs before his own. Compassion is the desire to sense/ understand other’s experience and caring as empathy, understanding for the needs of others. Excellence is the use of current knowledge and its application while understanding personal and professional limitations. Integrity is adherence to high ethical or professional standards. Professional duty is one’s commitment to the profession and society in terms of physiotherapy practice. Social responsibility is the promotion of the professional and social trust for the wellness. Global market competition inevitably compromises the core values of professionalism.

Lack of communication between the therapists and the doctor delay the treatment progression. The pay scale of physiotherapists is significantly less compared to the doctors and nurses in both private and government sectors. The number of students in the field has been increasing day by day which ultimately leads to tough competition for survival in the market. Also, the awareness regarding physiotherapy is quite low in India which also means that a large proportion of the population may not go to a therapist or may be unwilling to pay for it. In the government sector, the patient to therapist ratio is deficient. Thus, despite the desire to do well, compromise on all the fronts occur in real life practice.

India lacks a central regulatory council which is strong enough to define the rule and set specific guidelines in context of Indian scenario. Due to the survival crisis in the market, the treatment given in most of the places is outcome based. Hence, many a times, treatment of the pathology is compromised in lieu of treatment of symptoms. This scenario is true, especially in private sector. This compromise thus fails to put the complete knowledge of the therapist to practice resulting in unintentional/intentional patient exploitation as well as lack of patient satisfaction.

The academic curriculum does not specifically emphasize on the ethics of the profession in real life practice. The core values are interpreted as guide lines rather than the founding stones of the profession.

Studies regarding the level of professionalism are few in Gujarat. So, the purpose of this study is to find the perceived level of professionalism of postgraduate (PG) physiotherapy students.

METHODS

This cross-sectional survey was done via APTA’s self-assessment questionnaire- Professionalism In Physical Therapy : Core Values Self-Assessment (PPTCVSA) using convenience sampling. It has been used previously in India. PG physiotherapy students of various colleges of Ahmedabad were included in the study by convenience sampling. Permission to conduct the study was taken from the head of the institute. The time period of this study was from October to December 2019. Participation was voluntary and written informed consent was obtained. Students not willing to participate were excluded. 130 students were given the questionnaire out of which 100 students filled and returned the questionnaire. The response rate was 76.9 %. APTA’s self-assessment tool consists of 7 core values with various questions per core value. Each question was rated on a 5-point likert scale: one=never (N); two=rarely (R); three=occasionally (O); four=frequently (F), five=always (A). The core value score distribution in the questionnaire was as follows: accountability (10 questions, total score=50); altruism (7 questions, total score=35); compassion/caring (11 questions, total score=55); excellence (11 questions, total score=55); integrity (12 questions, total score=60); professional duty (7 questions, total score=35); social responsibility (12 questions, total score=60). There are 7 core values with 69 indictors and the total score is 345. Statistical analysis was done in Microsoft Excel 2013.

RESULTS

Out of the 100 students who completed the questionnaire, 33 were 2nd year PG students and 67 were 1st year PG students. The mean score for each core value is shown in Figure 1.

The total mean score found was 268.65±33.1/345. The mean score per domain is indicated in Table 1.

From the given results, it can be said that few persons rarely ‘never’ adapt/follow the core values. Few Indian students have membership with APTA; they have memberships with their respective state councils and the national level council. Twenty-nine people accept that they always prioritize the patient care/professional needs before their personal requirements. Two persons did not respond about providing pro bono services. Total two persons did not respond to the compassion qualities of empowering the patients, providing highest potential, refraining from discrimination, about using the acquired knowledge and using intellectual humility.

DISCUSSION

The current study shows that the total mean score & the mean score of individual domains are high for post graduate students. The mean score of the domains are as follows: accountability: 40.36±6.50 out of 50; altruism: 17.98±3.78 out of 25; compassion/caring: 43.65±6.62 out of 55; excellence: 44.01±6.73 out of 55; integrity: 43.69±6.16 out of 60; professional duty: 28.67±4.70 out of 35; social responsibility: 45.84±7.64 out of 60. Majority of the therapists agreed in their self-evaluation that they frequently or always follow the core values. The score is greater than 50% for each domain. The overall scores obtained are higher than the scores obtained in previous studies.

The mean score obtained in this study is 268.65±33.1/345 whereas in the study conducted by Kumar et al, the mean score obtained by PG students was 163.30±5.40.² More than 50% difference was found in the scores of accountability (40.36±6.50) compared to the study conducted by Kumar et al (18.06±1.49) which may be due to the sample size difference & the fact that the current study has been carried out in the PG students of one city whereas the former study was carried out on a national level.² The scores of altruism (17.98±3.78) are similar to the above study (12.54±1.12) which is indicative that this domain needs to be focused on properly.² According to Marques-Sule students do not consider values such as altruism, diligence, empathy and compassion compulsory for practicing the profession.³ This lack of awareness of altruism and compassion for practice of any profession is a global problem.

Pro bono services are considered a way of giving back to the society by providing good quality services to the needy. Students working in government hospitals provide free treatment & learn from their experience. Stickler et al found that patient satisfaction was found in quality of life, pain and physical measures in a student run clinic.⁴ In India, charitable organizations with low cost fees provide services to the persons who cannot afford to go to private clinics. However, the quality of care is debatable. Unnecessary wavering of fees, cost cutting at the expense of the therapist is not true altruism.

In the present study, the students have a high mean score of compassion/caring (43.65±6.62). However, studies have shown that students belonging to various medical & paramedical branches experience compassion fatigue.^5,6

In a study conducted by Klappa and Susan et al it was found that there was a negative correlation of compassion satisfaction and burnout in the physical therapists.⁷ Self-coping strategies’, early recognition of burn out signs may prevent it.

The mean score per question of the domain’s social responsibility and integrity (45.84±7.64/60) suggest that these domains need to be emphasized on. A study conducted by Mostert et al found that few therapists (6.1%) considered political activism to be significant.⁸ This is in accordance to the present study where the mean score of the question is 3.35 (the second lowest score).

Psychological aspect of the patient care in rehabilitation is important. A systematic review conducted by Aoife Synnott et al found that physiotherapists may fail to recognize the underlying psychosocial and emotional factors that may influence the patient’s behavior.⁹ Alexanders et al found that physiotherapists may recognize the importance of psychological interventions but feel under trained and are not thoroughly aware of their application.¹⁰ The present study agrees with the above findings as the least score (3.2) is obtained on the topic of embracing the psychological or emotional needs of the patient. Anderson et al found that physical therapy education helped improve the knowledge regarding each core values.¹¹ To conclude, overall scores of the self-evaluation of professionalism are high. Emphasis should be given in improving the duty of the physiotherapist towards the society at post graduate level. Thus, self-evaluation of the core values will help all the professionals, especially the students in recognizing the weaker aspects and thus start improving their approach, even before entering the market.

The study had a few limitations as it was carried out for post graduate students. The co-relation for various values was not done. PPTCVSA is a close ended questionnaire, hence the students’ views for the various barriers or facilitators in following the various aspects of the core values could not be known. Being a self-assessment questionnaire, the scores obtained depend on the honesty of the participants.

CONCLUSION

Thus, from the present study it can be concluded that post-graduate physiotherapy students have an overall high level of professionalism but are weak in addressing the psychosocial aspects of patient care and social aspects of the physiotherapy field. Acknowledging the problem and the weak areas will help the therapists to take steps to improve their clinical practice. This will guide other therapists in uplifting the profession of physical therapy.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Monrouxe LV, Rees CE. Healthcare professionalism: improving practice through reflections on workplace dilemmas. John Wiley & Sons; 2017 May 1.
2. 2. Kumar SP, Sisodia V, Jacob E. Levels of Professionalism among Physical Therapists in India-A National Cross-Sectional Survey. J Sports Med Doping Stud. 2013;3(123):2161-0673.
3. 3. Marques-Sule E, López-López L, Aguilar-Rodríguez M, Cortés-Amador S, Sempere-Rubio N, Faubel-Cava R. Which professional values do physiotherapy students consider more important for the profession? Inint Proceed. 2019:565-72.
4. 4. Stickler K, Sabus C, Gustafson H, Kueser M, Lavaveshkul B, Denney L. Pro-Bono Service Through Student-Run Clinics: How Does Physical Therapy Measure Up? J Allied Heal. 2016;45(3):207-11.
5. 5. Harr, Cynthia, Brenda Y. Moore. Compassion Fatigue Among Social Work Students in Field Placements. J Teach Soc Work. 2011:350-63.
6. 6. Beaumont E, Durkin M, Hollins Martin CJ, Carson J. Compassion for others, self-compassion, quality of life and mental well-being measures and their association with compassion fatigue and burnout in student midwives. Quantitat Surv Midwif. 2016;34:239-44.
7. 7. Klappa SG, Fulton LE, Cerier L, Peña A, Sibenaller A, Klappa SP. Compassion fatigue among physiotherapist and physical therapists around the world. Glob J Medic Physic Heal Educat. 2015;3(5):124-37.
8. 8. Mostert-Wentzel K, Masenyetse LJ, Dinat N, Botha A, Jonkers LD, Oosthuizen LC. Involvement in and views on social responsibility of Gauteng members of the South African Society of Physiotherapy: A cross-sectional survey. S Afr J Physiother. 2012;68(1):22.
9. 9. Synnott A, O'Keeffe M, Bunzli S, Dankaerts W, O'Sullivan P, O'Sullivan K. Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: a systematic review. J Physiother. 2015;61(2):68-76.
10. 10. Alexanders J, Anderson A, Henderson S. Musculoskeletal physiotherapists' use of psychological interventions: a systematic review of therapists' perceptions and practice. Physiother. 2015;101(2):95-102.
11. 11. Anderson DK, Irwin KE. Self-assessment of professionalism in physical therapy education. Work. 2013;44(3):275-81.