Professional Development: 1. Professional socialisation and professionalisation

Physiotherapy September 1999/vol 85/no 9

461Key WordsProfessional socialisation,professionalism,professionalisation, professional education,professional development.

by Barbara Richardson

IntroductionThe recent government initiatives (Secretaryof State for Health, 1997, 1998) have given afurther impetus to the changes occurring inthe provision of health care. A move towardsa central role for primary care in approachesto prevention of ill health has created a shiftin the balance of health promotion andtreatment of disease. These changes havearisen in response to relatively recentlyidentified phenomena such as the increasingnumbers of elderly people, concern forclient rights and changing views of societyon disability and handicap. They areparalleled with the on-going changes in theorganisation of health services whichrecognise the limits of health funding andseek to establish a health service which iscost-effective and market-responsive. Healthcare professionals are expected to beaccountable for the outcome of theirpractice and of their use of resources (DoH,1990, 1991).

The focus of health care is now client-centred rather than disease-oriented and approaches to care aim to empowerpatients in managing their own health.Comprehensive and holistic primary care is

thought to be most effective if based onmultidisciplinary and interdisciplinaryteamwork (Secretary of State for Health,1998). The advantages for clients areparamount but as practice moves tomultidisciplinary and interdisciplinary work, professional autonomy decreases(Tryssenaar et al, 1996) and the need toappreciate the distinctive qualities of theprofessions becomes more pressing (Barr,1998). There is a challenge to explore andutilise common skills in teamwork while still valuing the unique skills areas of eachprofession (Tryssenaar et al, 1996) andmaintaining an unambiguous public profilewhich reflects the value and unique purpose of the physiotherapy profession.Physiotherapy literature suggests there maybe a crisis of confidence in the profession(Bartlett, 1991) and ‘we, as a profession,may be doing more things, but in no wayhave we developed a true sense of who andwhat we are’ (Rothstein, 1986). This paperexamines professional socialisation inrelation to changes in health care and theconcomitant demands on the profession of physiotherapy. It questions how theeducation process prepares physiotherapiststo fulfill the purpose of physiotherapy in theface of multi-dimensional collaboration(Barr, 1998). Education has an importantfunction in fostering a professionalismwhich will encourage individual pract-itioners to develop their practice, but theyalso need to work towards maintainingdevelopment of the physiotherapyprofession through a continual process ofprofessionalisation.

Changes in Health CareA shift to health care which is grounded inthe patients’ social contexts (Inui et al, 1998)makes it necessary to gain access toappropriate care environments outside thehospital setting, and to identify, ‘name and

Professional Development1. Professional Socialisation and Professionalisation

Richardson, B (1999).‘Professional development:1. Professional socialisationand professionalisation’,Physiotherapy, 85, 9, 461-467.

Summary This is the first of two papers which explore therelationship between the continuing professional development ofindividual physiotherapists and the development of physiotherapyas a profession. It questions how the education process can ensurethat the professional purpose of physiotherapy will continue to be fulfilled in the context of the major changes in policies andpractice of health care heralded by the National Health Servicereforms. A clear distinction is made between concepts ofprofessional socialisation, professionalisation and professionalismand the implications each holds for physiotherapy practice. It is suggested that an increased emphasis on development of amotivation to professionalisation in undergraduates will facilitatetheir personal professional development as practitioners andensure a sustained development of the profession of physiotherapy over future years.


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frame’ (Schon, 1991), physiotherapyproblems in new and varying contexts ofcare. A quote from this journal sixty yearsago (Journal of the Chartered Society of Massageand Medical Gymnastics, 1936) portrays aspirited declaration of the purpose ofphysiotherapy which seems particularlyrelevant today:

‘We should be filled with thecrusading spirit, gathering thepopulation together in every emptyhall in the winter and in the parksand fields in the summer, teachingthem how to stand and breathe, howto walk, move and dance, how to develop a sense of rhythm and howto march with elastic step towards“physical literacy”.’

The shift in health care perspective makesmotivation to pursue physiotherapy goals innew and changing scenarios equal inimportance to an ability to apply models ofpractice appropriately to given problems inthe traditional clinical context. With eachclient contact there is a need to determinewhether the context of care is disease-oriented, rehabilitation, or maintenance,and to articulate goals of care which arespecific to the circumstances of individualclients and take into account the availableresources. Long-term care may involvemanagement of clients with high levels ofmobility, and a client-specific programme of intervention within the total package ofcare may or may not require the activeparticipation of physiotherapists.

Physiotherapists need a clear view of thepurpose and intent of their profession and aconscious awareness of a professionalidentity which encompasses purposefulactions to pursue professional goals inchanging practice contexts throughout thespan of their careers. A study of the historyand traditions of a profession promotes a‘proper understanding of the nature of thetask’ (Southon and Braithwaite, 1998) andthe character and the responsibilities ofprofessionals.

Physiotherapy as a Profession Accepted characteristics of a profession arean autonomy of practice, an exclusiveknowledge base, occupational control ofrewards, a ‘noble work ethic’ (Popkewitz,1994), a commitment to the task and ameans of maintaining standards (Southonand Braithwaite, 1998). Professional status

for physiotherapy has been sought overmany years and there has been a gradualacceptance of a structured body ofknowledge and expertise, a regulating body,a code of practice and recognition ofautonomy of practice (Palastanga, 1990;Barclay, 1994). The physiotherapy professionis relatively young. Although the Society ofTrained Masseuses ws formed in 1884, it wasnot until 1920 that there was sufficientorganisation of practice for the CharteredSociety of Physiotherapy to be recognised asthe only examining and professional bodyfor physiotherapists in the UK (Williams,1986). The acceptance of physiotherapy as aprofession occurred in the context of aNational Health Service practice which was based solely on consultant-referredclinically-defined problems which wereamenable to assessment, treatment andmanagement within a stable health caresystem (Richardson, 1992). Doctors tookresponsibility for the early development ofthe professional training and practice of physiotherapists and all qualifyingexaminations and prescriptions for patientreferrals were mediated through them(Parry, 1995). Their involvement in theprofession remained prominent and it wasnot until 1978 that an autonomy of patientcare for physiotherapists was endorsed in achange to the bye-laws of the Society (DoH,1977).

Shifts in the balance of power todaybetween professions and betweenprofessions and patients have upset theequilibrium maintained by the moreestablished professions (Barr, 1998). Theclaim of a professional status gained througha medical model of practice in a hierarchalconsultant-led health care system may beconsidered tenuous in the context of acompetitive client-focused health careservice which is based on accountability andcollaboration with others in clinicalgovernance. For physiotherapy, autonomy ofpractice may already be under threat fromthe potentially restrictive power given togeneral practitioners and administrators inestablishing service contracts (Secretary ofState for Health, 1998). In addition, themove towards evidence-based practice inwhich a ‘diversity of approach in routinepractice will be increasingly difficult todefend unless supported by a sustainableand convincing rationale’ (DoH, 1993)highlights the paucity of researchedevidence for many commonly usedphysiotherapy techniques and approaches.

Author and Address forCorrespondence

Dr Barbara RichardsonPhD MSc MCSP is a seniorlecturer at the School ofOccupational Therapy andPhysiotherapy, Universityof East Anglia, NorwichNR4 7TJ.

This article was receivedon January 31, 1998, andaccepted on November 12,1998.

Acknowledgement

I would like toacknowledge the interestand timely advice ofProfessor Joy Higgs inpreparing this paper.


463Professional articles

The label of ‘profession’ is used byoccupational groups to signify a highlytrained, competent, specialised anddedicated group that is effectively andefficiently serving the public trust(Popkewitz, 1994). The growth anddevelopment of any profession dependsupon maintaining a status, knowledge baseand scope of practice which together ensurea credibility of competence in professionalpractice. The concept of a profession issocially constructed and changes inrelationship to the social conditions inwhich people live (Popkewitz, 1994). Thereis an expectation that professionals willdefine problems and search for solutionswhich address the needs of the communityand lead to social progress (Schon, 1991). AsPurtilo (1986) has pointed out, aphysiotherapist, as a professional, needs todevelop a ‘powerful sense of responsibilityfor the conduct of his own professional lifeand the protection of the society of which itforms a part with respect to the area of hisprofessional expertise’. Eraut (1994)believes the five areas in which professionalsshould be accountable are a commitment toserve the interests of the client, anobligation to self-monitor and review theeffectiveness of one’s practice, an obligationto expand one’s repertoire, to reflect onone’s experience and develop one’sexpertise, an obligation to contribute toone’s organisation, and an obligation toreflect on and contribute to discussionsabout the changing role of one’s professionin wider society. The process through whicha responsibility to respond to change isrealised is neither clearly portrayed in theliterature nor delineated in physiotherapyeducation. There is a need to take a freshlook at the process of professionalsocialisation and consider how students aresocialised to a professional behaviour whichwill not only encourage their ownprofessional development but also thedevelopment of the physiotherapyprofession.

Professional SocialisationProfessional socialisation is the processthrough which individuals learn the values,attitudes and beliefs of their chosenprofession and develop a commitment to aprofessional career (Vollmer and Mills,1966). This occurs through a network ofsituational social exchange from whichstudents imperceptibly assimilate a web oftaken-for-granted values (Lave, 1988) based

on a social consensus of professionalbehaviour. It is more than merely a processby which students acquire competence inpractice skills. It is an important componentof preparation for professional practicethrough which the values and attitudes andbeliefs of the profession are internalisedintellectually and the ‘basic knowledge, skillsand theory, the world view which is theessence of each profession’ (Laurie, 1981,cited in Hayden, 1995) are conveyed. Quinnet al (1996) conceptualise a professionalintellect which operates on four levels:cognitive knowledge of ‘knowing what’ todo, advanced skills of ‘knowing how’ to do it,an understanding of the working system to‘know why’ to do it and, above all, a self-motivated creativity which comes from‘caring why’ to do it. Without the motiv-ation and adaptability for success, theyargue, advantages can be lost throughcomplacency or a failure to adapt toinnovations that make earlier skillsobsolescent.

The practice of physiotherapy has beenable to sustain the profession's credibilityand growth in a relatively stable system ofhealth care for one hundred years. Now,health care provision is entering a new andchallenging era. The changes in practicesettings, modes of health care delivery, andthe ethos of health care today placeprofessional practice within a widerperspective than treatment techniques andstrategies of application. The backdrop tophysiotherapy practice is an ever-changingfluid environment of health care with anextending workforce of carers and helpersand private sector agencies which aim toproduce a quality service. An observation byDyer (1982) that the traditional emphasis ofphysiotherapy on cure should change to thatof care and support is becoming critical.Negotiations for the quality of care andservice delivery depend on good teamwork,being in ‘the right place at the right time’and on confidently advancing a profile ofphysiotherapy practice in the face ofcompeting claims from other professions.

The manner in which students learn to actas professionals is determined by theirexperiences of being a student of aprofession. This includes their interactionswith tutors and other students, theirexperiences of professional practice, andtheir interactions with clinical supervisorsand with other practising physiotherapists.Presentation and acceptance of self as anautonomous, accountable professional who


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is willing to interact creatively and to adaptand interpret physiotherapy practice iscentral to achieving goals within health careteams which will show the full potentialcontribution of physiotherapy to health. Atthis stage of development of the profession,an understanding of the different conceptsof professionalism and professionalisation ispertinent to an analysis of the quality ofstudents’ professional socialisation inundergraduate programmes.

Professionalisation and ProfessionalismProfessionalism is a term commonly used todefine the manner adopted by professionalsin the conduct and organisation of theirwork. Southon and Braithwaite (1998) seethe main characteristics of professionalismto be an ability to apply sophisticated skillsto tasks which are unpredictable and havehigh levels of uncertainty as well ascomplexity. They distinguish the socialbehaviours of professionals and the functionof a profession to achieve a particular task.They suggest professionalism should bejudged by professionals’ ability to achieve atask and highlight concern for the ability ofthe medical professions to address the needsof the community today. In contrast toprofessionalism, the term professionalisationembraces the concrete features ofoccupations that have laid claim to beingprofessions, such as the increasing numbersof members of a profession, specifiedattributes of the group and identification oftraits of its members (Johnson, 1972), andalso conveys the purposeful movementtowards higher standards of professionalismthrough a continual refinement of practice.Professionalism can be regarded asprofessional behaviour which will maintainthe status of a profession in a static practiceenvironment, whereas professionalisation isrelated to professional action which showsthe character and spirit of a profession towork dynamically towards achieving goals ofprofessionalism (Houle, 1980) in responseto competition or change.

Professionalisation can progress forwardson many fronts at the same time. Anoccupation that lays claim to the distinctionconferred by the term profession seeksconstantly to improve itself throughrecognisable ways such as increasingcompetence in problem-solving, a capacityto use more complex knowledge and moresensitivity to ethical issues (Houle, 1980).Sim (1985) sees aspects of professionalism inphysiotherapy as ‘a widening of clinical and

administrative autonomy; an extension inboth breadth and depth of the professionalknowledge base; an increasingly criticalattitude to modes of treatment previouslytaken for granted; a readiness to tread theoften daunting paths of research; aheightened awareness of the social andethical ramifications of professionalpractice’. Campbell (1983) however graspsthe energy and vigour of this ‘process of making real and operative the passivewooden concept of professionalism’ forphysiotherapists. For him, professional-isation embodies an acquisition of under-standings, skills and techniques which‘enable practitioners to relate to thecommunity which they serve’. The processof professionalisation reclarifies andredefines professional functions, implyingnot only a mastery of the rudiments of theprofession but the continuing developmentof its knowledge base (Campbell, 1983).

The goal of a ‘seamless service’ betweenthe acute and community sectors ‘draws onthe assumption that the client is not somuch concerned with issues of multi-disciplinary demarcation as receiving aservice that is both effective and efficient’(Biggs, 1993). There are many opportunitiesfor physiotherapists to raise the profile oftheir practice. and to spend more time indeveloping the specialised aspects of care.They may see the relinquishing of many of their routine tasks to helpers as a threat to their work (Stewart, 1985), yet therecognition of the complexity anduncertainty of the professional task withinchanging contexts is a hallmark ofprofessional practice. Professionalisation isshown in an individual’s attitude, values andbehaviour, the level of involvement with theformal and informal culture of theprofession (Pong and Chok, 1994) and inindividuals’ attitude and perception of tasks’complexity, and the ways in which other staffare utilised (Hart et al, 1990). Taking aresponsibility in being a professional caninvolve activity other than direct patient care such as ‘policy formation and thedevelopment of morally good institutionalmechanisms’ (Purtilo, 1986). It can involvetaking the role of manager, facilitator oreducator as necessary to promote themobility of a client through interdisciplinaryteamwork.

It is clear that ‘professionalism may be anecessary constituent of professionalisationbut professionalism is not a sufficient causefor the entire professionalisation process’



(Vollmer and Mills, 1966). It is the conative(Ryle, 1980 ) orientation of the individualpractitioners and their will actively to pursueideals which operationalises the concept ofprofessionalism and actually moves aprofession forwards. Central to the conceptof professionalisation is an individualendeavour to life-long learning (Houle,1980). This encourages practitionerscontinually to re-appraise the occupationalmission (the professional purpose) andbecome aware of the need to redefine it inthe midst of change (Houle, 1980). Amotivation to develop personal practice andto work to professionalise the professionneeds a particular emphasis in under-graduate programmes.

Role of EducationWhether overtly or implicitly understood byeducators, students are prepared formembership of their professionalcommunity through the study ofcomponents of the professional paradigm(Kuhn, 1970). Professional education can becompared to students acquiring a lens whichfilters their attention to selected features ofthe professional world and to think about it in particular ways. They develop aphilosophy and values and attitudes whichwill lead them to identify particularproblems and to use particular methods forsolving them. Their external behaviour isguided and gated by their individualinternal view of the world (Törnebohm,1986). Their internal world picture willdetermine what they pay attention to, howthey use their knowledge of theory andpractice, how they evaluate good and badpractice, and how they develop their owntheories of practice. It will determine howthey perceive the purpose of their professionand the paths which they see as workingtowards achieving their professional goals.

In the new organisation of health care,new patterns of primary care will emergebottom-up from the ‘complex interplaybetween a variety of interested parties’ (Mayand Robinson, 1995). The extent to whichthis occurs for physiotherapy will rest verymuch on the sense of purpose andautonomy of individual practitioners andtheir ability to answer questions on who they are, what they do, how they do it, and why they do it (Peat, 1981).Educational processes aim to shapedivergent paradigms of individual studentstowards a convergent professional paradigmwhich will prepare them to take on the full

responsibilities of professionals. Theirexperiences need to endorse ‘thecomplexity, uncertainty, instability,uniqueness and value conflicts which areincreasingly perceived as central to theworld of professional practice’ (Schon,1991).

An investigation of the developingparadigms of physiotherapy of a cohort ofstudents in two schools of physiotherapy(Richardson, 1997) revealed stronginfluences of individual school programmeson the students' developing views of theirprofession. Questionnaires, administeredeach year, showed early in the first year thatstudents from one school were orientedtowards a scientific view of physiotherapywhile students from the other schoolacquired a more humanistic view. Studentsin one school showed little recognition ofteamwork or research as a means ofachieving goals, and students in the otherdemonstrated little understanding of theaims of the profession in the context ofhealth care in society. No purposeful effortto change their developing paradigms ofphysiotherapy could be determinedthroughout the three years of training.Students in one school remained morehumanistically concerned with creative andinterpersonal skills to communicate withindividual clients in work which addressedthe needs of society, while the other studentscontinued to be more scientifically orientedtowards research management and patienteducation in multidisciplinary teams, andshowed little concern for the role of theprofession in society. Students from bothschools lacked a full understanding of theaims, values and mode of practice of theirprofession. Large numbers of third-yearstudents in both schools were unable topinpoint a unique or essential part played byphysiotherapy in health care. This lack ofclarity of goal and professional purpose ledthem to give a low rating to their overallperceived understanding of the aims of theprofession of physiotherapy.

It is important to ensure that physio-therapists are equipped with a coherentcognition of physiotherapy which facilitateswise and independent professional actionsto professionalise and develop physiotherapywhen the task is not clear. Undergraduateeducation strongly influences the form-ation and development of a professionalparadigm. Problem-solving can simply focuson the ‘pathological condition or themechanism producing the problem’ (Olsen,


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1983). This narrow view of practice is notenough to cope with the increasinglycomplex situations commonly experiencedin health care which are ‘confusing messesincapable of technical solutions’ (Schon,1991). A conative disposition whichmotivates practitioners to pursue practicegoals is needed when challenged to take ‘aconvergent knowledge base and convert itinto professional services that are tailored tothe unique requirements of the clientsystem’ (Schien, 1973, cited in Schon, 1991).Taking responsibility for professionalisationmust be perceived as integral to being aphysiotherapist and the spur to continualprofessional development over theprofessional lifespan. Students need to have

an opportunity to learn about the history ofthe profession, to consider whatcontribution physiotherapy makes to healthcare and what it means to be a physio-therapist. They need to be prepared toaccept the responsibility to makejudgements which are mindful of theaspirations of the wider profession as well asthe immediate needs of intervention. Anactive and continual quest towards achievingthe full potential of physiotherapy will leadto a professional growth which keeps theconfidence of society by fulfilling the role towhich the physiotherapy profession laysclaim -- that of meeting people’s needs formobility and movement in their lives.

References

Barclay, J (1994). In Good Hands, ButterworthHeinemann, Oxford.

Barr, H (1998). ‘Competent to collaborate:Towards a competency-based model forinterprofessional education’, Journal ofInterprofessional Care, 12, 2, 181-187.

Bartlett, R C (1991). ‘In our hands’, 25th MaryMcMillan Lecture, Physical Therapy, 71, 11, 833-841.

Biggs, S (1993). ‘User participation andinterprofessional collaboration in communitycare’, Journal of Interprofessional Care, 7, 2, 151-159.

Campbell, D (1983). ‘Progressing towardsprofessionalisation: The role of continuingeducation’, Physiotherapy Canada, 35, 5, 248-251.

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Dyer, L E (1982). ‘Professional development’,Physiotherapy, 68, 12, 390-393.

Eraut, M (1994). Developing Professional Knowledgeand Competence, Falmer Press, London.

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Inui, T S, Williams, W T, Goode, L, Anderson, R J, Bhak, KN, Forsyth, J D, Wallace, A G and Daugherty, R M (1998).‘Sustaining the development of primary care inacademic medicine’, Academic Medicine,73, 3, 245-257.

Journal of the Chartered Society of Massage andMedical Gymnastics (1936). March, page 234,cited in: Barclay, J, In Good Hands, ButterworthHeinemann, Oxford.

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Kuhn, T S (1970). The Structure of ScientificRevolutions, University of Chicago Press, 2nd edn.

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Pong, W W and Chok, B (1994). ‘A study ofperceived complexity level of physiotherapyprocedures by physiotherapists’, Journal of theSingapore Physiotherapy Association, 15, 2, 4-10.

Key Messages

■ A well-developedview of our professionalidentity will guide thecontinuingdevelopment of theprofession throughconsiderable changesin health care.

■ Autonomy ofprofessional practicemay be under threat ina competitive client-focused health careservice.

■ Taking responsibilityfor the development ofthe profession isintegral to being aphysiotherapist.

■ Educationalprocesses must preparestudents to play a partin the development ofphysiotherapy as aprofession throughouttheir careers.



Purtilo, R (1986). ‘Professional responsibility inphysiotherapy: Old dimensions and newdirections’, Congress Lecture, Physiotherapy, 72,12, 579-583.

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Richardson, B (1992). ‘Professional educationand professional practice - Do they match?’Physiotherapy, 78, 1, 23-26.

Richardson, B (1997). ‘A longitudinal study ofstudent physiotherapists' understanding of theirprofession’, Nordisk Fysioterapi, 1, 34-39.

Rothstein, J M (1986). ‘Pathokinesiology: A nameof our times ?’ Physical Therapy, 66, 3, 364-5.

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Vollmer, H M and Mills, D L (eds) (1966).Professionalisation, Prentice-Hall, Englewood Cliffs,New Jersey.

Williams, J I (1986). ‘Physiotherapy is handling’,Physiotherapy, 72, 2, 66-69.

Professional Development2. Professional Knowledge and Situated Learning inthe Workplace

Key Words

Workplace culture, symbolicinteraction, situated learning,experiential learning,professional development.

by Barbara Richardson

IntroductionContinual changes in the ethos and deliveryof health services point to an increasing needfor physiotherapy practitioners to be able toidentify and solve physiotherapy problems innew and unforeseen fields of health care.Undergraduate education programmes todayare challenged to ensure that physiotherapistsare prepared to respond to changes in healthcare demands over the extent of a careerwhich may span forty years. Theirprofessional development is dependent upontheir ability to be situationally responsive andcontinually to review and evaluate their workthrough critical thinking, clinical reasoningand processes of reflection. This paper

Summary This is the second of two papers which look at therelationship between the development of individualphysiotherapists and the development of physiotherapy as aprofession. It explores the nature of professional knowledge andthe process of professional learning which is seen to be crystallisedthrough an integration of theory with practice in the workplace.Important influences of situated cognition and situated learning onphysiotherapy practice are identified and discussed in the contextof theories of social action and symbolic interaction. These theorieschallenge the curricular assumptions on which manyundergraduate education programmes are based. It is concludedthat education programmes which aim to facilitate professionaldevelopment may more effectively link theory and practice topromote professional learning which is relevant to changes in theethos and delivery of health services and work in healthcare teams.

Documents

Professional Development: 1. Professional socialisation and professionalisation