... ISSUES OF PROFESSIONALISM IN NEW OTS Issues of Professionalism in New Occupational Therapists Paige McIntire Hannah Hackman Kristen Dyson Angella Chen Erika Wilson December 2020 A research project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the research advisor: Dr. Taylor McGann, Assistant Professor Dr. Kate E., DeCleene Huber, Associate Professor 1 ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS A Research Project Entitled Issues of Professionalism in New Occupational Therapist Submitted to the School of Occupational Therapy at the University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Paige McIntire Hannah Hackman Kristen Dyson Angella Chen Erika Wilson Student Approved by: Taylor McGann Research Advisor (1st Reader) Date 2nd Reader Date Accepted on this date by the Doctor of Occupational Therapy Program Director: Alison Nichols OTD Program Director Dec 14, 2020 Date Accepted on this date by the Chair of the School of Occupational Therapy: Kate DeCleene Huber Chair, School of Occupational Therapy Dec 14, 2020 Date 2 ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 3 Abstract Literature: Professionalism in occupational therapy has been challenging to identify due to differing values and behaviors across contexts and professions (Aguilar et al., 2012; Mazor et al., 2007; Robinson et al., 2012; Stickley et al., 2017; Sullivan & Thiessen, 2015). There is a difference between how occupational therapy students and faculty both view and comprehend professionalism (Robinson et al., 2012; Sullivan & Thiessen, 2015), suggesting that new occupational therapists do not have an established sense of professionalism when entering into the health care field for the first time. Purpose: The purpose of the study was to examine occupational therapy facultys perceptions of essential professional behavior attributes that students should possess to be successful in entrylevel occupational therapy practice. Methods: This study utilized survey methodology to anonymously collect opinions from 150 occupational therapy faculty members across the United States regarding professional behavior attributes that are essential for entry-level occupational therapy education. Results: Researchers found that the five most frequently observed professional behavior attributes in occupational therapy students were team player, responsible, time-efficient, personable, and organized. Furthermore, the top seven most important professional behavior attributes are being clinically competent and ethical, having communication and interpersonal skills, and being adaptable, responsible, and empathetic. Conclusion: The results of this study indicate that occupational therapy faculty believe that many important attributes contribute to professionalism within the occupational therapy field and that teaching professionalism is an integral part of occupational therapy education. This study contributes to the current literature of defining professionalism within occupational therapy to better equip occupational therapy students entering into practice. Keywords: occupational therapy, professionalism, faculty perceptions, students, attributes, behavior ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 4 Issues of Professionalism in New Occupational Therapists Professionalism is a vast phenomenon, differing in definition by profession (Mazor et al., 2007; Robinson et al., 2012; Stickley et al., 2017; Sullivan, & Thiessen, 2015; Zafiropoulos, 2017). Defining professionalism is difficult secondary to varying values across professions (Gauger et al., 2004; Koenig et al., 2003; Mason & Mathieson, 2018). Although professionalism is vital in all disciplines, it is an essential element in the health care field as several researchers have found that professionalism directly relates to patient outcomes (Aguilar et al., 2012; Robinson et al., 2012; Sullivan & Thiessen, 2015). Professions frequently reference the American Board of Internal Medicine (ABIM, 2001) definition which states that the essential elements of professionalism include accountability, altruism, duty, excellence, honor, integrity, respect for others, and service (Blackall et al., 2007; DeLisa et al., 2001; Noronha et al., 2016; Shrank et al., 2004). Students in health care fields often struggle with understanding the meaning of professionalism due to its subjective nature of know(ing) it when they see it (Gauger et al., 2004, p. 479). Professional behaviors are challenging to learn, teach, and evaluate despite the significance to professional practice (Hackenberg & Toth-Cohen, 2018; Hodges et al., 2011; Robinson et al., 2012; Stickley et al., 2017). These difficulties correlate with several unsuccessful attempts to establish and validate a tool to assess professionalism (DeLisa et al., 2001; Yuen et al., 2016). Professionalism may vary over time (Hammer et al., 2000; Hodges et al., 2011), across contexts and environments (Aguilar et al., 2012; Burford et al., 2014; Chandratilake et al., 2012; Hodges et al., 2011; Hultman & Wagner, 2015; Jha et al., 2015; Robinson et al., 2012), as well as with different populations (Noronha et al., 2016; Sullivan & Thiessen, 2015). The subjectivity that surrounds professionalism relates to the need for ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 5 practicing occupational therapists to identify professional behavior attributes required of occupational therapy students and new graduates to best help them succeed in professional practice and generate positive patient outcomes. Researchers created this study to identify and understand what professional behavior attributes occupational therapy (OT) faculty deem as essential for entry-level occupational therapy practitioners in professional practice. Literature Review Defining Professionalism Clinical practice requires professionalism to be successful, but what constitutes professionalism can often be vague and difficult to establish (Stickley et al., 2017). In recent years, there has been increased attention in defining professionalism (Brissette et al., 2017; Robinson et al., 2012; Shrank et al., 2004), to clarify its meaning across contexts. Advances in technology, changes in delivery and reimbursement of health care, an explosion of information in the health care field, and an increasingly complex environment have all contributed to the increase of attention on professionalism (Green et al., 2009; Thistlethwaite & Spencer, 2008), as each of these has impacted how health care professionals carry out their jobs. Nortje (2017) stated that these changes in health care delivery threaten both the nature and value of professionalism, as well as frustrate current health care professionals. This threat stems from an increasingly complex health care system where practitioners must uphold the principles of patients welfare, patients autonomy, and social justice despite increasing numbers of disparities and limited resources that tempt practitioners to abandon their commitment to their professional values (Medical Professionalism Project, 2002). Professionalism includes things such as professional identity, and professional behaviors exhibited both at and away from work. Klemenc-Ketis and Vrecko (2014) stated that ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 6 professionalism includes attitudes, values, behaviors, and relationships that hold a health professional responsible in their society. It has been noted as one of the most important topics to learn in the health care field (Klemenc-Ketis & Vrecko, 2014; Taibah, 2018). Aguilar et al. (2012) defined professionalism in two ways: a behavioral perspective and a values perspective (Gauger et al., 2005; Sullivan & Thiessen, 2015). When defining the concept from a behavioral perspective, professionalism is the demonstration of the professional behaviors desired by that occupation, which does not account for the intrinsic factors that lead individuals to act in the ways that they do (Hammer et al., 2003). Professional behaviors are independent of the core knowledge and expertise that one has in his/her field of practice, meaning that individuals must learn these behaviors over time (Stickley et al., 2017). Defining professionalism from a values perspective shifts the focus from observable behaviors to the values that can guide and motivate practitioners, as well as unite a profession as a whole (Duque, 2004; Kanny, 1993). Social, cultural, political, and institutional environments shape these values, which go beyond observed behaviors (Martimianakis et al., 2009). These values must be explicitly stated for each profession as they enable practitioners to align their values with those of their profession (Byng et al., 2002), shape future practice (Aguilar et al., 2012), allow identification of conflicts that can occur between professions (Colombo et al., 2003), and clarify what it means to be a professional within each practice area (Aguilar et al., 2012). Although common, definitions based upon a list of proposed professional attributes, values, and behaviors do not adequately define professionalism, nor do they capture the social functions of the phenomenon (Wynia et al., 2014). Defining professionalism as a list of attributes, values, and behaviors suggests that individuals can obtain professionalism so long as they demonstrate the desired traits (Wynia et al., 2014). To address this issue, Wynia et al. ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 7 (2014) defined professionalism as, a normative belief system about how best to organize and deliver health care (p. 3), stating that it should ensure practitioners are deserving of the trust that their patients and the public place on them. List-based definitions are beneficial nonetheless, as professionalism requires specific behaviors (Wynia et al., 2014). Additionally, list-based definitions enable for a more functional way of teaching and measuring professionalism (Wynia et al., 2014) but should not be an exclusive method for defining professionalism (Wynia et al., 2014). Professionalism in Context In addition to the definition from Klemenc-Ketis & Vrecko (2014), The ABIM (2001) set forth a description of professionalism, stating that the phenomenon includes elements of accountability, altruism, duty, excellence, honor, integrity, respect for others, and service. To demonstrate professionalism in their work, practitioners must see these elements as both behaviors and values that they must uphold. Multiple researchers have used this definition since debuting in the late 20th century (Chisholm et al., 2006; DeLisa et al., 2001; Noronha et al., 2016). Noronha et al. (2016) used this definition to examine the similarities and differences of professionalism across physician assistants, physical therapists, occupational therapists, clinical psychologists, and biomedical sciences students finding that different disciplines emphasize different parts of the ABIM (2001). DeLisa et al. (2001) also used the ABIM definition of professionalism when surveying professional behaviors and values in physiatry students, finding that excellence, altruism/respect, and honor/integrity were the most commonly observed elements. Furthermore, Chisholm et al. (2006) found that six of the nine attributes established by the ABIM (2001) to be important to professionalism in pharmacy students. ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 8 Each discipline defines professional behaviors in their terms, which can complicate the perception of professional behaviors in health care (Stickley et al., 2017). Nursing defines professional behaviors as accountability, advocacy, autonomy, collaborative practice, commitment, competence, and knowledge (Stickley et al., 2017). This definition varies from the definition set forth by the American Occupational Therapy Association (AOTA), which identifies professional behaviors for occupational therapists as altruism, equality, freedom, justice, dignity, truth, and prudence (AOTA, 2015). Furthermore, physicians define professional behaviors to be awareness of their limitations, compassion, empathy, respectful/collaborative interactions with professional colleagues, and respect for patient dignity (Stickley et al., 2017). Lastly, Jette and Portney (2003) found that physical therapists should demonstrate seven main professional behaviors in practice. These behaviors include communication management, critical thinking, interpersonal skills, personal balance, professional development, professionalism, and working relationships (Jette & Portney, 2003; Stickley et al., 2017). Many of these definitions include aspects of communication, compassion, and autonomy, but no two definitions are the same. The issue with these varying definitions is in the way each practitioner understands and practices the professional behaviors defined by their profession (Zafiropoulos, 2017). These studies further show that the definition of professionalism, including values and beliefs, needs to be explicitly stated within each health care profession (Aguilar et al., 2012). Not only does the definition of professionalism differ by profession (Jette & Portney, 2003; Noronha et al., 2016; Stickley et al., 2017; Zafiropoulos, 2017), it also differs by context, because cultural background significantly influences how an individual perceives professionalism (Chandratilake et al., 2012). Chandratilake et al. (2012) found altruism to be highly important to Asian practitioners, moderately important to North American practitioners, ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 9 and unimportant to UK practitioners. The North American multicultural society is the only culture in the study by Chandratilake et al. (2012) that values being culturally sensitive to others. According to Nortje (2017), being culturally sensitive is important, as crossing cultural boundaries can make a patient feel disrespected or treated unprofessionally. Lastly, Chandratilake et al. (2012) found that Asian practitioners value discipline much more than European and North American practitioners. Core values of professionalism in South Africa differ as well, with the Health Professionals Council of South Africa defining 13 essential values (Nortje, 2017). These include respect for persons, beneficence, non-maleficence, human rights, autonomy, integrity, truthfulness, confidentiality, compassion, tolerance, justice, professional competence, self-improvement, and community (Nortje, 2017). Despite these differences in professional values, individuals of all cultures examined agreed on some essential values that must be present to be considered professional (Chandratilake et al., 2012). Some of these include being accountable for ones actions, being reliable and dependable, showing compassion, treating patients and colleagues fairly, following the laws, and communicating clearly and effectively with others (Chandratilake et al., 2012; Nortje, 2017). Values such as personal appearance, leadership, health, and composure were not deemed essential by any of the cultures examined (Chandratilake et al., 2012). Each culture represents its own set of values and beliefs that are essential to their definition of professionalism in that geographical region (Jha et al., 2015) which further complicates the construct. This additional complication leads to difficulty in understanding what values and beliefs must be present to be considered professional in the health care system. This complication exists in both a global and a local context, which further emphasizes the demand to ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 10 study professionalism in health care in the context of cross-cultural beliefs, values, and attitudes (Latif et al., 2018). It is also important to consider generational differences in the definition of professionalism as behavior is shaped by events and social conditions that each generation experiences throughout life (Hills et al., 2012; Hills et al., 2016; Noonan et al., 2019). Hills et al. (2012) called these differences generational characteristics. Each generation has its own set of generational characteristics, including beliefs, values, attitudes, and expectations (Hills et al., 2016), which have the potential to cause differences in definitions of professionalism. Noonan et al. (2019) found differences in communication style and values between Baby Boomers, Generation X, and Millennial physical therapists, stating that Millennials value more frequent feedback, open communication with their supervisors, and working in teams. This difference in Millennials is supported by Hills et al. (2016), who stated that this generation is more techno-savvy and overconfident. This form of communication is often seen by other generations as unprofessional (Hills et al., 2016) and may cause conflict or a misunderstanding within the workplace (Noonan, et al., 2019). Millennials also value respect more than other generations who place more value on trust and dependability (Hoonpongsimanont et al., 2018). Hoonpongsimanont et al. (2018) found that Generation X health care workers also value respect but view it differently than Millennials. Along with respect for patients, participants from both the Millennial group and Generation X group placed a high value on being trustworthy, dependable, and compassionate towards their patients (Hoonpongsimanont et al., 2018). In a separate study by Noonan et al., (2019) physical therapists from all three generations agreed that communication skills and interpersonal skills were the top two abilities relating to professionalism. All three generations ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 11 also ranked critical thinking and problem solving as important for professionalism within practice (Noonan et al., 2019). These results suggest that professional values are more important than differences in generational characteristics as there were no significant differences in ranking of the previously mentioned abilities related to professionalism by generation or years of work experience (Noonan et al., 2019). Despite differences in generational characteristics, research on age and years of experience does not suggest that these translate into significant differences in definitions of professionalism. Learning and Teaching Professionalism Although significant, the various beliefs and values that researchers use to define professionalism are challenging to learn, teach, and evaluate (Hackenberg & Toth-Cohen, 2018; Hodges et al., 2011; Stickley et al., 2017; Robinson et al., 2012). Educators rarely teach professionalism on its own, and instead instill the concept in other subjects, without making the objective clear (Klemenc-Ketis & Vrecko, 2014). This educational technique means that students often learn about professionalism through indirect methods (Novak-Antolic & Steblovnik, 2012). Additionally, what students are learning may differ from what they are seeing or experiencing when providing direct patient care in fieldwork or on clinical rotations (Reynolds et al., 2019). Hilton (2008) stated that professionalism is best taught through role modeling of educators in clinical settings so that students can observe interactions between the educators and patients or other professionals in an applicable environment (Johnston et al., 2011). Reynolds et al. (2019) stated that role modeling can be very beneficial so long as the modeling is positive, as 93% of participants in their study reported having a role model that positively influenced their professionalism. Also, they found that more than 58% of participants in their study changed their perception of the importance of professionalism in practice after seeing a teacher act in an ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 12 unprofessional manner (Reynolds et al., 2019), further showing how important it is that a role model demonstrates proper behaviors at all times. Palis & Alszul (2019) supported this notion. They found that professionalism is learned more effectively through the influence that clinicians have on students as compared to what the students learn in the classroom, further demonstrating the need for positive role models (Palis & Alszul, 2019). Hackenberg & Toth-Cohen (2018) stated that teaching methods should include more than just role modeling and suggested including formal advisor meetings/mentoring, lectures, practice/experience opportunities, reading assignments, and small group discussions to assist with teaching professionalism (Brown et al., 2016; Cruess & Cruess, 2006; Davis 2009). Students also have difficulty with learning and understanding professionalism due to their lack of lived experiences (Birden et al., 2014). Researchers believe that practitioners could resolve this difficulty if students had an increased amount of practice or several opportunities for professional interactions before entering the professional world (Hackenberg & Toth-Cohen, 2018). Reynolds et al. (2019) found that students learned more about professionalism when seeing it demonstrated in residency programs rather than when learning about the topic in the classroom. Students are not entirely at fault, as educators feel challenged when teaching professionalism due to its complex and ever-changing definition (Birden et al., 2014). Cohen (2006) stated that to teach professionalism, the educators must address three areas: improving the selection of future professionals, improving the formal instruction of professionalism, and ensuring that the learning environment is free of unprofessional practices. Harris et al. (2018) found that professional behaviors are the least focused upon topic in educating professional students. Grus et al. (2018) stated professionalism should be taught through both didactic and experiential learning, as well as through civic engagement. Didactic ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 13 education is highly effective if educators make implicit concepts more explicit and if they help students develop interprofessional thinking and communication strategies (Grus et al., 2018). Didactic learning has been linked to greater maturity for cultural and ethical issues, humanism, and professional values (Jha et al., 2007), with experiential learning allowing for more sophisticated learning needed for optimal professional functioning (Boenink et al., 2005). According to Coulehan (2005), students should also be provided opportunities for servicelearning activities to assist them with learning the importance of community service for their role as a professional in the health care field. Educators must also be equipped to teach professionalism to their students (Grus et al., 2018; Palis & Alszul, 2019). They must have access to professional development, have a good knowledge of the elements of professionalism, and understand their role in teaching and demonstrating professionalism within their field (Grus et al., 2018). Palis & Alszul (2019) stated that it is essential to train teachers on how to teach and model professionalism to their students, also noting that it is uncommon to train educators on how to explicitly teach ethics and accountability (Steinert et al., 2005). It is essential not only to evaluate the professionalism of students but also to assess the effectiveness of the teachers who teach this vital concept (Palis & Alszul, 2019). Evaluating Professionalism Evaluation of professionalism is also challenging. Researchers have designed many measurement approaches, but there are few proposed methods and instruments that can fully evaluate an individuals level of professionalism (Ginsburg et al., 2000). This challenge stems from the concept that professionalism is a complex construct with many facets that are hard to operationalize (Grus et al., 2018). Many researchers have used the ABIM (2001) measurement ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 14 tool to measure professionalism, but this tool has not validated across all professions and it may not capture professionalism in its entirety (Chisholm et al., 2006; DeLisa et al., 2001; Noronha et al., 2016). Shrank et al. (2004) suggested that no one tool is adequate to measure the complexity of professionalism and that assessments should utilize many sources to fully capture the concept. Grus et al. (2018) suggested that each health care profession should have their own assessment tool to ensure that professionalism within that specific health care realm is adequately measured. Researchers have traditionally assessed professionalism by using the global performance rating that retrospectively rates behaviors using a numerical scale (Accreditation Council of Graduate Medical Education & American Board of Medical Specialties Joint Initiative, 2000). This method lacks direct observation and relies heavily on the raters responses, which can lead to bias (Cunnington et al., 1997). Simulated patient assessments and objective structured clinical exams (OSCEs) reduce this bias and provide a more stable assessment of professionalism (Roberts & Norman, 1990). Peer evaluation can also add value to the assessment of professionalism through evaluation and training techniques that practitioners use in health care (Shrank et al., 2004). Goldie (2013) indicated that peer assessments and OSCEs are essential in measuring professionalism, but also stated that observation from faculty members is beneficial. A combination of these assessment types could lead to a tool that accurately measures professionalism across contexts and within different health care professions. Frost et al. (2018) used the Interprofessional Professionalism Assessment (IPA) to measure professionalism, which has proven to be both reliable and valid for measuring professionalism across multiple professions and contexts. This observational tool can be used by a faculty member or preceptor to evaluate a learner or by the learner as a self-assessment (Frost et al., 2018). The IPA focuses on collaboration and teamwork, as well as an individuals ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 15 behaviors that contribute to professionalism by measuring 26 behaviors across four domains (Frost et al., 2018). These four domains are communication, respect, excellence, and altruism and caring (Frost et al., 2018), which align with elements of professionalism defined in the ABIM (2001). This tool lays the foundation for assessing interprofessional professionalism across health care practices and settings (Frost et al., 2018) but is still in the beginning stages of research meaning research will need to continue before establishing the tool as the sole tool for measuring professionalism. The Professional Assessment Tool (PAT) has proven to be reliable and valid for use with pharmacy students but may also be suitable to measure professionalism with athletic training, occupational therapy, physical therapy, physician assistant, and respiratory therapy students (Harris et al., 2018). When tested among these professions, the tool showed high levels of internal consistency for all professions and seems to address the weakness of other tools that measure professional behaviors in these health care fields, as it aligns with their respective expected professional attributes (Harris et al., 2018). Researchers found the PAT to be valid with all professions except for athletic training and respiratory therapy in its initial testing (Harris et al., 2018). Not only does this tool measure the professionalism of students, but it also measures how effective the curriculum and clinical education were in developing professionalism (Harris et al., 2018). Professionalism in Occupational Therapy The current study examines professionalism in occupational therapy specifically and, therefore, should include the existing literature on the topic. Many studies done on professionalism in occupational therapy have found that it is challenging to identify the values and behaviors of professionalism due to the differing expectations across contexts (Aguilar et al., ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 16 2012; Robinson et al., 2012; Sullivan & Thiessen, 2015). Researchers have conducted most of their studies on occupational therapy students, and how this population learns professionalism through time in the classroom and on fieldwork (Ashby et al., 2016; Hackenberg & Toth-Cohen, 2018; Robinson et al., 2012; Sullivan & Thiessen, 2015). Hackenberg & Toth-Cohen (2018) stated that occupational therapy students would benefit most from explicit education on the topic, with a specific focus on aspects such as communication, responsibility, work behaviors, and time management. They indicated that professionalism should be addressed at the beginning of the students program, and throughout the program by fieldwork placements and assessments by faculty and the students (Hackenberg & Toth-Cohen, 2018). Role models can be vital within the student population as well (Silva et al., 2019). Silva et al. (2019) found that clinical tutors believe that demonstrating empathy towards patients, having good relationships with students, and being enthusiastic about the profession of occupational therapy made them good role models for students. On the other hand, students identified good relationships with students, integrity and ethical behavior, respectful relationship with colleagues, patient management skills, a commitment to personal and professional growth, and enthusiasm for the profession of occupational therapy as qualities of a positive role model (Silva et al., 2019). Students have also stated that they lack confidence in their ability to adjust to the differing expectations of professionalism when in different contexts (Robinson et al., 2012). Lower levels of confidence could be due to a lack of experience and is not a phenomenon seen in occupational therapy faculty who have had more practice navigating unfamiliar environments (Robinson et al., 2012). Furthermore, students are ambiguous about where professionalism begins and ends (Robinson et al., 2012) as well as have difficulty identifying professionalism ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 17 when their knowledge of the topic is different than the professionalism they observe in the field. (Ashby et al., 2016). There is a difference between how occupational therapy students and faculty view and comprehend professionalism, which indicates that professionalism is an ongoing developmental process (Robinson et al., 2012; Sullivan & Thiessen, 2015). This difference suggests that new occupational therapists do not have an established sense of professionalism when entering into the health care field for the first time. Mason and Mathieson (2018) found that employers look for aspects of professionalism such as client centeredness, communication, respect, and teamwork when hiring occupational therapists. Of these behaviors, Mason and Mathieson (2018) cited communication and respect as the most important. In an additional study, Swan et al. (2019) found that communication, self-management, and critical thinking were the most important attributes that contribute to being an excellent occupational therapist in an adult acute care setting. Of these, communication was the most important (Swan et al., 2019). Sullivan and Thiessen (2015) stated that advocating for occupational therapy is also an essential aspect of professionalism, meaning that occupational therapists should foster a positive perception of their profession and demonstrate professionalism in all settings. Not only does professionalism vary by profession (Mazor et al., 2007; Robinson et al., 2012; Stickley et al., 2017; Sullivan, & Thiessen, 2015; Zafiropoulos, 2017), but it also differs within a profession based on context (Aguilar et al., 2012; Robinson et al., 2012; Sullivan & Thiessen, 2015). Occupational therapy is a demonstration of this. These differences in professionalism could lead to problems in the workplace. Increased professionalism has been linked to improved patient outcomes (Aguilar et al., 2012; Robinson et al., 2012; Sullivan & Thiessen, 2015), suggesting that a lack of professionalism could lead to lower patient outcomes ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 18 among other problems. To combat this issue, occupational therapy students must have a clear expectation of the professional behavior attributes expected of them when entering professional practice. This study seeks to identify what professional behavior attributes occupational therapy faculty deem as essential for entry-level occupational therapy practitioners so that future occupational therapists are better equipped when entering professional practice. Methods This study utilized survey methodology to anonymously collect opinions from faculty in occupational therapy programs regarding professional behavior attributes that are essential for entry-level occupational therapy education. Researchers adapted the survey from components of surveys by Campbell et al. (2015) and Davis (2009) to cover all topics on demographics adequately, and professional behavior attributes needed for the current study. Researchers adapted the structure of the survey from Davis (2009), with all references about physical therapy modified to represent the occupational therapy profession. Researchers omitted some questions from the original study by Davis (2009) due to a lack of relevance to the current research. The 22 professional behavior attributes used in the present study were borrowed from Campbell et al. (2015) to apply to academic education. Participants The participants for this study consisted of 150 individuals who are faculty in an entrylevel occupational therapy program in the United States. Researchers sent the survey out to 655 individuals, with a response rate of 22.9%. Of these participants, 146 were occupational therapists. All respondents had a minimum of a bachelors degree in their respective fields, with 124 (83%) having earned a doctorate as his or her highest level of education. Represented doctorate degrees include Doctor of Philosophy (PhD), Doctor of Education (EdD), post-professional doctorate, ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 19 post-professional doctorate in occupational therapy, entry-level Doctor of Occupational Therapy (OTD), Doctor of Physical Therapy (DPT), Doctor of Science (ScD), Juris Doctor (JD), and Doctor of Public Health (DrPH). Table 1 shows responses for the highest earned degree. Table 1 Highest level of degree earned Degree earned n Percentage Post-professional doctorate in occupational 53 35.5 PhD 45 30.0 Entry-level MOT 11 7.38 Post-professional masters 11 7.38 Post-professional doctorate 10 6.71 EdD 8 5.37 Other 7 4.70 Entry level OTD 4 2.68 therapy Note. n= Total participants with an earned level of degree. PhD = Doctor of Philosophy. MOT = Master of Occupational Therapy. EdD = Doctor of education. OTD = Doctor of Occupational Therapy Respondents between 36 to 65 years of age accounted for 78% of the sample size, with 19 participants ranging between 26 and 35 years of age and 12 participants ranging between 66 and 75 years of age. One participant preferred not to say their age. Table 2 Age range of participants ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS Age range 20 n Percentage 20-25 0 0.00 26-35 19 12.84 36-45 38 25.68 46-55 40 27.03 56-65 38 25.68 66-75 12 8.11 >75 0 0.00 Prefer not to say 1 0.68 Note. n= number of participants in the selected age range Years of teaching experience ranged from less than five years to more than 35 years, with the highest representation from those with 0 to 5 years of experience (36%), closely followed by 6 to 15 years of experience (34%). Only five participants (3%) had more than 35 years of teaching experience. A majority of participants (58%) taught at a private program within the United States. The geographical representation of the respondents showed that a majority of the participants teach at programs in the Midwest and Southeast. Respondents teaching in the Midwest region of the United States accounted for 39%, with an additional 25% teaching in the Southeast. Only 5% of participants report teaching in the Western part of the United States, making it the least represented geographical area. Procedures The researchers obtained Institutional Review Board approval from a small university in the Midwest region of the United States and conducted the study at the same university. Researchers formed the sample through convenience sampling by obtaining emails for all faculty ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 21 at each Accreditation Council of Occupational Therapy Education (ACOTE) accredited occupational therapy program across the United States. Researchers contacted all program administrators for the programs whose website did not provide emails to obtain direct faculty emails for the survey to be sent. Researchers omitted faculty when programs failed to provide emails. Researchers sent the survey to faculty at 209 ACOTE accredited programs across the United States with 180 entry-level masters programs and 29 entry-level doctorate programs. All responses from participants in this study remained anonymous to minimize the chance of researcher and participant bias. Researchers collected data electronically between May 13, 2019, and June 12, 2019, using an online survey created on Qualtrics. Researchers sent a total of two reminder emails, one at two weeks (May 28, 2019) and one at four weeks (June 10, 2019) after participants received the initial survey. The first part of the survey asked participants questions related to demographics and their position within their respective programs. The second part of the survey asked participants to respond to six statements relating to their beliefs regarding their current teaching experience using a Likert scale ranging from strongly disagree to strongly agree. Researchers asked one additional yes/no question about a course teaching professionalism at their respective universities. The following section asked participants to identify how frequently they observe 22 different professional behaviors in their entry-level students by responding with never, infrequently, occasionally, often, or very often. Researchers then asked participants to rate each of the 22 professional behaviors on their level of importance ranging from (1), not at all important to (5) extremely important. Participants then chose what they believe are the seven most important professional behaviors attributes. Finally, participants shared how their programs ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 22 teach or foster professionalism for their entry-level students. An optional prompt was provided for participants to share feedback regarding the survey or their personal opinions/experiences with the topic. Results The results of this study indicate that the majority of participants (98%) agreed either strongly or somewhat that teaching and fostering professional behaviors is an important part of occupational therapy education, while only three participants strongly disagreed with this statement. Table 3 shows this in more detail. Table 3 Attitudes Related to Teaching and Fostering Professionalism in Occupational Therapy Strongly Somewhat Neither agree Somewhat Strongly Question disagree disagree nor disagree agree agree Teaching and fostering 3 (2.05) 6 (4.11) 137 (93.84) 65 (44.52) 65 (44.52) professional behaviors is an important part of occupational therapy education. At the present time, I have concerns about the professional behaviors of one or more of my entrylevel occupational therapy students. 4 (2.74) 4 (2.74) 8 (5.48) ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS The program for which I teach 1 (0.68) 7 (4.79) 23 6 (4.11) 42 (28.77) 90 (61.64) 2 (1.36) 55 (37.41) 90 (61.22) 2 (1.36) 57 (38.78) 88 (59.86) 56 (37.84) 7 (4.73) places a high degree of emphasis on assessing professional behaviors as part of the entry-level occupational therapy program. Professionalism is a construct (concept) that can be learned. Professionalism is a construct (concept) that can be taught. A students age at the time of 11 (7.43) 35 (23.65) 39 (26.35) admission to an entry-level occupational therapy program is a strong predictor of professionalism during the occupational therapy program. Note. All values are expressed as n (%). Questions in table adapted from work by Davis (2009) When looking at a breakdown of the same question by age range, 89% or more of respondents in each age range strongly agree that teaching and fostering professional behaviors is an important part of occupational therapy education. For age ranges 26-35 years, 46-55 years, and 56-65 years, one participant in each group responded with strongly disagree. Only three participants ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 24 across all age range responded with somewhat agree, with no answers of neither or somewhat disagree. Ninety-three percent or more of those in each range of years of teaching experience strongly or somewhat agreed with the statement, with all of those with more than 35 years of experience responding with strongly agree. One participant from 0-5 years of experience, 16-25 years of experience, and 26-35 years of experience each strongly disagreed with the statement. One hundred percent of participants with all degrees other than post-professional master's, postprofessional doctorate in OT, and PhD stated that they agree that teaching and fostering professional behavior is an important part of occupational therapy education. Only one participant with each of the remaining degrees said that they strongly disagree with the concept. Most participants (90%) indicated that they strongly agreed that the program in which they taught placed a high degree of emphasis on asserting professional behaviors as part of the program. Table 3 shows the results of this question. Researchers asked participants if they had concerns relating to the professional behaviors of one or more entry-level occupational therapy students. The majority of participants (89%) indicated they either somewhat agreed or strongly agreed, meaning that the majority of participants have experienced concerns relating to the professionalism of their students. Eight of the total participants disagreed with the statement, suggesting that they do not have concerns regarding the professional behaviors of their students. Table 3 shows additional responses. All participants between the ages of 26 and 35 either strongly or somewhat agree about having concerns with the professional behaviors of one or more of their occupational therapy students. Over 80% of respondents for all remaining age ranges except those between the ages of 66 and 75 either strongly or somewhat agree with the statement. Three participants in the age range 46-55 and 56-65, along with two participants in the age range 66-75, disagreed with the ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 25 statement in some capacity. Ninety-six percent of those with 0-5 years of teaching experience agree about having concerns about the professional behaviors of one or more of their occupational therapy students, but only 60% of those with more than 35 years of experience agree with the statement. Over 75% of all other ranges of years of teaching experience also agreed with the statement. At least one of the participants from each range responded with neither, with a total of eight participants across all ranges disagreeing either somewhat or strongly. Eighty percent of participants or more with each type of degree agreed that they had concerns about the professional behavior of one or more of their occupational therapy students. When asked if professionalism is a construct (concept) that can be learned, 90 participants (61%) indicated that they strongly agreed with this statement, while 55 participants (37%) indicated that they only somewhat agreed with this statement. Only two individuals (1%) neither agree nor disagree with this statement, with none of the participants disagreeing in any capacity. When asked to respond to the statement, Professionalism is a construct (concept) that can be taught, 88 (60%) participants indicated that they strongly agreed with this statement, while 57 (39%) participants indicated that they somewhat agreed with this statement. Two individuals (1%) responded with neither agree nor disagree, and none of the participants disagreed with the statement. Fifty-six participants (38%) stated that they somewhat agree that a students age at the time of admission to an entry-level occupational therapy program is a strong predictor of professionalism. Thirty-nine participants (26%) indicated that they neither agree nor disagree. Only 7 participants (5%) reported that they strongly agree with this idea, with 46 participants (31%) suggesting that they disagree in some capacity. Participants across all age ranges varied in their responses. A maximum of three respondents (8%) from any age range strongly agreed with ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 26 the statement. Over half of respondents for age ranges 46-55 and 56-65, along with the one respondent who preferred not to provide their age agreed with the statement either somewhat or strongly. Sixty-six percent of those aged 66-75 either somewhat or strongly disagreed. Eight of the 14 (57%) participants with 16-25 years of teaching experience somewhat agreed that a students age at the time of admission would strongly predict their professionalism during their program. Sixty percent of those with more than 35 years of teaching experience disagreed. Responses were varied when assessing this question by the highest level of degree. A maximum of 60% of respondents from any one degree agreed that a students age at the time of admission to an OT school would impact their professionalism during the program. At least one participant with each degree disagreed with the concept. Up to 54% of respondents with any one degree responded with neither suggesting that they neither agree nor disagree with this concept. Researchers presented participants with 22 professional behavior attributes from Campbell et al. (2015) and asked them to identify the frequency of which they observed these behaviors in their occupational therapy students. The five most frequently observed professional behavior attributes were team player, responsible, time-efficient, personable, and organized as shown in Table 4. Table 5 shows the frequency at which participants have observed all other professional behavior attributes in students. Table 4 Five most frequently observed professional behavior attributes of entry-level occupational therapy students Professional Never Infrequently Occasionally Often Very often Total 3 (2.14) 18 (12.86) 85 (60.71) 34 (24.29) 140 behavior attribute Team Player ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 27 Responsible 2 (1.42) 18 (12.77) 84 (59.57) 37 (26.24) 141 Time Efficient 5 (3.55) 33 (23.40) 82 (56.16) 21 (14.89) 141 Personable 2 (1.42) 14 (9.93) 81 (57.45) 44 (31.21) 141 Organized 4 (2.84) 30 (21.28) 80 (56.74) 27 (19.15) 141 Note. All values are expressed as n (%). Attributes derived from a study by Campbell et al., 2015 Table 5 Frequency of Student Behavior Behavior Infrequently Occasionally Often Very Often Total Adaptable 6 (4.26) 40 (28.37) 69 (48.94) 26 (18.44) 141 Adherence to policies 4 (2.86) 19 (13.57) 78 (55.71) 39 (27.86) 140 Clinically Competent 4(2.86) 33 (23.57) 80 (57.14) 23 (16.43) 140 Communication Skills 5 (3.55) 40 (28.37) 67 (47.52) 29 (20.57) 141 Confident 10 (7.09) 61 (43.26) 58 (41.13) 12 (8.51) 141 47 (33.57) 51 (36.43) 19 (13.57) 140 Constructive Criticism Never 1 (0.71) 22 (15.71) Creative 6 (4.26) 31 (21.99) 73 (51.77) 31 (21.99) 141 Culturally Competent 6 (4.29) 35 (25) 70 (50) 29 (20.71) 140 Empathetic 1 (0.71) 17 (12.06) 80 (56.74) 43 (30.5) 141 Enthusiastic 2 (1.43) 13 (9.29) 76 (54.29) 49 (35) 140 Ethical 1 (0.71) 23 (16.43) 69 (49.29) 47 (33.57) 140 Independent 12 (8.51) 43 (30.50) 74 (52.48) 12 (8.51) 141 Initiator 5 (3.55) 49 (34.75) 68 (48.23) 19 (13.48) 141 Interpersonal Skills 8 (5.71) 25 (17.86) 81 (57.86) 26 (18.57) 140 Leadership Skills 6 (4.26) 62 (43.97) 60 (42.55) 13 (9.22) 141 ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 28 Organized 4 (2.84) 30 (21.28) 80 (56.74) 27 (19.15) 141 Patient 4 (2.84) 43 (30.50) 76 (53.90) 18 (12.77) 141 Personable 2 (1.42) 14 (9.93) 81 (57.45) 44 (31.21) 141 Positive attitude 3 (2.14) 17 (12.14) 79 (56.43) 41 (29.29) 140 Responsible 2 (1.42) 18 (12.77) 84 (59.57) 37 (26.24) 141 Team Player 3 (2.14) 18 (12.86) 85 (60.71) 34 (24.29) 140 Time Efficient 5 (3.55) 33 (23.40) 82 (58.16) 21 (14.89) 141 Note. All values are expressed as n (%). Attributes derived from a study by Campbell et al., 2015 Researchers asked participants to rank the importance of the 22 professional behavior attributes on a scale ranging from not at all important to extremely important in relation to being a successful occupational therapist in practice. Participants did not rank any attributes as not at all important and only ranked eight as being slightly important. Participants aged 26-35 ranked all 22 professional behavior attributes as at least moderately important when demonstrating professionalism in practice. Participants in this age range rated ethical, personable, adherence to policy, clinically competent, and communication skills as extremely important most frequently. The skills of adaptable and constructive criticism was also at times ranked as extremely important but also appeared as very important within this age range. Over 75% of participants age 36-45, ranked ethical, responsible, and communication skills as extremely important. At least one participant from this age range ranked culturally competent, leadership skills, and organizer as only slightly important, yet over 50% of those in the age range rated culturally competent and leadership skills as extremely important. Sixty-eight percent or more of participants in the 46-55 age range ranked ethical, clinically competent, ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 29 interpersonal skills, communication skills, and responsible as extremely important, with all professional behavior attributes being at least slightly important. Those aged 56-65 agreed, ranking four of the five same attributes as extremely important with leadership skills taking precedence over clinically competent. All participants aged 66-75 rated ethical and communication skills as extremely important, with all but one in this group also ranking interpersonal skills as extremely important. Ten of the 12 in this age range also ranked leadership skills as extremely important, with all participants listing organizer as at least moderately important. Consistencies between age ranges include having ranked ethical as an extremely important professional behavior attribute. In addition, interpersonal skills, clinically competent, and responsible as extremely important, most often behind ethical. An identified discrepancy between ages 26-35 and all other participant age ranges is that the younger age group ranked adherence to a policy as much more important than their older counterparts indicated. When analyzing the same question broken down by the highest level of degree earned commonalities and discrepancies were discovered. Over 80% of participants with a PhD ranked clinically competent, communication skills, ethical, interpersonal skills, and responsible as extremely important, with ethical being ranked extremely important most frequently. Participants with an EdD ranked ethical and interpersonal skills as extremely important most often, while ranking confident and patient as very important most often. Over 70% of those with postprofessional OTD degrees ranked clinically competent, communication skills, ethical, and interpersonal skills as extremely important. Seventy-two percent of participants reported confidence as very important. All participants with a post-professional doctorate reported ethical and responsible as extremely important while over 75% also listed adaptable, adherence to policies, clinically competent, communication skills, empathetic, interpersonal skills, positive ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 30 attitude, and team player as extremely important. Over 70% of participants with a postprofessional masters degree ranked 10 of the 22 professional behavior attributes as extremely important but had varied responses regarding the importance of leadership skills and organizer as some said they were only moderately important with others ranking them as extremely important. All participants with an entry-level OTD degree ranked eight of the attributes as extremely important, with 75% of participants ranking an additional nine as extremely important. Those with post-professional masters degrees and entry-level OTD degrees agreed on the importance of clinical competence, communication skills, cultural competence, empathy, ethics, responsibility, and being a team player. Over 70% of participants with a degree other than those listed in the survey ranked the same attributes as extremely important but also reported creative, independent, and time efficient as extremely important. Participants with an entry level masters of occupational therapy degree most frequently ranked adaptable, adherence to policies, communication skills, ethical, and being responsible as extremely important. Despite having different levels of education, participants with all degree types ranked ethical as extremely important with all groups other than EdD also ranking communication skills as one of the most important attributes. Participants with an OTD degree ranked more attributes as extremely important than any other group. When looking at the ranking of importance of professional behaviors broken down by years of experience, participants with 0-5 years of experience most frequently cited clinically competent, communication skills, ethical, interpersonal skills, being personable, and being responsible as extremely important. Participants with 6-15 years of experience had varied beliefs about the importance of many of the attributes, with only five of the attributes being ranked extremely important by over 70% of those with this much experience. These participants most ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 31 frequently cited being ethical as extremely important. Individuals with 16-25 years of experience most frequently rated communication skills, being confident, and being ethical as extremely important, with being independent as very important. Ninety-two percent of participants with 2635 years of experience ranked communication skills, being ethical, and being responsible as being extremely important. Additionally, over 70% also reported adaptable, clinically competent, culturally competent, and team player as extremely important. There were only five participants with over 35 years of experience, all of whom ranked ethical and communication skills as extremely important. Participants across all ranges of experience agreed on the importance of both ethical and communication skills. Those with fewer years of experience emphasized a higher level of importance for being personable while those with more experience more valued being culturally competent and being a team player. Finally, researchers asked participants to indicate the seven most important attributes for a practicing occupational therapist, as derived from a list of professional behavior attributes (Campbell et al., 2015). Participants reported being clinically competent and ethical, having communication skills and interpersonal skills, and being adaptable, responsible, and empathetic as the seven most important professional behavior attributes, as seen in Table 6. Table 6 Seven Most Important Professional Behavior Attributes for Practicing Occupational Therapists Professional Behavior No. of Times Ranked as One of the % of Times Ranked as One of Attribute Seven Most Important the Seven Most Important Clinically Competent 109 11.34 Ethical 109 11.34 Communication Skills 92 9.57 ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 32 Interpersonal Skills 84 8.74 Adaptable 83 8.64 Responsible 77 8.01 Empathetic 66 6.87 Culturally Competent 60 6.24 Team Player 58 6.04 Adherence to Policies 35 3.64 Constructive Criticism 32 3.33 Time Efficient 27 2.81 Patient 25 2.60 Personable 24 2.5 Independent 15 1.56 Initiator 15 1.56 Creative 14 1.46 Confident 13 1.35 Leadership Skills 11 1.14 Enthusiastic 6 0.62 Organizer 6 0.62 When looking at responses for most important professional behavior attributes by age range, highest earned degree, and years of teaching experience, all subgroups in each category rated clinically competent as one of the seven most important attributes needed by new ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 33 occupational therapists. Participants in all subgroups for age range and years of teaching experience rated ethical and responsible as two of the seven most important attributes. Participants in all age ranges rated ethical, clinically competent, and responsible as most important. All age ranges other than prefer not to answer indicated that communication skills and interpersonal skills were in the top seven. Four of the six age groups rated empathetic as one of the most important attributes, with those aged 46-55 and 56-65 not having the attribute in their top seven. Those aged 46-55 and 56-65 rated culturally competent in the top seven, while participants in age groups 56-65 and 66-75 both rated team player as one of their most important attributes. The prefer not answer respondent and those in the age group 26-35 believed that time-efficient was one of the top seven most important. All participants with all degrees rated communication skills and clinically competent as two of the most important attributes for new occupational therapists to demonstrate. All groups except those with a degree other than what was listed stated that ethical was also one of the top seven most important attributes. Six of the eight groups reported responsible, adaptable, and culturally competent as one of the most important attributes. Those with post-professional doctorate degrees, entry-level OTD degrees, and entry-level MOT degrees were the only groups to not rate interpersonal skills as a top seven most important professional behavior attribute. Those with entry-level OTD degrees, post-professional masters degrees, post-professional doctorate degrees in OT and other degrees rated empathetic as one of the most essential attributes. Those with an EdD degree, an entry-level OTD degree, or a post-professional masters degree all ranked team player in their ranking of most important attributes. Two of the eight groups mentioned initiator and team player as two of the most important attributes. Only one participant in each group mentioned independent, constructive, adherence to policy, and patient. ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 34 Both independent and constructive were only mentioned as most important by those with an EdD degree. All participants of varied years of experience rated clinically competent, ethical, interpersonal skills, and responsible as four of the most important attributes for new occupational therapists. All but one group agreed that communication skills and adaptable are also in the top seven. Therapists with 26-35 years of experience did not report communication skills in their top seven, and those with more than 35 years of experience did not mention adaptable. Neither those with 0-5 years of experience nor those with 16-25 years of experience said culturally competent. Only those with 0-5 years of experience and those with more than 35 years of experience mentioned empathetic. Only those with 16-25 years of experience and those with 26-35 years of experience said team player in their top seven professional behavior attributes. Discussion Several studies found that professional behaviors, although significant to professional practice, are challenging to learn, teach, and evaluate (Hackenberg & Toth-Cohen, 2018; Hodges et al., 2011; Robinson et al., 2012; Stickley et al., 2017). Our study contraindicates this, as a majority of participants believe that professionalism can be both learned and taught. Notably, 98% of participants agreed that teaching professional behaviors in OT education is important yet only 71% state that they specifically teach professionalism. Klemenc-Ketis & Vrecko (2014) report that educators rarely teach professionalism on its own, which begs the question of if the participants in this study are teaching about professionalism directly when addressing the topic. Participants report addressing professionalism most often in education through reading assignments, small group discussions, lectures, and formal faculty meetings but it is still unclear if this information is directly related to professionalism or only incorporates the topic. ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 35 Birden et al. (2014) indicated a lack of experience might be the reason that students have difficulty learning and understanding professionalism. In the current study, 63 participants stated that they agree that a students age at the time of admission to their respected occupational therapy program is a strong predictor of professionalism. This lack of experience may or may not correlate with the age of the students upon admission and is recommended for further investigation. Nonetheless, it is a concept that over 40% of participants believe has an impact on professionalism in practice. In previous studies, students reported a lack of confidence in their ability to adjust to the differing expectations of professionalism when in different contexts (Robinson et al. 2012). Participants in this study did not rank confidence as one of the most important attributes to demonstrate professionalism as a new occupational therapist. This difference may align with the research studies that reported the differences in how OT students and faculty view and comprehend professionalism (Robinson et al., 2012; Sullivan & Thiessen, 2015). In our study, 89% of participants had concerns relating to the professionalism of one or more of their students, which supports the thought of many new OTs not having established professionalism when entering into practice and thus potentially negatively impacting patient outcomes (Aguilar et al., 2012; Robinson et al., 2012; Sullivan & Thiessen, 2015). Jette & Portney (2003) and Stickley et al. (2017) found that physical therapists should demonstrate seven main professional behaviors in practice, which include communication management, critical thinking, interpersonal skills, personal balance, professional development, professionalism, and working relationships. Our study indicated that occupational therapists valued different professional behaviors when compared to physical therapists. These included clinical competence, ethical, communication skills, adaptable, responsible, and empathetic. The ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 36 differences in valued professional behaviors among physical therapy and occupational therapy may be due to differences in the guidelines for practice that each profession has established. What is important in one profession may not be equally as important in another. This difference in importance supports previous research that highlights the broad and vast nature of professionalism within the health care field (Mazor et al., 2007; Robinson et al., 2012; Stickley et al., 2017; Sullivan, & Thiessen, 2015; Zafiropoulos, 2017). Throughout the literature on professionalism, the skill of communication has been talked about many times (Jette & Portney, 2003; Stickley et al., 2017). Mason & Mathieson (2018) found communication to be specifically important to occupational therapy employers. The current research reverberates this phenomenon as participants consistently rated communication as one of the top seven most important professional attributes. The combination of previous and current literature solidifies the importance of communication in demonstrating professionalism in occupational therapy practice. The current study echoes findings by Noonan et al., (2019) regarding the importance of both communication skills and interpersonal skills in professionalism within health care. Researchers found these two professional behavior attributes to be two of the top seven most important attributes for all age ranges of occupational therapists in the current study, except for the one respondent who preferred not to state their age. Participants across the age ranges of occupational therapists ranked both of these professional behavior attributes as extremely important. Physical therapists also ranked these two professional behavior attributes to be important (Noonan et al., 2019), suggesting congruence across both therapy professions. Participants with varying years of experience showed some differences in the importance of these two attributes. While all ranges of experience ranked communication skills as extremely ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 37 important, those with 26-35 years of experience did not put communication skills in the top seven most important attributes. All other ranges of experience ranked it as a top seven attribute, with all groups also ranking interpersonal skills in the top seven most important. While not a significant difference from the Noonan et al. (2019) findings, this does beg the question of why those with more experience did not feel that communication skills were in the top seven most important attributes despite reporting that these skills are extremely important to professionalism. The current study supports additional findings of Noonan et al. (2019) in regard to a lack of differences in rankings of professional behavior attributes based upon age of participant. Being ethical, clinically competent, and responsible were ranked by participants from all age ranges as the most important professional behavior attributes, supporting the thought that professional values trump generational characteristics (Noonan et al., 2019). Additionally, only 38% of participants believe that age at time of admission into an entry-level occupational therapy program influences overall professionalism, further showing that OT faculty believe that professionalism is not related to age or generation but rather to the profession of occupational therapy. Participants across multiple demographics rated ethical as a top seven attributes. Our results highlight the importance of ethics in demonstrating professionalism as a new occupational therapist. While being ethical is important to occupational therapists, it has not explicitly been documented as an independent professional attribute throughout the existing literature. In a previous study by Sullivan and Thiessen (2015), occupational therapy students noted advocacy as an important component of professionalism. It is also important to discuss respect as a major professional trait, as researchers have identified it as such in two influential studies (ABIM, 2001; DeLisa et al., 2001). The researchers in this study utilized a survey adapted from ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 38 Campbell et al (2015), which did not include the professional attributes of respect and advocacy. Therefore, it remains unknown if occupational therapists believe these to be important professional behavior and attributes. It would be beneficial to assess the importance of both respect and advocacy as major professional traits among occupational therapists in future studies on professionalism in practice. Future Research The results of this study identified the seven most important professional behavior attributes that occupational therapy faculty deemed necessary for new occupational therapists to exhibit professionalism in practice. Additionally, this study indicated that all of the listed professional behavior attributes are important in some capacity to demonstrate professionalism within occupational therapy practice. To expand on the findings of this study, future research should focus on establishing what practicing occupational therapists working in the field believe are the most important professional behavior attributes for new occupational therapists to demonstrate. This information would further support the inclusion of education on certain attributes within the didactic education of occupational therapy students. An additional exploration should include analyzing differences between the expected professional behavior attributes of practitioners and those that students exhibit to better understand the difficulties in the teaching and learning of these attributes. Andonian (2013) suggested that emotional intelligence is crucial to address in the teaching of professionalism as it leads to an increase in understanding emotions and emotional self-management. These characteristics relate to communication, increased client centeredness, and increased intervention skills (Hackenberg & Toth-Cohen, 2018, p. 3) suggesting that emotional intelligence and its relation to these professional behavior attributes is a topic for researchers to study in the future. ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 39 Limitations Not all participants in the current study were occupational therapists and, therefore may have different views of what professional behavior attributes are expected within the occupational therapy field. Of the participants, not all played a large or full-time role in the education of students meaning they may or may not have a conclusive knowledge of how other educators teach professionalism within their respected programs. Regarding the administered tool, one question omitted one of the attributes listing only 21 professional behavior attributes instead of 22. Although the literature does not support the omitted attribute as a significant behavior attribute, future research should include it in the list of 22 attributes when administering the tool. The current study has a response rate of 22.9% with only 150 responses from the 655 individuals who received the survey. Despite this response rate, occupational therapy faculty from all regions of the United States participated in the current study. Conclusion The goal of this study was to identify what professional behavior attributes occupational therapy faculty deem necessary for new occupational therapy graduates to demonstrate to be successful in practice. The results of this study indicate that occupational therapy faculty believe that many important attributes contribute to professionalism within the occupational therapy field. Of the 22 professional behavior attributes, participants ranked all as at least slightly important to demonstrate professionalism. Of these, faculty believe the most important attributes are being clinically competent, being ethical, having communication skills and interpersonal skills, and being adaptable, responsible, and empathetic. Despite differences in the ranking by participants age range, highest earned degree, and years of teaching experience, all participants agreed that being clinically competent was the most important attribute related to ISSUES OF PROFESSIONALISM IN OT PRACTITIONERS 40 professionalism with almost all participants stating that being ethical was the second most important professional behavior attribute. This study also indicates that occupational therapy faculty believe that teaching professionalism is an integral part of occupational therapy education and state the concept can both be taught and learned. Despite this and the fact that over 90% of participants believe that their program emphasizes assessing the professionalism of their students, occupational therapy faculty continue to have concerns relating to the professionalism of one or more of their students. Faculty still believe that their students demonstrate professionalism, reporting that they most frequently observe students being a team player, being responsible, being time-efficient, being personable, and remaining organized, although these are not necessarily the most important professional behavior attributes identified by participants. While this study indicates that professionalism within occupational therapy is still a difficult concept to operationalize, as well as what attributes occupational therapy faculty believe are most important for new occupational therapists to demonstrate. This study contributes to the current literature of defining professionalism within occupational therapy and can assist occupational therapy programs in the education of their students to ensure that they demonstrate professionalism in their future practice. 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Educational Research and Reviews, 12(7), 380-386. https://doi.org/10.5897/ERR2017.3132 Signature: Alison Nichols (Dec 14, 2020 10:59 EST) Email: anichols@uindy.edu Signature: Email: decleenek@uindy.edu McGann & DeCleene Huber Issues of Professionalism in New Occupational Therapists Final Audit Report 2020-12-14 Created: 2020-12-14 By: Kristin Arnes (arnesk@uindy.edu) Status: Signed Transaction ID: CBJCHBCAABAAEIVpudIp-9ECIMubs-VYcNcCrF5XVOF7 "McGann & DeCleene Huber Issues of Professionalism in New Occupational Therapists" History Document created by Kristin Arnes (arnesk@uindy.edu) 2020-12-14 - 3:51:53 PM GMT- IP address: 199.8.28.36 Document emailed to Alison Nichols (anichols@uindy.edu) for signature 2020-12-14 - 3:52:41 PM GMT Email viewed by Alison Nichols (anichols@uindy.edu) 2020-12-14 - 3:59:17 PM GMT- IP address: 66.102.6.59 Document e-signed by Alison Nichols (anichols@uindy.edu) Signature Date: 2020-12-14 - 3:59:29 PM GMT - Time Source: server- IP address: 98.220.43.242 Document emailed to Kate DeCleene Huber (decleenek@uindy.edu) for signature 2020-12-14 - 3:59:31 PM GMT Email viewed by Kate DeCleene Huber (decleenek@uindy.edu) 2020-12-14 - 4:00:26 PM GMT- IP address: 69.108.47.154 Document e-signed by Kate DeCleene Huber (decleenek@uindy.edu) Signature Date: 2020-12-14 - 5:29:11 PM GMT - Time Source: server- IP address: 69.108.47.154 Agreement completed. 2020-12-14 - 5:29:11 PM GMT ...