i

PHYSICAL THERAPISTS’ PROFESSIONAL ROLE IDENTITY AND THE TRANSITION

TO LEADERSHIP: A PHENOMENOLOGY

by

Christopher Michael Wiedman

A dissertation submitted in partial fulfillment of the requirements for the degree of

DOCTOR OF PHILOSOPHY OF EDUCATION

Dissertation Committee:
Robyn Cooper, Ph.D., Chair
Carol Heaverlo, Ph.D.
Randal Peters, Ed.D.

Dean of the School of Education:

Ryan Wise, Ed.L.D.

Drake University

Des Moines, Iowa

2022

Copyright © Christopher Michael Wiedman, 2022. All rights reserved.

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TABLE OF CONTENTS

LIST OF FIGURES ...................................................................................................................... vii

LIST OF TABLES ....................................................................................................................... viii

ACKNOWLEDGEMENTS ........................................................................................................... ix

DEDICATION ................................................................................................................................x

ABSTRACT ................................................................................................................................... xi

CHAPTER 1. INTRODUCTION ...................................................................................................1

Statement of the Problem .....................................................................................................1
Statement of Purpose ...........................................................................................................5
Research Question ...............................................................................................................5
Significance of the Study .....................................................................................................6
Conceptual Framework ........................................................................................................6
Giddens’ Structuration Theory ................................................................................8
A Conceptual Framework of Healthcare Professional Role Identity.....................11
Researcher Positionality.....................................................................................................13
Definition of Key Terms and Acronyms ...........................................................................15
Summary ............................................................................................................................16

CHAPTER 2. LITERATURE REVIEW .......................................................................................18

Why Clinician Leadership Matters ....................................................................................18
Leadership in Physical Therapy .........................................................................................22
Historic Approaches to Studying Physical Therapy Leadership ...........................23
Leadership as Part of the Physical Therapist Role Identity ...................................28
Lack of Academic Support ........................................................................30
Dominance of the Clinician Identity ..........................................................31
Physical Therapist Leadership Self-Perception in Context .......................32
The Physical Therapist Transition from Clinician to Leadership Positions ..........34
Issues with the Clinician to Manager/Leader Transition ...................................................36
Insufficient Training, Mentoring, and Succession Planning .................................37
Motivations to Enter Leadership ............................................................................38
Role Identity Conflict ............................................................................................39
Professional Role Identity Formation ................................................................................40
Professional Role Identity as Self-Identity ............................................................40
Identity Regulation.................................................................................................41
Identity Work and the Effect on Role Identity.......................................................43
Healthcare Professional Socialization as Identity Regulation ...............................44
Professional Role Identity as an On-going Narrative of Self ................................48
Identity Work as a Response to Professional Socialization ...................................49
Role Conflict in the Clinician to Leader Transition...........................................................54
Leadership as a Component of Healthcare Professional Role Identity..................56
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Leadership and Management as Organizational Identities ....................................59

Role Conflict in the Leadership/Management Transition ......................................61
Identity Work as a Response to Role Conflict .......................................................62
Rejection of Organizational Identity..........................................................64
Removal of Existing Professional Role Identity........................................65
Occupation of Multiple Professional Role Identities .................................65
Co-opting Identities to Sustain Professional Role Identity ........................67
Role Identity Integration and Hybridization ..............................................68
Summary ............................................................................................................................69

CHAPTER 3. METHODOLOGY .................................................................................................71

Qualitative Approach to Research .....................................................................................71
Philosophical Assumptions and Research Design .............................................................72
Epistemology: Constructionism .............................................................................72
Theoretical Perspective: Interpretivism .................................................................73
Methodological Approach .................................................................................................74
Intentionality, Consciousness, and the Natural Attitude........................................75
The Phenomenological Attitude and Bracketing of Pre-supposition .....................76
Application of Phenomenological Methods to this Study .....................................78
Participants and Sampling..................................................................................................79
Data Collection Procedures................................................................................................80
Qualitative Interviews ............................................................................................81
Interviewing in Qualitative Inquiry and Phenomenology..........................81
Interviews as Structured Conversations .....................................................82
Basic Interview Structure ...........................................................................83
Constructing the Semi-Structured Interview Guide ...................................84
The Three Interview Process .....................................................................85
Qualitative Interview Location and Recording ..........................................87
Collection of Demographic Information ................................................................88
Document and Audiovisual Material Analysis and Post-Interview Notes ............88
Ethical Considerations .......................................................................................................89
Building Trust and Rapport ...................................................................................89
Practicing Self-Management and Reflexivity ........................................................90
Institutional Review Board ....................................................................................91
Informed Consent...................................................................................................92
Confidentiality .......................................................................................................92
Data Analysis and Procedures ...........................................................................................93
Interview Transcription and Memoing ..................................................................93
Coding ....................................................................................................................94
Document and Audiovisual Material Analysis ......................................................94
Design Issues – Goodness and Trustworthiness ................................................................95
Credibility ..............................................................................................................95
Transferability ........................................................................................................96
Consistency ............................................................................................................97
Delimitations ......................................................................................................................97
Limitations .........................................................................................................................98
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Summary ............................................................................................................................98

CHAPTER 4. PARTICIPANT PROFILES ...................................................................................99

General Participant Demographics .................................................................................100
Amanda ...................................................................................................................101
Employer ..............................................................................................................101
Education and Training ........................................................................................102
Current Position ...................................................................................................103
Melissa .....................................................................................................................104
Employer ..............................................................................................................105
Education and Training ........................................................................................106
Current Position ...................................................................................................107
Doug .........................................................................................................................107
Employer ..............................................................................................................108
Education and Training ........................................................................................109
Current Position ...................................................................................................109
Nicole .......................................................................................................................110
Employer ..............................................................................................................111
Education and Training ........................................................................................112
Current Position ...................................................................................................113
Sarah .........................................................................................................................113
Employer ..............................................................................................................114
Education and Training ........................................................................................115
Current Position ...................................................................................................115
Katelynn ...................................................................................................................116
Employer ..............................................................................................................117
Education and Training ........................................................................................118
Current Position ...................................................................................................119
Bryan ........................................................................................................................119
Employer ..............................................................................................................120
Education and Training ........................................................................................121
Current Position ...................................................................................................121
Stacy .........................................................................................................................122
Employer ..............................................................................................................123
Education and Training ........................................................................................124
Current Position ...................................................................................................125
Summary ..........................................................................................................................125

CHAPTER 5. FINDINGS ...........................................................................................................127

Theme 1: Begin. with a Strong Role Identity Focused on More Than Clinical Skills ....130
A Focus on Affective and Interpersonal Skills ........................................................130
A Focus on Growth, Flexibility, and an Ever-expanding Identity ...........................134
Alignment Between Self-Identity, Clinical Identity, and a Leadership Identity ......136
Identification with Their Organization .....................................................................139
Theme 2: Accepting the Role of Discomfort During the Transition Process ..................143
Feeling Overwhelmed ..............................................................................................143
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Adjusting to the Loss of Patient Care .......................................................................146

Using Past Experiences to Embrace Discomfort ......................................................149
Separating Management from Leadership in Identity Construction ........................152
Theme 3: Focusing on Relationships ...............................................................................155
Work Relationships ..................................................................................................155
Mentoring Relationships ..........................................................................................158
Theme 4: Exercising Agency Over Construction of Their Leader Identity.....................163
Responding to a Lack of Formalized Organizational Identity Regulation Efforts...163
Charting Their Own Path .........................................................................................165
Getting Things Done ................................................................................................168
Theme 5: Recognizing Consistency Between Physical Therapist and Leader Roles ......171
Recognizing a Clinical Skill Set is Applicable to Organizational Leadership .........171
Recognizing Clinical Work and Leadership Work Focus on Service to Others ......174
Recognizing the Alignment of Org. Values with Clinical/Personal Values ............177
Theme 6: Establishing a Professional Identity Informed By, But Not Bound By, Their
Physical Therapist Identity .............................................................................................180
Becoming the “Go To” Person .................................................................................181
Having a Foot in Both Worlds .................................................................................183
Redefining Success in Their New Role ....................................................................187
Expanding Their Focus ............................................................................................189
Summary ..........................................................................................................................192

CHAPTER 6. SUMMARY, DISCUSSION, RECOMMENDATIONS, CONCLUSION..........193

Summary of the Study .....................................................................................................193
Summary Answers to the Research Question ..................................................................197
Theme 1: Beginning with a Strong Role Identity Focused on More Than Clinical
Skills .........................................................................................................................197
A Focus on Affective and Interpersonal Skills ....................................................197
A Focus on Growth, Flexibility, and an Ever-Expanding Identity ......................198
Alignment Between Self-Identity, Clinical Identity, and Leader Identity ...........198
Identification with Their Organization ................................................................199
Theme 2: Accepting the Role of Discomfort During the Transition ........................199
Feeling Overwhelmed ..........................................................................................200
Adjusting to the Loss of Patient Care ..................................................................200
Using Past Experiences to Embrace Discomfort .................................................201
Separating Management From Leadership in Identity Construction ...................201
Theme 3: Focusing on Relationships .......................................................................202
Work Relationships..............................................................................................202
Mentoring Relationships ......................................................................................203
Theme 4: Exercising Autonomy Over Construction of Their Leader Identity ........203
Responding to a Lack of Formal Organizational Identity Regulation Efforts .....204
Charting Their Own Path .....................................................................................204
Getting Things Done ............................................................................................205
Theme 5: Recog. Consistency Between Physical Therapist and Leader Roles .......205
Recognizing a Clinical Skill Set is Applicable to Organizational Leadership ....205
Recognizing Clinical Work and Leadership Work Focus on Service to Others..206
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Recognizing the Alignment of Organizational Values with Clinical and Personal

........................................................................................................................ Values
206
Theme 6: Establishing a Professional Identity Informed By, But Not Bound By,
Their Physical Therapist Identity .............................................................................207
Becoming the “Go To” Person ............................................................................207
Having a Foot in Both Worlds .............................................................................208
Redefining Success in Their New Role ...............................................................208
Expanding Their Focus ........................................................................................209
Discussion of Themes with Prior Literature ....................................................................209
Theme 1 ....................................................................................................................210
Theme 2 ....................................................................................................................214
Theme 3 ....................................................................................................................218
Theme 4 ....................................................................................................................219
Theme 5 ....................................................................................................................222
Theme 6 ....................................................................................................................225
Implications and Significance of the Study .....................................................................228
Recommendations for Practice ........................................................................................230
Recommendations for Practicing Physical Therapists .............................................230
Recommendations for Physical Therapy Educators .................................................231
Recommendations for Employers ............................................................................231
Recommendations for Future Research ...........................................................................233
Conclusion .......................................................................................................................236

REFERENCES ............................................................................................................................238

APPENDIX A. SAMPLE E-MAIL FOR SOLICITING PARTICIPANTS ................................262

APPENDIX AA. SAMPLE E-MAIL WITH CLARIFICATIONS ............................................ 263

APPENDIX B. RECRUITMENT EMAIL ..................................................................................265

APPENDIX C. SEMI-STRUCTURED INTERVIEW GUIDE ..................................................266

APPENDIX D. INFORMED CONSENT DOCUMENT ............................................................269

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LIST OF FIGURES

Figure 1.1 Alvesson and Willmott’s (2002) Original Conceptual Framework ...............................8

Figure 1.2 Integrating Conceptual Framework of Healthcare Professional Role Identity ............13

Figure 5.1 Themes and Subthemes Situated Within the Integrated Conceptual Framework ..... 129
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LIST OF TABLES

Table 4.1 ..................................................................................................................................... 100

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ACKNOWLEDGEMENTS

Upon finishing my graduate education in physical therapy over 20 years ago, I vowed

never to return to school again. Thankfully, this is a vow I chose not to keep. Yes, the journey

toward attaining a PhD included hard work, late hours, sleep deprivation, and a persistent

headache from trying to figure out what the word “epistemology” really meant. But it has also

changed how I view challenges in my practice, my work, my life, and my world.

I would like to begin by thanking each and every one of my classmates in the 2019

cohort. It has truly been my privilege to work, study, struggle, and succeed with such an

accomplished and diverse group of people. I also want to thank our program director and my

dissertation advisor, Dr. Robyn Cooper, for pushing us all to be better and for directing such an

excellent PhD program, a program which set me up to be successful. Thank you to all the PhD

program faculty for your love of teaching and commitment to all of us. I would like to

specifically thank Dr. Randal Peters for his willingness to serve on my dissertation committee. I

would also like to thank Dr. Carol Heaverlo for her guidance, her service on my dissertation

committee, and most importantly, for showing me how qualitative research can make an impact

in my profession.

I must thank all of my family and friends for their on-going support and understanding

over the last three years. To my daughters Aubrey and Maisie, thank you for understanding and

respecting why I needed to work through weekends and evenings. To my mother, Theresa, a life-

long educator, for instilling in me a love of learning and a respect for education. Most

importantly, thank you to my wife Heather, for loving and supporting me, for taking up a

tremendous amount of slack in every aspect of our life, and for dutifully staying awake while I

groaned on and on about my conceptual framework.

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DEDICATION

This dissertation is dedicated to my late father, Henry Wiedman, an educator, scientist,

and life-long learner in all aspects of life. Thank you for showing me that hard work, does in

fact, pay off, and that obstacles in life are not really barriers, but simply opportunities to test your

will and perseverance, and once overcome, seem small in the rear view and strengthen you for

the ones to come. Thanks Dad.

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ABSTRACT

Leadership in physical therapy is an under-researched phenomenon. The transition from a

clinical position to a leadership position in physical therapy has received even less attention. The

purpose of this study was to understand how physical therapists make meaning of their

professional role identity when transitioning from clinical to leadership positions. This study

approached the research question from a constructionist epistemology and basic interpretivist

theoretical framework, using a qualitative phenomenological methodology. Three-part, semi-

structured qualitative interviews were conducted with eight physical therapists currently

transitioning from clinical to leadership positions. Interview transcripts were analyzed using a

qualitative coding process which resulted in the development of six main themes, including

subthemes. Each of the six main themes answered the research question. The six themes which

emerged from the data analysis included beginning with a professional role identity which

included more than clinical skills, accepting the role of discomfort during the transition, focusing

on relationships, exercising autonomy over the construction of their leader identity, recognizing

consistency between their physical therapist and leader roles, and establishing a professional role

identity informed by, but not bound by, their physical therapist identity. How these themes

answer the research question is discussed in detail, using the study’s conceptual framework as a

guide and situating the findings within the existing literature. Conclusions and recommendations

for practice and future research are also discussed.

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CHAPTER 1

INTRODUCTION

The experience of transitioning from a clinical physical therapist to a leadership position

is a phenomenon which has garnered little attention in the research literature. As the landscape of

healthcare has changed, so has the need for healthcare leaders with clinical backgrounds

(Brocklehurst et al., 2013; Delmatoff & Lazarus, 2014; Desveaux, 2015; Hamilton, 2008;

Masoumi, 2019; Spehar et al., 2012; Wikstrom & Dellve, 2009). While the transition from

clinician to leader has been studied in healthcare fields such as nursing and medicine (Barrow et

al., 2011; Camilleri, 2020; Masoumi, 2019; McGowan et al., 2020; Phillips et al. et al., 2018;

Sofritti, 2020; Sonnino, 2016; Spehar et al., 2012; Young et al., 2018), there remains a deficiency

in the literature concerning this transition in physical therapy.

Statement of the Problem

The rapid pace of change in healthcare has created a demand for leadership and a need to

research healthcare leadership from alternative perspectives (Delmatoff & Lazarus, 2014;

Desveaux, 2015; Desveaux & Verrier, 2014; Kutz et al., 2018; McGowan & Stokes, 2015;

McGowan & Stokes, 2017; Wikstrom & Dellve, 2009). Recent changes in healthcare include a

shift from volume-based to quality-based payments and a movement toward standardization of

care to improve efficiency, fiscal responsibility, and patient outcomes (Brocklehurst et al., 2013;

Hamilton, 2008; Masoumi, 2019; Sofritti, 2020).

The need to effect direct changes at the level of care delivery has necessitated the

involvement of clinicians in management and leadership processes at an organizational level

(Brocklehurst et al., 2013; Delmatoff & Lazarus, 2014; Desveaux, 2015; Hamilton, 2008; Lyons

et al., 2020; Masoumi, 2019; Spehar et al., 2012; Wikstrom & Dellve, 2009). The desire to bring
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more clinicians into leadership and management roles is rooted in the desire to improve the

legitimacy of administrative initiatives and improve compliance amongst front-line care

providers (Masoumi, 2019; Soffriti, 2020). The result of this shift is an increasing demand for

clinician leaders to bridge the gap from the administrative to the clinical realms in healthcare.

Additionally, the changing environment of healthcare leadership mirrors the progression

of leadership studies in general (Antonakis & Day, 2018). Leader-centric theories have

traditionally focused on identifying leader traits or characteristics. These leader-centric theories

were prominent historically. However, the emergence of follower-centric, relational, contextual,

and social identity theories has expanded the available conceptual frameworks from which to

study leadership (Antonakis & Day, 2018).

Recent research in the realm of healthcare leadership has paralleled this progression in

leadership theory from leader-centric to a more nuanced and contextual view of the

competencies required of healthcare leaders (Aggarwal & Swanwick, 2015; Cavaness et al.,

2020; Delmatoff & Lazarus, 2014; Endres & Weibler, 2017; Kutz et al., 2018; Wikstrom &

Dellve, 2009). In today’s healthcare environment, business skills and authoritative leadership

must be balanced with emotional intelligence, contextual intelligence, nuanced leadership styles,

and political acumen in order to effectively lead front-line healthcare practitioners while seeking

to implement the initiatives promoted by administrators (Aggarwal & Swanwick, 2015;

Cavaness et al., 2020; Delmatoff & Lazarus, 2014; Kutz et al., 2018; Wikstrom & Dellve, 2009).

The role of clinicians as leaders in the healthcare environment is important for improving

healthcare outcomes and implementing the changes in healthcare delivery desired by

administrators, policy makers, and the general public.

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Transitioning clinicians from front-line care providers to leadership positions is not

without difficulties. In a systematic review of factors affecting the leadership effectiveness of

clinicians as first-time managers, Masoumi (2019) highlighted several obstacles faced by

clinicians undergoing this transition. These factors included issues adjusting to a new role

identity, ineffectiveness in either role as a clinician or leader due to role identity confusion,

delegitimization by other front-line care staff after pursuing a leadership position, difficulties

adjusting to new role demands, and a lack of preparation and leadership development training.

The bulk of research concerning the transition from front-line clinician to healthcare leader has

occurred in the fields of nursing and medicine (Barrow et al., 2011; Camilleri, 2020; Lyons et al.,

2020; Masoumi, 2019; McGowan et al., 2020; Phillips et al., 2018; Sofritti, 2020; Sonnino,

2016; Spehar et al., 2012; Young et al., 2018). In contrast, the clinician to leadership transition

remains under-researched in the rehabilitation professions generally, and in physical therapy

specifically. The majority of research on clinician to leader transition has occurred in the field of

occupational therapy (Fleming-Castaldy & Patro, 2012; Heard, 2014; Krishnasamy et al., 2019;

Shams et al., 2019). The majority of research on transitioning to leadership in physical therapy

has been done within the academic environment, not the clinical environment (Barrett et al.,

2019a, 2019b, 2020; Greathouse et al., 2018; Vore, 2019).

Leadership in physical therapy is an under-researched phenomenon (McGowan & Stokes,

2015; McGowan & Stokes, 2017; Sebelski, 2020; Vore, 2019). The literature in physical therapy

has focused on the traits of physical therapy leaders already in an established leadership or

management position (Chan et al., 2015; Desveaux, 2015; Desveaux et al., 2016; Lopopolo et al.,

2004, McGowan et al., 2019a, 2019b). Additionally, the literature fails to develop a unified

definition of leadership in the field (Desveaux, 2015; Desveaux & Verrier, 2014; McGowan &
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Stokes, 2015; McGowan & Stokes, 2017). This traits-based approach persists in more recent

research concerning the desirable leadership traits of graduate physical therapy school applicants,

graduates, and early career clinicians (Conard & Schweiger, 2018; Roll et al., 2018; Sebelski et

al., 2020). The overall existing body of research in physical therapy fails to consider a more

nuanced and contextual view of leadership in line with the contemporary requirements of

healthcare leaders (Aggarwal & Swanwick, 2015; Cavaness et al., 2020; Delmatoff & Lazarus,

2014; Kutz et al., 2018; Wikstrom & Dellve, 2009) and in keeping with the contemporary views

of leadership on the whole (Antonakis & Day, 2018).

Some researchers in physical therapy and the related field of occupational therapy have

begun to investigate the lived experience of leadership and the role of self-perception in therapy

leadership (Desveaux & Verrier, 2014; Heard et al., 2018; Krishnasamy et al., 2019; LoVasco et

al., 2016; McGowan & Stokes, 2017; McGowan et al., 2017; Pascal et al., 2017; Pitts, 2020).

Rasmussen-Barr et al. (2019) and Heard (2014) identified the lack of leadership self-recognition

and its implications for pursuit of leadership positions in physical and occupational therapists

respectively. In contrast, Shams et al. (2019) identified the motivation to lead as a driving force

behind the transition to leadership in new occupational therapy leaders. Additional recent

research in the realm of physical therapy leadership has focused on the need for leadership

development to improve leadership competencies in physical therapists who transition to

leadership or may be appropriate to engage in such a transition (Krishnasamy et al., 2019;

McGowan et al., 2020; Pascal et al., 2017).

Despite the presence of recent research on perceptions and leadership development in

physical therapy (Desveaux & Verrier, 2014; McGowan & Stokes, 2017; McGowan et al., 2017;

Pascal et al., 2017; Rasmussen-Barr et al., 2019; Vore, 2019), there continues to be a notable
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absence in the physical therapy literature on the lived experience of transitioning from a physical

therapy clinician to a leadership position. This absence stands in contrast to research on the

experiences of first-time clinical management transitions in other medical fields (Heard, 2014;

Lyons et al., 2020; Masoumi, 2019; Sofritti, 2020).

Research from the fields of nursing and medicine have investigated the effect of

professional role identity on the successful transition from clinician to leader (Barrow et al.,

2011; Camilleri, 2020; Masoumi, 2019; Mitchell, 2019; Phillips et al., 2018; Sofritti, 2020;

Sonnino, 2016; Young et al., 2018). In contrast, the body of physical therapy literature possesses

limited investigations into the impact of professional role identity outside of the professional

socialization process (Chan et al., 2015; Desveaux et al., 2016; Glendinning, 1987). Furthermore,

studies investigating how physical therapists make meaning of their professional role identity

when transitioning to a leadership position have not been found in a search of the literature. A

lack of research on the physical therapist’s transition from clinician to leader leaves a gap in the

profession’s understanding of this transition and the effect it has on a physical therapist’s

professional role identity. Successful and unsuccessful clinician to leadership transitions hold

implications for individual organizations and the healthcare system as a whole (Masoumi, 2019).

Statement of Purpose

The purpose of this study was to understand how physical therapists make meaning of

their professional role identity when transitioning from clinical to leadership positions.

Research Question

The overarching research question for this study was: How do physical therapists make

meaning of their professional role identity when transitioning from a clinical to a leadership

position?
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Significance of the Study

The transition from a clinical physical therapist to a leadership or management position in

healthcare remains an understudied phenomenon. Given the growing importance of clinicians

serving in healthcare leadership (Brocklehurst et al., 2013; Delmatoff & Lazarus, 2014;

Desveaux, 2015; Hamilton, 2008; Masoumi, 2019; Spehar et al., 2012; Wikstrom & Dellve,

2009) and the growing recognition of physical therapy’s role in reducing healthcare costs and

improving outcomes (Vore, 2019), this study holds significance for society, the healthcare

industry, and the physical therapy profession. The effects of role identity conflict on the

effectiveness and longevity of other health professionals in leadership has been established

(Barrow et al., 2011; Camilleri, 2020; Masoumi, 2019; Mitchell, 2019; Phillips et al., 2018;

Sofritti, 2020; Sonnino, 2016; Young et al., 2018). Retaining health professionals in leadership

positions has been linked to improved health outcomes, patient safety, and reduced cost

(Aggarwal & Swanwick, 2015; Masoumi, 2019; Sofritti, 2020). Investigating the transition to

leadership and the impact of this transition on a physical therapist’s professional role identity

helps shed light on how the physical therapist makes meaning of this phenomenon. Doing so

holds significance for the recruitment, retention, and success of physical therapy leaders in

helping to realize society’s goals of improved healthcare quality at lower cost.

Conceptual Framework

A conceptual framework provides structure to a study’s design and implementation. The

conceptual framework narrows the scope of inquiry in a study, establishing boundaries which

help inform the process of data collection and analysis (Merriam & Tisdell, 2016). The

conceptual framework used for this study represents an integrated conceptual framework derived

from the work of Alvesson and Willmott (2002). Using Giddens’ (1984) structuration theory as a
 7

foundation, Alvesson and Willmott (2002) sought to develop a more complete understanding of

the process of identity regulation as a means of producing an individual with self-image

congruent with the defined objectives of the organization (Alvesson & Willmott, 2002). In doing

so, Alvesson and Willmott (2002) outlined a conceptual framework for the analysis of identity

regulation with a focus on the interplay between organizational efforts to regulate an individual’s

identity, the individual’s self-identity, and the process of identity work by which the individual

actively makes meaning of attempts at identity regulation in relation to their self-identity

(Alvesson & Willmott, 2002).

Healthcare professionals are subjected to the process of identity regulation in the form of

professional socialization during training and throughout their careers (Cowin et al., 2013;

Hamilton, 2008; Langendyk et al., 2015; Thomas & Hardy, 2011; Volpe et al, 2019;

Vivekananda-Schmidt et al., 2015). Likewise, healthcare professionals who transition into

leadership positions are subjected to additional attempts at identity regulation as the organization

attempts to socialize these previously autonomous professionals into an organizational culture

defined by logics of managerialism, organizational business objectives, and organizational

culture rather than the logic of professionalism from which they come (Bernardi & Exworthy,

2020). For these reasons, the conceptual framework of Alvesson and Willmott (2002) was

applicable to this research study. Alvesson and Willmott’s (2002) original conceptual framework

is represented in Figure 1.1.

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Figure 1.1

Alvesson and Wilmott’s (2002) Original Conceptual Framework (p. 627)

Giddens’ Structuration Theory

An understanding of the theory of structuration proposed by Giddens (1984) is necessary

in order to understand the conceptual framework of Alvesson and Willmott (2002). Structuration

theory was proposed as a response to the dualism which dominated sociology’s

conceptualizations of self-identity between the 1950’s and the 1970’s. In the initial post-war

period of the 1940’s and 1950’s, a functionalist/objectivist perspective espoused by Parsons

(1937) formed the dominant sociological conceptualization of self-identity. The functionalist

perspective shared the same logical framework as the natural sciences. The idea that human

behavior was the result of structural forces in society over which the individual human actor did
 9

not exert control was the central premise of the functionalist perspective (Giddens, 1984). The

1960’s marked the emergence of interpretivist and post-empiricist philosophies in the social

sciences. While these philosophies varied and offered no specific consensus in terms of human

behavior, they shared one defining characteristic: the recognition of the reflexive character of

human conduct and the rejection of human behavior as a result of forces outside of one’s control

or comprehension (Giddens, 1984). The rise of these post-empiricist philosophies led to a

dualistic controversy in sociology, with one side espousing the dominance of the object (society)

over the individual and the other side advocating for a rejection of functionalist/objectivist views

and an embrace of a distinctly subjectivist view of human behavior (Giddens, 1984).

It was this sociological dualism which led to the development of structuration theory as

an attempt to mitigate the shortcomings of both objectivism and subjectivism (Giddens, 1984) by

recognizing the role of systemic social structures in determining human behavior and actions,

while simultaneously recognizing the role of human agency in perpetuating as well as reflecting

upon, challenging, and changing the structures themselves (Giddens, 1984). This concept of

duality of structure is central to structuration theory. Giddens describes duality of structure by

stating the “rules and resources drawn upon in the production and reproduction of social action

are at the same time the means of system reproduction” (Giddens, 1984, p. 19).

Structures in Giddens’ (1984) theory consist of the rules and resources by which a social

entity determines human behavior, including self-identity. Rules are procedures of action which

are understood and generalizable and may be intensive or shallow, tacit or discursive, informal or

formal, and weakly sanctioned or strongly sanctioned (Giddens, 1984). Resources may be

tangible material resources. However, in a larger societal or organizational setting, resources

may also be political, psychological, organizational, or economic resources employed by social

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structures to influence human behavior. As such, structures exert control over human behavior

by defining the language and day to day communicative activities of individuals (signification),

determining access to and allocation of resources (domination), and providing normative and

legal regulation and oversight of the activities of human agents (legitimation). In Giddens’

(1984) theory of structuration, these same structures also provide rules and resources by which

human actors can influence the structures themselves, a concept termed the dialectic of control.

In describing the dialectic of control, Giddens (1984) recognizes social structures not as entities

capable of self-perpetuation, but as entities reliant on the agency of human actors for their

reproduction or modification.

Giddens (1984) recognized human consciousness as the possession of reflective capacity.

Often times this consciousness is manifested as practical consciousness, what individual people

tacitly know about their day-to-day activities without giving direct, discursive expression to

them. While humans are capable of reflexivity, doing so in every day-to-day activity would

cause constant tension. As a result, human actors practice routinization of day-to-day activities as

a way of controlling this tension and creating a social environment of predictability.

Routinization serves to perpetuate and strengthen social structures and thus is one means by

which humans exert control over structures in Giddens’ theory (1984). In contrast, moments

occur in day-to-day life when the structural rules and/or resources available are inconsistent with

the needs of the situation, resulting in an active pattern of reflective practice, termed discursive

consciousness (Giddens, 1984, 1991). In these periods of discursive consciousness, the human

actor comes to the realization that routinized activities of daily life may no longer be sufficient to

meet their needs. By practicing agency, the individual will modify or transform social structures

as a means of diminishing this anxiety (Giddens, 1991). An individual develops and redevelops
 11

self-identity through practical and discursive consciousness as well as unconscious and reflexive

activity (Giddens, 1991).

A Conceptual Framework of Healthcare Professional Role Identity

Alvesson and Willmott’s (2002) conceptual framework of identity regulation within

organizations was initially proposed in the business management literature. Nevertheless, it holds

direct correlations to the process of professional role identity formation in the healthcare

professions, particularly during professional role transitions. Fitzgerald (2020) recognized the

lack of conceptual clarity in the health professions literature regarding professional identity,

citing how other terms such as professionalism are often used interchangeably while not

necessarily representing conceptual consistency with the idea of a professional identity. Through

a review of the literature, Fitzgerald (2020) identified six aspects of healthcare professional work

and training which are consistently used to develop a healthcare professional role identity.

Alvesson and Willmott’s (2002) concepts of self-identity correlate closely to the conceptual

analysis created by Fitzgerald (2020). Likewise, the concept of identity work has been used to

investigate role transition in medical doctors (Gordon et al., 2020) and the concept of provisional

selves was linked directly to prior research on medical students by Ibarra (1999).

The conceptual framework for this study drove data collection in the form of qualitative

interviews and served as a structure to guide data analysis. The concept of identity regulation

was used to frame the investigation of the processes of professional socialization prior to a

leadership transition, as well as organizational attempts to regulate the physical therapist’s role

identity after assuming a leadership or management position. The component aspects of identity

described by Alvesson and Willmott (2002) and Fitzgerald (2020) were used to frame

investigation into professional role identities constructed in physical therapy training and those
 12

constructed during the job transition. Finally, the process of identity work is conceptually

consistent with investigating how study participants make meaning of their role identity. Thus,

the three components of Alvesson and Willmott’s (2002) conceptual framework were used to

frame the investigation of how physical therapists make meaning of their professional role

identity when transitioning from clinical to leadership positions. A visual representation of the

conceptual framework (Alvesson & Willmott, 2002), including the integration of prior and

subsequent research, is presented in Figure 1.2.

 13

Figure 1.2

Integrated Conceptual Framework of Healthcare Professional Role Identity

Researcher Positionality

In qualitative research, the researcher acts as the primary instrument of data collection

and analysis (Creswell & Poth, 2018; Merriam & Tisdell, 2016). The philosophical stance and

life experiences of the qualitative researcher infuse all aspect of research design from initial

conception to development of the research question, to the methodology and methods used
 14

(Crotty, 1998). Qualitative research methodologies do not make the same assumption of

researcher objectivity as quantitative methods (Creswell & Poth, 2018; Merriam & Tisdell,

2016). However, it is still necessary for the qualitative researcher to define their own

positionality so that the consumer of a qualitative research product may assess whether the

researcher sufficiently bracketed out their own personal opinions and experiences when

analyzing data, so as to tell the story of study participants rather than their own (Creswell &

Poth, 2018; Merriam & Tisdell, 2016).

I am a licensed physical therapist in the state of Iowa, having practiced actively for the

last 20 years. In the course of those 20 years, my practice included a wide variety of clinical

settings from rural to urban, inpatient to outpatient, treating diverse patient populations across

the lifespan and continuum of care. Additionally, 13 years of my career were spent in clinical

leadership positions, including service as a lead physical therapist, a manager of therapy services

at a rural critical access hospital, and manager of outpatient therapy services for a larger hospital

in a mid-size metropolitan area. For the last three and a half years, I have served in a leadership

capacity as a Director of Clinical Education for a developing Doctor of Physical Therapy

graduate educational program.

As a result of this career trajectory, I have personal experience with the challenges of

transitioning from a clinical physical therapist position to a leadership position. This career

trajectory required the navigation of personal challenges to my professional role identity as a

physical therapist during this transition, having been confronted several times with the need to

decide whether to prioritize work as a clinician or prioritize work as a manager and a leader. My

early development as a leader was marked primarily by trial and error, with success in

management functions such as financial and clinical outcomes but difficulty adjusting to the
 15

relational and contextual requirements of leading others. Only after being actively mentored by a

more experienced leader did my leadership style mature and my overall leadership outcomes

improve. These personal experiences influenced the choice of study topic.

Definitions of Key Terms and Acronyms

The following terms and acronyms are important to this study and defined below:

ABPTS: American Board of Physical Therapy Specialties, the professional organization

responsible for oversight of the process of attaining a physical therapy clinical specialist

certification in the United States.

APTA: American Physical Therapy Association, the professional organization representing

physical therapists in the United States.

CAPTE: Commission on Accreditation of Physical Therapy Education, the accrediting agency

responsible for regulating all physical therapy educational programs in the United States.

Clinician: For the purposes of this study, any professional engaged in direct, clinical patient-

care.

Identity regulation: The act of causing one to identify with the organization (Alvesson &

Willmott, 2020)

Identity work: The continual forming, repairing, maintaining, or revising a coherent narrative of

self (Alvesson & Willmott, 2020)

Physical therapist: A professional who practices physical therapy. A movement expert

specializing in the treatment of movement dysfunction resulting from injury, illness, or disease

(Choose PT, n.d.; Merriam-Webster, n.d.).

 16

Physical therapy: Therapy for the preservation, enhancement, or restoration of movement

and physical function impaired or threatened by disease, injury, or disability (Merriam-

Webster, n.d.). The term physical therapy is most commonly used in the United States.

Physiotherapist: Synonymous with “physical therapist”, this term is used to described

practitioners of physical therapy/physiotherapy in Canada, Australia, and most European

countries.

Physiotherapy: Synonymous with “physical therapy”, this term is used to describe the practice

of physical therapy in Canada, Australia, and most European countries.

Professionalism: The conduct, aims, or qualities that characterize or mark a profession or

a professional person (Merriam-Webster, n.d.).

Professional role identity: Self-identity as it pertains to the role of the professional in the

workplace; the precarious outcome of identity work comprising a narrative of self (Alvesson &

Willmott, 2002; Fitzgerald, 2020; Ibarra, 1999)

Professional socialization: The process through which a person becomes a legitimate member

of a professional society (Shahr, 2019).

PT: “PT” may be used interchangeably to represent “physical therapy” or “physical therapist”

depending upon sentence context.

Socialization: The process through which individuals acquire the knowledge, skills, attitudes,

values, norms, and actions of a community they wish to join (Shahr, 2019).

Summary

Clinician leadership is important for the future of healthcare reform. Healthcare

organizations with strong clinician leadership enjoy better patient safety, improved patient

outcomes, and greater overall patient safety. Such leadership requires the successful transition of
 17

potential leaders from the ranks of practicing clinician to the ranks of leadership and

management. Successful transitions face several roadblocks, including the potential for

professional role identity conflict. The transition from clinician to leadership/management

remains an understudied phenomenon in the physical therapy literature. The effect of this

transition on the professional role identity of the physical therapist has likewise escaped

attention. This study sought to better understand how physical therapists make meaning of their

professional role identity when transitioning from a clinical to a leadership role.

 18

CHAPTER 2
LITERATURE REVIEW

In order to examine the physical therapist’s professional role identity and the transition

from clinician to leader, several concepts must first be understood. This chapter will begin with a

discussion of why clinician leadership matters in healthcare generally and physical therapy

specifically. The current status of the leadership literature in the field of physical therapy will

then be explored, including an examination of current gaps in the literature. Identified issues with

the clinician to leadership transition will then be explored, including the prominent issue of role

conflict which plays a role in first-time clinician manager ineffectiveness (Masoumi, 2019).

The process of professional role identity formation will be examined in detail. How

healthcare professionals initially construct a professional role identity is central to understanding

role conflict in the clinician to leader transition and the various responses of healthcare

professionals to this conflict. Due to demonstrated gaps on these topics in the physical therapy

literature, research from other professional disciplines including business and science as well as

related fields of medicine, nursing, and occupational therapy will be presented.

Why Clinician Leadership Matters

In industrialized nations, the healthcare sector makes up a significant portion of gross

domestic product and is often one of the largest employers (Gilmartin & D’Aunno, 2007). In

2018, the healthcare sector accounted for 17.7% of the gross domestic product of the United

States and employed 11% of all Americans (Centers for Disease Control and Prevention, 2021;

Nunn et al., 2020). Additionally, healthcare costs accounted for 24% of government spending

and 26% of all non-wage employer compensation expenses in the United States (Brookings

Institute). The performance of the healthcare sector holds obvious implications for the health and
 19

well-being of society as well as significant economic implications for the nation (Gilmartin &

D’Aunno, 2007).

The healthcare industry has undergone significant change in the last three decades.

Healthcare shifted from primarily a locally-owned, operated, and loosely affiliated group of

individual providers serving the immediate local community, to an industry punctuated by the

rise of large healthcare organizations responsible for controlling healthcare costs while

maintaining and improving the health of large and diverse populations of people across

geographic areas (Page, 2015; Sandstrom et al., 2014).

Additionally, total healthcare expenditures in the United States have risen dramatically.

In 1990, the total of all healthcare expenditures in the United States was over 718 billion dollars.

By 2000, expenditures had increased to almost 1.4 trillion dollars (Centers for Medicare and

Medicaid Services, 2020). The rising costs and inefficiencies in healthcare led to the formation

of managed care organizations designed to improve efficiency and reduce healthcare costs

through the application of market and business principles (Masoumi, 2019; Sandstrom et al.,

2014). Healthcare leadership shifted from healthcare providers, typically physicians, to health

system administrators with business or management training (Masoumi, 2019). Traditionally,

healthcare professionals were granted a significant amount of autonomy and self-regulation by

society. In turn, society expected the professions to self-govern and to consistently act in

society’s best interest (Hamilton, 2008). The shift to professional business management

techniques and a market-driven focus in healthcare represented a significant change in the social

contract between society and healthcare (Hamilton, 2008; Page, 2015; Sandstrom et al., 2014).

The shift to professional business management has not resulted in reduced healthcare

expenditures. In 2019, the total expenditures on healthcare in the United States rose to 3.8 trillion
 20

dollars (Centers for Medicare and Medicaid Services, 2020). Part of the continued expansion in

healthcare expenditures can be blamed on the continuation of fee-for-service reimbursement

patterns, in which a healthcare provider or organization is reimbursed based on the number and

type of services or procedures provided without consideration for patient outcomes (Page, 2015;

Sandstrom et al., 2014). This volume-based pattern of reimbursement created a system by which

healthcare providers were financially rewarded for the volume of care provided without reward

for quality, value, cost-effectiveness, and patient outcomes (Brocklehurst et al., 2013; Desveaux,

2015; Masoumi, 2019; Page, 2015; Sandstrom et al., 2014). As a result, regulatory and

reimbursement policies have shifted even further in the last 10 years. Currently, healthcare

providers are being incentivized to focus on improving patient outcomes, patient satisfaction,

employee engagement, and efficiency while reducing costs and controlling repetitive and

wasteful healthcare spending (Brocklehurst et al., 2013; Desveaux, 2015; Masoumi, 2019; Page,

2015; Sandstrom et al., 2014).

The incorporation of business principles into the healthcare environment has increased

the need for competent leadership and management in the healthcare industry (Masoumi, 2019;

Page, 2015). As noted previously, the introduction of professional business managers into the

healthcare industry has not produce the desired changes in efficiency and quality. This lack of

change may be due, in part, to the unique nature of the healthcare industry. Despite the changing

social contract between healthcare providers and society, healthcare remains an industry largely

populated by powerful professionals (Gilmartin & D’Aunno, 2007). The business principles of

financial and market-driven management practices espoused by professional business managers

often conflict with the professional training and patient-care focus of the very front-line
 21

healthcare workers responsible for enacting the administration’s agenda (Barrow et al., 2011;

Kreindler et al., 2012; Masoumi, 2019).

There is a growing recognition of the need for healthcare professionals to assume roles in

management and leadership in order to bridge this divide, create balance between the unique

demands of patient-care and business practices, and lend legitimacy to the market-based

initiatives being proposed by non-clinician healthcare administrators (Barrow et al., 2011;

Brocklehurst et al., 2013; Desveaux, 2015; Gilmartin & D’Aunno, 2007; Kreindler et al., 2012;

Masoumi, 2019; Spyridonidis & Currie, 2016). Healthcare organizations have recognized this

need by implementing efforts to increase the representation of clinicians in the management and

leadership ranks (Barrow et al., 2011; Brocklehurst et al., 2013; Cabell et al., 2021; Desveaux,

2015; Gilmartin & D’Aunno, 2007; Kreindler et al., 2012; Masoumi, 2019; Specchia et al., 2012;

Spyridonidis & Currie, 2016). Healthcare organizations which successfully integrate clinicians

into leadership and management generally enjoy improved patient safety, improved business

performance, decreased prevalence of medical errors, and improved healthcare quality and

outcomes (Aggarwal & Swanwick, 2015; Georgiou et al., 2021; Niki et al., 2021; Masoumi,

2019). Increasing clinician representation in leadership and management has also been shown to

increase job satisfaction and employee retention in nursing (Specchia et al, 2021) and

physiotherapy (Niemi et al., 2018).

The current focus on reducing costs and improving outcomes has led to a growing

recognition of the role physical therapy may play in achieving these outcomes (Vore, 2019).

Physical therapy represents a conservative and cost-effective treatment option for many

healthcare issues when compared to more invasive and expensive treatment options such as

surgery or pharmaceuticals. The use of physical therapy as a first-line treatment for many
 22

common musculoskeletal conditions has been shown to lower overall cost of care, reduce overall

health resource utilization, improved outcomes, and reduce disability when compared to other

forms of medical care (Burge et al., 2016; Garrity et al., 2019; Hon et al., 2021; Vore, 2019). The

growing body of evidence supporting physical therapy’s role in reducing costs and improving

healthcare outcomes is reflected in current employment statistics. According to the United States

Bureau of Labor Statistics (2021), employment in the healthcare field is expected to increase

16% from the year 2020 to 2030. In contrast, U.S. demand for physical therapists is expected to

increase 21% during the same time frame (United States Bureau of Labor Statistics, 2021). The

growing importance of clinicians serving in healthcare leadership (Brocklehurst et al., 2013;

Delmatoff & Lazarus, 2014; Desveaux, 2015; Hamilton, 2008; Masoumi, 2019; Spehar et al.,

2012; Wikstrom & Dellve, 2009) and the growing recognition of physical therapy’s role in

reducing healthcare costs and improving outcomes (Vore, 2019) implies a need to understand the

nature of leadership in the physical therapy profession.

Leadership in Physical Therapy

The physical therapy profession has evolved from a technical level occupation to a true

profession over the last century (Moffat, 2003). The training and use of “reconstruction aides” to

rehabilitate service members after World War I is widely accepted as the birth of the physical

therapy profession. The role of physical therapists expanded greatly in the 1920s and 1930s due

to the polio epidemic. Despite this increasing role, physical therapy was primarily a technical

profession, with physical therapists carrying out specific orders and rehabilitation regimens

prescribed by physicians. Between the 1950s and 1970s, physical therapy progressed to a true

profession, increasing entry-level education to a bachelor degree and securing formal definition

in the form of state practice acts defining physical therapy practice (Moffat, 2003). As the
 23

physical therapy profession began to acquire its own base of scientific and theoretical

knowledge, the scope of practice of physical therapists expanded. By the year 2010, the

profession has progressed from bachelors to masters to a doctoral degree requirement for entry-

level education (Commission on Accreditation of Physical Therapy Education, n.d.). Currently,

physical therapists in all 50 United States are allowed some degree of freedom to see patients

without the referral or oversight of a physician. In many states, physical therapists enjoy

unrestricted direct access rights (Federation of State Boards of Physical Therapy, n.d.). The

changes in healthcare and the progression to autonomous practice create the need for effective

leadership in physical therapy to meet society’s healthcare needs and uphold the social contract

inherent in the relationship between a profession and the society it serves (Desveaux, 2015;

Hamilton, 2008).

Leadership in physical therapy is an under-researched phenomenon (McGowan & Stokes,

2015; McGowan & Stokes, 2017; Sebelski, 2020; Vore, 2019). The leadership research in

physical therapy is heavily skewed toward a leader-centric and traits-based model and fails to

develop a unified definition or overall conception of leadership in the field (Chan et al., 2015;

Desveaux, 2015; Desveaux & Verrier, 2014, Desveaux et al., 2016; Lopopolo et al., 2004,

McGowan & Stokes, 2015; McGowan & Stokes, 2017; McGowan et al., 2019a, 2019b). This

section will discuss the overall body of physical therapy leadership literature, the inclusion of

leadership in the professional role identity of physical therapists, and the literature concerning

role transitions in physical therapy.

Historic Approach to Studying Physical Therapy Leadership

Compared to the body of leadership research in other healthcare professions such as

nursing and medicine, leadership remains an understudied phenomenon in the physical therapy
 24

literature (McGowan & Stokes, 2015; McGowan & Stokes, 2017; Sebelski, 2020; Vore, 2019).

On the whole, research on leadership in physical therapy has sought the identification of traits,

skills, competencies, and patterns of behaviors. Additionally, much of this research was

conducted on or in consultation with physical therapists who self-identified as leaders, were

already in a leadership position, or employed in an academic setting (Chan et al., 2015;

Desveaux et al., 2012; Desveaux et al., 2016; Lopopolo et al., 2004; Luedtke-Hoffman et al.,

2010; McGowan & Stokes, 2017; McGowan et al., 2016; Schafer et al., 2007; Vore, 2019).

In a foundational study on leadership, Lopopolo et al. (2004) sought the opinions of existing

leaders and managers in physical therapy regarding leadership, administration, management, and

professionalism (LAMP) skills needed by physical therapists upon entry into the profession.

Participants in the study ranked communication, professional involvement, ethical practice,

delegation and supervision, time management, stress management, understanding of

reimbursement sources, and healthcare industry scanning as the LAMP skills most needed by

entry-level physical therapists (Lopopolo et al., 2004). Remaining LAMP skills were felt to be

unnecessary for entry-level physical therapist and could be acquired with time and experience.

Ranked last in importance were skills in strategic analysis, organizational analysis, contracting,

international management, and accounting. The study by Lopopolo et al. (2004) sought to inform

the curriculum content of entry-level physical therapy educational programs and suggested many

LAMP skills may not need to be incorporated into entry-level PT education.

Schafer et al. (2007) sought to further define the administration and management skills

needed for entry-level physical therapists. In a survey of practicing PT clinicians and academics,

46% of whom were in management positions, self-management, compliance, ethics, and coding

were identified as the top four administrative and management skills needed by new graduates.
 25

Each of these were directly related to the management of day-to-day functions in patient care

operations. Schafer et al.’s (2007) results indicated all other skills in leadership and management

could be the focus of educating physical therapy managers after graduation. The early results of

Lopopolo et al. (2004) and Schafer et al. (2007) played an important part in defining the

leadership and management skills needed for entry-level practice. In listing such common

leadership and management attributes as strategic analysis, organizational analysis, and

accounting near the bottom of the list, the participants in Lopopolo et al.’s (2004) study affirmed

that leadership and management were not necessarily part of the professional identity developed

during a PT education. Additionally, the works of Lopopolo et al. (2004) and Schafer et al.

(2007) are limited in their conceptual viewpoint, focusing on leadership and management as a

series of skills or traits which need to be acquired, as opposed to a role, mindset, or identity

which may be introduced during the socializing process of a physical therapy education and

cultivated throughout a professional career.

A focus on identifying the traits, behaviors, and competencies required of leaders in

physical therapy can be found consistently in much of the PT leadership research in the 17 years

since Lopopolo et al. (2004) published their findings. While Lopopolo et al. (2004) and Schafer

et al. (2007) focused on entry-level traits and skills needed, other researchers turned their

attention to identifying the traits and behaviors perceived to be important for leadership and

management in the larger PT workforce. Desveaux et al. (2012) found communication,

credibility, and professionalism to be the leadership traits perceived as important by Canadian

physiotherapists. This led to a series of studies on the traits and behaviors of physiotherapy

leaders, primarily in Canada and Ireland (Chan et al., 2015; Desveaux et al., 2016; McGowan &

Stokes, 2017; McGowan et al., 2016). Communication and professionalism were identified as
 26

key attributes or skills (McGowan & Stokes, 2017; McGowan et al., 2016) in support of the

work of Lopopolo et al. (2004). Furthermore, the attributes of communication and

professionalism were perceived to be the most important amongst both Canadian and Irish

physiotherapists (McGowan et al., 2016). This cross-cultural finding contributed to the

positivistic idea of inherent leadership traits in physical therapy which could be found via

quantitative investigation (McGowan et al. 2016).

Two studies conducted on the personality strengths of physiotherapy leaders found

significant overlap between clinicians in non-leadership positions and those in leadership

positions as well as significant overlap dependent upon the type of leadership position occupied,

manager or academic (Chan et al., 2015; Desveaux et al., 2016). The “achiever” strength was

found to be common amongst physical therapy leaders regardless of role (Chan et al., 2015;

Desveaux et al., 2016) and was found to be significantly more common in leaders than non-

leaders in PT (Chan et al., 2015). These studies serve as additional evidence of the leader-centric,

traits-based, and positivistic view employed in the PT leadership research.

More recently, Sebelski et al. (2020) sought to identify the leadership knowledge, skills,

and behaviors required of physical therapists at the entry-level. Sebelski et al. (2020) noted

“disagreement among the panelists regarding expectations of new graduate physical therapists

when considering leadership knowledge, skills, and behaviors. This finding may be symptomatic

of the gap between academicians and those physical therapists in clinical practice” (p. 99).

Practicing physical therapist clinicians perceived a greater sense of urgency and need for the

development of leadership competencies and capacities than the academic panelists. It is striking

that 16 years after Lopopolo et al. (2004) and 13 years after Schafer et al. (2007) sought to define

the leadership skills and competencies needed at entry-level, Sebelski et al. (2020) would find
 27

the same need and continue to uncover notable discrepancies in the perceived importance of

leadership within the physical therapy profession.

Leadership in academic physical therapy comprises another area of focus in the PT

leadership literature. Despite the difference in practice setting, leadership research in academic

physical therapy bears a strong resemblance to clinical PT leadership research in terms of its

focus on traits, behaviors, and characteristics. Luedtke-Hoffman et al. (2010) sought to identify

common skills and traits used by physical therapy educational program directors. Interpersonal

skills and communication were identified as the skills most confidently used and displayed.

Subsequent studies examining academic PT leadership continued the same focus on

identification of skills, traits, and characteristics commonly. This included the identification of

the traits of physical therapist clinical instructors (Greenfield et al., 2012), characteristics of

entry-level physical therapy educational program directors (Bennie & Rodriguez, 2019), the

perceived traits that drive a faculty member to pursue program directorship (Vore, 2019), and the

traits and behaviors displayed by academic physical therapy Directors of Clinical Education and

Site Coordinators of Clinical Education (Silberman et al., 2020).

Viewed as a whole, the recent body of research in PT leadership does develop a picture

of the skills, traits, behaviors, and personality styles perceived to be important for a PT leader to

possess. The overall body of research in PT leadership has shortcomings as well. Among these

shortcomings is the lack of a unifying definition of what leadership in physical therapy is

(Desveaux, 2015; Tschoepe et al., 2021). Furthermore, the body of research also approaches the

investigation of PT leadership from a highly leader-centric point of view, making the inherent

assumption that because an individual occupies a leadership or management position, they are in

fact an effective leader or manager. While not exclusively utilizing quantitative methods, the
 28

overall body of PT leadership research relies heavily on these methods as opposed to qualitative

inquiry. This traits-based, leader-centric, and positivistic perspective is inconsistent with most

contemporary views of leadership as a social construct which manifests itself dependent upon

leader-follower expectations, relationships, and the social context in which these interactions

take place (Antonakis & Day, 2018).

Leadership as Part of the Physical Therapist’s Role Identity

While the larger body of research on PT leadership has focused on discovering consistent

traits amongst existing physical therapy leaders, the issue of leadership self-perception amongst

physical therapists has received attention. Desveaux et al. (2012) identified a gap in the research

literature on the perceptions of leadership in physical therapy. Desveaux and Verrier (2014)

followed up by noting the difference in perceived leadership traits between physical therapists

and the perceptions of nurses and physicians. The inability to extrapolate nursing and physician

leadership research to physical therapy led Desveaux and Verrier (2014) to suggest the need for

further research into the physical therapy profession’s perceptions of leadership.

The integration of physical therapists into the interdisciplinary care teams of modern

healthcare necessitated the investigation of how physical therapists perceive leadership and

whether this perception fit with their larger professional role identity (Clark, 2016). Studies on

the strengths of physical therapists in multiple settings found significant overlap between

physical therapists occupying leadership positions and those in non-leadership positions (Chan et

al., 2015; Desveaux, 2015). Furthermore, Chan et al. (2015) found the strength of strategic vision

remained relatively stable over several years of experience. The findings of overlap and stable

strengths led some researchers to speculate that many of the inherent leadership traits identified

had little to do with the integration of these strengths into the socialization process. Instead, some
 29

researchers suggested these may be inherent strengths which draw individuals to the physical

therapy profession, and their presence has little to do with the process of developing a physical

therapy professional identity (Chan et al., 2015; Desveaux, 2015; LoVasco et al., 2016). Despite

the passage of several years since Desveaux (2015) originally identified the gap in PT

perceptions of leadership, recent research has continued to note the need to recognize the

obligation of all physical therapists to develop in leadership and the obligation of educational

programs to prepare physical therapists to do so (Tschoepe et al., 2021). The leadership

perceptions of physical therapists warrant continued attention so the professional development of

physical therapists may meet the demands of a modern healthcare environment (Desveaux, 2015;

McGowan & Stokes, 2015; Tschoepe et al., 2021).

Whether or not physical therapists perceive themselves to be leaders has received limited

attention in the last 10 years. The body of research on this topic presents conflicting findings.

Over the course of several studies, Irish and Canadian physiotherapists perceived of themselves

as leaders (Desveaux et al., 2012; McGowan, 2017; McGowan & Stokes, 2017; McGowan et al.,

2015; McGowan et al., 2019b). Desveaux et al. (2012) found 79.6% of Canadian

physiotherapists perceived of themselves to be leaders while McGowan and Stokes (2017) found

75% of Irish physiotherapists did as well. In the United States, leadership self-efficacy was found

to be moderately high in a sample of U.S. physical therapists (Sebelski, 2017). First-year U.S.

physical therapy doctoral students also possessed a high degree of leadership self-perception

(LoVasco et al., 2016). although this finding could also be indicative of an inherent degree of

leadership self-efficacy upon entering the PT profession as suggested earlier.

While these results suggest a high degree of leadership self-efficacy and self-perception

amongst physical therapist/physiotherapists in several cultures, other research from the same
 30

time frame offers a conflicting perspective. As noted previously, Shafer et al.’s (2007) early

study suggested the PT professional preparation did not need to include leadership and

management, indicating that those skills and competencies could be acquired later in one’s

career. McGowan and Stokes (2015) conducted a literature review of available PT leadership

research and concluded physical therapists needed to change the perception of their professional

selves to recognize leadership in order to meet the challenges of modern healthcare. These

findings were further supported by Mallini (2019), who found understanding of leadership and

management by physical therapist to be inconsistent with contemporary definitions. Physical

therapists also equated leadership with job title (Mallini, 2019).

It has been suggested that a patient-first mentality and culture may actually limit the

perceived importance of leadership and management development in physical therapists.

Additional studies have confirmed that physical therapists in Rwanda (Pascal et al., 2017) and

physiotherapists in Sweden (Rasmussen-Barr et al., 2019) and Portugal (Pereira, 2020) did not

perceive themselves to be leaders. The conflicting findings in the research suggests the issue of

leadership self-perception amongst physical therapists is more complex than a simple

dichotomous choice between two viewpoints. Possible reasons for conflicting leadership self-

perceptions may include the failure of academic PT programs to support a strong leader identity,

the dominance of the clinician identity, and the contextual nature of physical therapist leader

self-perception.

Lack of Academic Support

Lopopolo et al.’s (2004) early research on physical therapy leadership and management

uncovered the perceived lack of importance of several leadership and management skills for

entry-level physical therapists. Lopopolo et al. (2004) commented on a lack of linkage between
 31

the overarching physical therapist professional identity belief system and the need to acquire

leadership and management skills. Seven years later, Green-Wilson (2011) found the persistence

of this mentality when noting the minimal integration of practice management content into entry-

level Doctor of Physical Therapy (DPT) curricula. Green-Wilson (2011) sought to uncover the

forces which drove or restrained DPT faculty from including this content. Restraining forces

included the strong perception of physical therapists as clinicians, the negative perception of

physical therapists as businesspeople, the view of management content as competing with

clinical content, the lack of faculty awareness of the role of practice management in

contemporary physical therapy practice, and a faculty view of clinical and business work-roles as

mutually exclusive (Green-Wilson, 2011). The inconsistency between faculty perceptions of

leadership and management importance in DPT training and the demands of contemporary

physical therapy practice have been noted in subsequent studies (Clark, 2016; Sebelski et al.,

2020). Given the role of academic preparation in the process of professional socialization and

professional role identity development, the lack of content and support in academic physical

therapy for the inclusion of leadership and management preparation is one possible reason for

findings of low leadership self-perception amongst physical therapists (Mallini, 2019; McGowan

& Stokes, 2015; Pascal et al., 2017; Rasmussen-Barr et al., 2019).

Dominance of the Clinician Identity

The dominance of the clinician identity in physical therapy may be another impediment

to the inclusion of leadership and management in the professional role identity of the physical

therapist (Mallini, 2019). An apparent need to legitimize leadership and management identities

by linking them to a clinician identity is seen in the literature. In Lopopolo et al.’s (2004)

foundational study, the leadership, administration, management, and professionalism skills

 32

identified were framed in terms of their relationship or correspondence to clinical skills, instead

of discussing them as separate but equal components of an overall professional role identity. The

primacy of the clinical identity as the benchmark against which leadership and management

skills are compared, and thus legitimized, is present several times more in the literature (Bennie

& Rodriguez, 2019; Luedtke-Hoffman et al., 2010; McGowan et al., 2016; Silberman et al.,

2020). This practice may be undertaken as a way to relate leadership and management skills to

the widely-accepted conceptual framework of patient management in order to facilitate

understanding and acceptance of the research findings. Viewed differently however, this practice

further delegitimizes leadership and management by suggesting these constructs may only be

important to the professional identity of the physical therapist if they can be directly related to

clinical care (Green-Wilson, 2011).

Physical Therapist Leadership Self-Perception In Context

The perceived need to connect leadership and management to a clinical care framework

may help explain the nuanced and conflicting findings of physical therapist leadership self-

perception present in the literature. Studies indicate physical therapists in several countries,

including Canada, Ireland, and the U.S., perceive themselves to be leaders (Desveaux et al.,

2012; LoVasco et al., 2016;, McGowan, 2017; McGowan & Stokes, 2017; McGowan et al.,

2016; McGowan et al, 2019b). A closer examination of the literature reveals the positive leader

self-perception is limited in scope and relates directly back to the dominance of the physical

therapist’s clinician identity. Once again, Lopopolo et al.’s (2004) foundational work on physical

therapy leadership uncovered a trend which would be repeated in subsequent studies. When

ranking the importance of leadership and management skills, study participants ranked

organizational level leadership and management skills near the bottom (Lopopolo et al., 2004).
 33

Schafer et al.’s (2007) follow-up study reaffirmed the importance of leadership and management

skills that were important for patient-client management but not necessarily those that related to

organizational-level leadership or management. These early findings confirmed the perception of

leadership and management at the clinical level as important, while leadership and management

at the organizational level was not (Lopopolo et al., 2004; Schafer et al., 2007).

This theme repeats itself in the subsequent literature on physical therapist leadership self-

perception. Consistently, physical therapists have been found to value leadership at the clinical

level and recognize the importance of leadership as it pertains to patient care (Desveaux &

Verrier, 2014; McGowan & Stokes, 2017; Rasmussen-Barr et al., 2019). McGowan (2017)

found Irish physiotherapy leaders tended to use human resources and structural frames of

leadership more. These frames can be directly correlated to the skills needed in the management

of patients.

In contrast, physical therapists fail to value leadership outside of the realm of their day-

to-day clinical work. Despite common traits making physical therapists suitable for

individualized and inspirational leadership (McGowan & Stokes, 2015), physical therapists are

rarely present on boards and at the executive level (McGowan et al., 2019a). While physical

therapists regularly display leadership qualities in their clinical work (Rasmussen-Barr et al.,

2019), they do not value leadership at an organizational and societal level (Desveaux & Verrier,

2014). Irish physiotherapy managers rarely used their power to advocate, were rarely represented

on boards of directors, and used organizational-level leadership frames such as symbolic and

political frames much less than the more clinically applicable human resources and structural

frames of leadership (McGowan, 2017; McGowan et al., 2019a). Physical therapists appear to

possess a professional role identity which values leadership at a clinical level, but does not
 34

promote the ability or desire to lead at an organizational or societal level (McGowan, 2017). This

separation may serve to explain the variation in leadership self-perception noted in the literature

as well as the disconnect between the high leadership self-efficacy noted in some studies and the

low number of physical therapists represented in higher level leadership positions in the clinical

and academic worlds (Sebelski, 2017).

The Physical Therapist Transition from Clinician to Leadership Positions

The transition from clinical physical therapist to a leadership or management position has

received little attention in the PT leadership body of research. In a systematic review on the

effectiveness of first-time clinician managers, Masoumi (2019) reviewed 67 articles, none of

which addressed the phenomenon in the physical therapy profession. Within the PT leadership

literature, the only comparable transitions investigated have been from practicing clinician to

physical therapy faculty member, or the transition from academic physical therapy faculty

member to program director.

The transition from clinician to junior physical therapy or athletic training faculty

member includes a role identity transition punctuated by role conflict and role overload which

leads to a perceived inability to perform any role at the level of quality desired (Barrett et al.,

2019a). Physical therapy and athletic training clinicians turned faculty have confirmed the

salience of the clinician identity in affirming their success in an academic role (Barrett et al.,

2020). Participants felt clinical experience gave them credibility with their students and better

prepared them for their academic roles than receiving their terminal academic doctoral degrees

(Barrett et al., 2020).

In the separate but linked population of clinical instructors, novice physical therapy

clinical instructors reported difficulty balancing dual roles as teacher and clinician. In contrast,
 35

experienced physical therapy clinical instructors learned to integrate their teacher and clinician

role identities in order to reduce dissonance and perform effectively in each role (Greenfield et

al., 2014). These findings were also found by Ong et al. (2019) in a study of occupational and

physical therapy clinical instructors in Singapore. OT and PT clinical instructors with more

salient educator roles were better able to integrate that role identity into their overall professional

role identity, in harmony with their clinician identity (Ong et al., 2019). Taken as a whole, the

limited research on the clinician to teacher transition indicates a clinician identity is an important

factor in the success of physical therapists undergoing the transition, with the ability to integrate

a new role identity into a prior role identity being an integral part of that success (Barrett et al.,

2019a, 2019b; Greenfield et al., 2014; Ong et al., 2019).

In contrast to the findings of recent research on clinician to faculty transitions, early

research on academic physical therapy program directors found clinical practice to be

insufficient in preparing physical therapists for the transition (Luedtke-Hoffman et al., 2010).

Luedtke-Hoffman et al. (2010) did find physical therapy faculty who transition to an academic

program director position experienced role uncertainty, anxiety, and burnout due to a lack of

leadership preparation and role identity conflict. Hinman (2014) later confirmed the effect of role

identity on a successful transition from faculty to program director. Doctor of Physical Therapy

program directors with previous leadership experience and an understanding of the program

director role stayed in their position longer. The possession of a professional role identity which

includes leadership allowed for a better integration into the program director role with reduced

role identity conflict (Hinman, 2014). More recent research on the program director role has

focused on faculty member perceptions of which factors influence a decision to pursue program

directorship, without mention of role identity or the lived experience (Vore, 2019). Additional
 36

research on the program director role has focused on quantitatively identifying triggers of job

satisfaction or dissatisfaction, again without mention of role identity conflict (Bowen et al.,

2021).

While the phenomenon of academic role transitions has received some limited attention

in the research, studies of the transition from clinician to leadership or management positions are

almost non-existent. Glendinning (1987) conducted one of the earliest investigations into the role

of physiotherapist managers in Australia. Glendinning (1987) found many Australian

physiotherapy departments were led by physical therapists with little to no management training.

The participants also felt the need to maintain clinical caseloads in order to maintain legitimacy

and the appearance of competence in the eyes of their employees, highlighting the dominant role

of the clinician identity even after transitioning to a management role. Finally, the participants

reported the ambiguity between their clinician role and their manager role caused job stress

(Glendinning, 1987). Based on these findings, Glendinning (1987) called for further research on

the stress brought on by role ambiguity in physiotherapists who transition from clinician to

management positions. In the 34 years since Glendinning’s (1987) publication, no additional

studies directly addressing Glendinning’s (1987) suggestion have been located. A citation search

revealed only one citation of Glendinning’s (1987) work, dealing with the competing priorities of

hybrid clinician/physical therapy managers (Hoekstra et al., 2021).

Issues with Clinician to Manager/Leader Transitions

While the transition from clinician to management/leadership positions remains

understudied in the physical therapy literature, other healthcare fields have recognized the

potential impact of successful and unsuccessful transitions. This recognition is represented in a

 37

growing body of research on the potential issues which may impact a clinician to manager/leader

transition.

Masoumi (2019) conducted a systematic review of the evidence concerning the

effectiveness of clinicians as first-time managers. Sixty-seven articles were included in the final

systematic review, revealing six themes linked to the effectiveness of first-time clinician-

managers. These themes included motivation to transition, insufficient in-house training, the

presence of mentorship, successful succession planning, a lack of alignment to management and

organizational culture, and the effects of role identity conflict. While zero of the 67 articles

reviewed pertained to physical therapist transitions, the findings of Masoumi’s (2019) review

along with a review of the current literature on this topic may help frame the potential issues

worth examining when expanding the investigation of this topic into the PT profession in the

course of this study.

Insufficient Training, Mentorship, and Succession Planning

Insufficient leadership/management training, mentorship, and succession planning were

separate but linked reasons for ineffectiveness in first-time clinician-managers (Masoumi, 2019).

Identifying potential clinician-leaders (succession planning), providing sufficient initial training,

and following up that training with mentorship were identified as keys to a successful transition

(Masoumi, 2019).

Succession planning involves identifying potential clinician-managers or leaders and

preparing them to become successors to a new organizational position (Rishel, 2013). Masoumi

(2019) found successful succession planning resulted in improved participation of the identified

clinician in their own career planning, increased motivation and interest to transition to

management, and deeper commitment to the process. By and large, the healthcare industry does
 38

not take advantage of formal succession planning processes as part of the strategic development

of healthcare providers (Masoumi, 2019). While there is limited evidence of healthcare provider

readiness to take over clinical management duties (Fanelli et al., 2021), overall findings indicated

clinicians who move into management/leadership positions are underprepared and face a steep

learning curve (Daly et al., 2014, Shams et al., 2019; Sonnino, 2016; Thompson & Henwood,

2016). A lack of leadership preparation in training has been identified as a barrier to taking on

leadership positions in the first place (Daly et al., 2014; Masoumi, 2019; Sonnino, 2016).

Additionally, many clinicians do not transition to management or leadership positions as part of

a structured succession and development plan, but instead are nominated for positions and take

on these positions reluctantly (Boucher, 2007; Kippist & Fitzgerald, 2009; Thompson &

Henwood, 2016).

Additionally, the healthcare sector like many others, displays a tendency to promote high

performing and technically-proficient individual contributors to management and leadership

positions (Crane, 2021; Cavaness et al., 2020; Delmatoff & Lazarus, 2014; Masoumi, 2019;

Maurer & London, 2018; Sonnino, 2016). Promotion of the most technically proficient

individual contributors has been identified as an ineffective strategy for integrating clinicians

into management (Sonnino, 2016). High performing individual contributors may often lack a

leadership mindset and skillset, focusing on themselves and their personal needs as opposed to

those of a team (Crane, 2021; Masoumi, 2019; Maurer & London, 2018; Sonnino, 2016).

Motivation to Enter Leadership

Individual motivations for entering leadership may be linked to an effective transition for

first-time clinician managers (Masoumi, 2019). Individuals with a drive toward excellence and a

desire to make other people better were typically more effective in the first-time manager role
 39

(Masoumi, 2019). Occupational therapists identified a strong desire to lead as a key motivation

for their transition from clinician to manager/leader (Shams et al., 2019).

The pursuit of leadership or management positions for reasons of self-benefit or pay

increase were typically associated with ineffectiveness in first-time clinician managers

(Masoumi, 2019). Many healthcare managers enter leadership or management positions by

accident, reluctantly, and not of their own choosing (Boucher, 2007; Kippist & Fitzgerald, 2009;

McGivern et al., 2015; Thompson & Henwood, 2016). For some clinicians, pursuing a position

in management may be viewed as the only option for advancement, as a mid-career opportunity,

or as an alternative career path (Bender, 2005; Evans & Reiser, 2003; Henson, 2016; McGivern,

2015; Spehar, 2012). Additionally, some clinicians may deliberately take positions in

management or leadership in an attempt to protect or shield their profession from management

and downplay management’s influence due to a persistent cynical view of their motives (Daly et

al., 2014; McGivern, 2015). Each of these motivations speaks to a lack of motivation to embrace

the role of a manager or leader and a lack of commitment to the goals of the organization over

the goals of oneself or those of the individual’s profession (Masoumi, 2019).

Role Identity Conflict

Role identity conflict is another potential factor affecting the transition from clinician to

leadership or manager positions (Masoumi, 2019). Of the 67 articles included in Masoumi’s

(2019) systematic review, 22 of them included references to the impact of role conflict on the

effectiveness of first-time clinician managers. Role conflict may result from a failure to achieve

alignment between one’s values and the role one inhabits and may result in feeling a loss of

autonomy, feeling ineffectual or stymied by bureaucracy, managerial isolation and loneliness,

and a perceived inability to perform well in either role as a clinician or a manager (Harviksen,
 40

2021; Masoumi, 2019; Sofritti, 2020; Spyridonidis & Currie, 2016). To better understand

professional role identity conflict during the clinician to leadership transition, one must first

understand the processes by which healthcare professionals form their professional role identities

and the forces of identity regulation and professional socialization which influence them.

Professional Role Identity Formation

Within the conceptual framework of this study, professional role identity is the precarious

outcome of identity work comprising a coherent narrative of self (Alvesson & Willmott, 2002).

Identity regulation is the process by which an organization attempts to cause an individual to

recognize with the organization. These attempts will then spur identity work, in which the

individual forms, repairs, maintains, or revises the professional role identity (Alvesson &

Willmott, 2002). The focus of the proposed study is how physical therapists make meaning of

their professional role identity when transitioning from clinician to leadership positions. This

requires an understanding of how the original physical therapist professional role identity is

formed. This section will first describe how professional role identity is formed through the

interplay of identity regulation and identity work. The section will then examine the research on

healthcare professional role identity formation by framing the professional socialization process

in academic preparation as a form of identity regulation followed by an examination of student

and professional responses to these efforts as a form of identity work.

Professional Role Identity as Self-Identity

Using Giddens’ structuration theory (1984, 1991), Alvesson and Willmott (2002)

described self-identity as a reflexively organized narrative of self. This narrative is derived from

participating in competing discourses and a variety of activities, and is considered malleable

(Alvesson & Willmott, 2002). This narrative is the result of conscious and unconscious as well
 41

as interpretive and reflexive actions which are in turn influenced by organizational attempts at

identity regulation (via modes of structure). Identity work is the on-going process of self-identity

creation, revision, or confirmation which results in a self-identity which subsequently serves to

reinforce or challenge existing social structures (Alvesson &Willmott, 2002).

In defining self-identity within a conceptual framework for understanding organizational

efforts to prompt identity work amongst employees, Alvesson and Willmott (2002) effectively

defined professional role identity as a form of self-identity. Six concepts of this professional self-

identity were identified: central life interest, coherence, distinctiveness, direction, values, and

self-awareness (Alvesson & Willmott, 2002). A subsequent literature review by Ashforth et al.

(2008) supported this conceptual definition. In a conceptual analysis of the literature on

professional identity amongst healthcare workers, Fitzgerald (2020) found similar themes.

Healthcare workers identify with their profession by the actions and behaviors of its members,

the possession and use of knowledge and skills unique to the profession, the values or ethics of

the profession, a strong personal identification and sense of autonomy, and a sense of

distinctiveness which separates the professional group from other professionals in society

(Fitzgerald, 2020). The conceptual consistency amongst these sources (Alvesson & Willmott,

2002; Ashforth et al., 2008; Fitzgerald, 2020) makes Alvesson and Willmott’s (2002) concept of

professional self-identity appropriate for use in answering the central research question posed by

this study.

Identity Regulation

Identity regulation is the process by which an organization prompts an individual to

identify with the organization as a core component of their identity. Identity regulation may be

accomplished through the creation of boundaries which restrain an individual’s choice of actions
 42

to those which fit within the organization’s conceptualization of member identity (Alvesson &

Willmott, 2002). As such, identity regulation represents the process by which Giddens’ (1984)

structures of society are employed in an effort to influence self-identity. As noted previously,

rules are procedures of action which are understood and generalizable as a component of group

membership (Giddens, 1984). These rules manifest themselves as organizational structures, a

code of ethics or values, organizational or occupational culture, member demographics, and the

defined behaviors, knowledge base, and skills expected of membership (Alvesson & Willmott,

2002; Ashforth et al., 2008; Fitzgerald, 2020; Ibarra, 1999).

Resources are the political, psychological, organizational, or economic resources

employed by social structures to influence human behavior (Giddens, 1984). In terms of

organizational identity regulation, these resources manifest themselves as specific cultural raw

materials of language and symbols (Alvesson & Wilmott, 2002). Access to these raw materials

comes in the form of recognition and admission to an organization as well as the provision of

training opportunities which allow a new member to develop the knowledge, skills, and defined

characteristics for full acceptance into the group (Alvesson & Willmott, 2002; Ashforth et al.,

2008). Additionally, an organization provides access to psychological resources such as

emotional feedback and social validation (Ibarra, 1999) in an attempt to influence the

professional role identity of the individual.

Organizations and occupations use these structures as a means to influence the self-

identity of the individual (Alvesson & Willmott, 2002; Ashforth & Mael, 1989). As awareness of

these rules and access to resources becomes available, it may be perceived as either a validation

of existing professional role identity or a challenge to it. The defined expectations,

characteristics, rules, and codes of ethics or values may be viewed as consistent or inconsistent
 43

with an existing professional role identity with which the individual identifies (Alvesson &

Willmott, 2002; Ashforth & Mael, 1989; Ashforth et al., 2008; Fitzgerald, 2020; Ibarra, 1999).

Both challenges to or reinforcement of an existing professional role identity by attempts at

identity regulation will then stimulate the process of identity work, by which the individual will

maintain/strengthen or modify/revise/reject components of their professional role identity. In

turn, this will result in a coherent narrative of professional identity which is responsive or

resistant to the identity regulation efforts of the organization (Alvesson & Willmott, 2002).

Identity Work and the Effect on Role Identity

Identity work is the process of continually forming, repairing, revising, or strengthening

self-identity (Alvesson & Willmott, 2002; Ashforth et al., 2008). Identity work represents the

exercise of agency over one’s concept of professional role identity, while also representing the

exercise of agency over the social or organizational structures which seek to regulate

professional identity (Alvesson & Willmott, 2002). Identity work is grounded in self-doubt and

openness to change and is stimulated by the liminality which occurs when the structures which

typically reinforce self-identity instead challenge it (Alvesson & Willmott, 2002; Ashforth et al.,

2008; Gordon et al., 2020).

The process of identity work may result in the production, alteration, continuation, or

discarding of a professional role identity (Alvesson & Willmott, 2002; Ashforth & Saks, 1995;

Ashforth et al., 2008; Ibarra, 1999). After conducting identity work, an individual may first

respond to a challenged professional role identity by trying out “provisional selves”, trial

identities which seek to control the tension arising from a state of liminality (Ibarra, 1999;

Robak, 2006). If the challenge to professional role identity occurs during a work role transition,

the individual may also engage in a process of “personal development” in which they adjust their
 44

self-identity to the defining characteristics of their new role (Ashforth & Saks, 1995). Individuals

may also demonstrate flexibility in role identity, a willingness to renegotiate identity, or an

ability to suppress or defer to the most appropriate of multiple identities in response to identity

regulation efforts (Ashforth et al., 2008).

Ibarra’s (1999) foundational study on professional role adaptation in work role changes

also recognized socialization (conceptually consistent with identity regulation) not as a process

of imposing conformity, but rather a negotiated process of adaptation between one’s role identity

and the work environment (Ibarra, 1999). As such, not only can the process of identity work

result in an alteration of professional role identity, but may also result in an alteration of the

modes of structure being used to regulate identity (Alvesson & Willmott, 2002; Ashforth & Saks,

1995; Ashforth et al., 2008; Ibarra, 1999). Individuals with strong or rigid identity beliefs are

more likely to attempt “role development”, the process of altering the rules and resources

employed by social structures in their attempts to regulate identity (Ashforth & Saks, 1995;

Ashforth et al., 2008)

Healthcare Professional Socialization as Identity Regulation

Identity regulation refers to the efforts of an organization or group to influence the role

identity of an individual. The process of socializing an individual into a healthcare profession is

commonly referred to as “socialization” (Hamilton, 2008). Socialization into a healthcare

profession involves educators and professional organizations defining the role identity expected

of a member of their profession by defining the rules and controlling the resources needed to

establish this identity (Cowin et al., 2013; Shahr et al., 2019; Volpe et al., 2019).

Terms such as professionalism, professional self-concept, and professional socialization

have often been used to describe both the concept of a professional role identity as well as the
 45

processes by which that identity is developed and the attempts to regulate its development

(Fitzgerald, 2020). While the concept of healthcare professional role identity has often lacked a

clear conceptual definition in the literature (Fitzgerald, 2020), the processes of identity regulation

in the form of professional socialization have been more readily researched. Healthcare

professional education programs serve as gate keepers into the professional ranks by determining

admission of non-professionals into their respective training programs (Shahr et al., 2019). Upon

admission, a student’s first substantial exposure to the profession and its members occurs via the

educational program. As a result, educational programs hold significant influence over the

formation of a healthcare professional’s role identity (Barrow et al., 2011). The process of

professional socialization in helping professions such as medicine and nursing typically begins

generally through the sharing of knowledge exclusive to the profession as well as the norms and

expected behaviors of members of the profession (Shahr et al., 2019; Volpe et al., 2019). This

sharing of information and expectations is an early example of identity regulation by defining

professional role identity via the sharing of resources and the setting of boundaries and rules by

the profession.

Professional socialization in healthcare professional programs will typically progress

with students being given opportunities to emulate the professional role identity through

experiences with patients and further role refinement through more personalized feedback

(Fitzgerald, 2020; Shahr et al., 2019; Volpe et al., 2019). Finally, healthcare professional

students are accepted into the professional culture and hierarchy and welcomed as recognized

members by fellow professionals and by society at large (Shah et al., 2019; Vivekananda-

Schmidt et al., 2015; Volpe et al., 2019). The intent of identity regulation via professional

socialization is to make professional role identity a defining aspect of the individual’s overall
 46

self-identity and viewed as exclusive by both its members and by society (Fitzgerald, 2020;

Hamilton, 2008; Shahr et al., 2019; Vivekananda-Schmidt et al., 2015). This intra-professional as

well as societal recognition is tied to the social contract which defines professional role identity

and serves as the professional’s source of authority (Barrow et al., 2011; Hamilton, 2008). The

development and recognition of this professional role identity is required before a professional

may take on a role within an organization and is precisely the reason why education programs

hold significant power over the process of professional role identity regulation in the healthcare

professions (Barrow et al., 2011).

Research in the field of physical therapy education supports the idea of socialization into

the PT profession as a form of identity regulation. The physical therapist’s professional role

identity has been recognized as a key component of the overall concept of professionalism, with

one framework for the conceptualization of professionalism in physical therapy being identity-

based (Nesbit & Fitzsimmons, 2021). The acquisition of expert knowledge alone is likely

insufficient in producing competent physical therapists (Plack, 2006).

As a result, assisting students in becoming part of the professional physical therapy

community has been recognized as an important goal of physical therapy professional education

(Plack, 2006; Plack & Driscoll, 2017; Stiller, 2000). Given the importance of professional role

identity as a key component of professionalism (Nesbit & Fitzsimmons, 2021) and the goal of

assisting students in becoming professionals (Plack, 2006; Stiller, 2000), the professional

socialization process enacted by physical therapy educational programs represents a strong initial

attempt at professional identity regulation. Previous research has noted the strong influence on

professional socialization played by physical therapy academic faculty and physical therapist

clinical instructors (Greenfield et al., 2012, 2015; Teschendorf & Nemshick, 2000). The process
 47

of identity regulation via professional socialization begins in much the same manner as with

other helping professions. Socialization begins with sharing the specific knowledge base

belonging to the PT profession (Plack, 2006). The early transition from student to physical

therapist is also highlighted by the internalization of the commonly held beliefs of the profession.

Students are socialized to conform to the values and professional identity of a physical therapist

and are regularly assessed and provided feedback in an effort to regulate the formation of an

accepted professional identity (Foord-May & May, 2007; Plack, 2006; Stiller, 2000; Teschendorf

& Nemshick, 2000).

Once physical therapy students demonstrate sufficient progress in the process of

socialization, they are provided access to a patient population and opportunities for practical

experience with regular feedback in the form of clinical education experiences. Clinical

experiences often make-up the culminating educational experience in a physical therapy

curriculum. Clinical education experiences play a significant role in professional role identity

formation (Barrett et al., 2020; Greenfield et al., 2012, 2015), culminate in the student’s full

identification with the profession, and the profession’s recognition and acceptance as one of its

members (Greenfield et al., 2012, 2015; Plack, 2006). This process of internalizing knowledge,

skills, beliefs and values and progressing to opportunities for practice and ultimately full

acceptance in and identification with the PT profession is consistent with conceptual analyses of

professional identity formation in other healthcare professions (Fitzgerald, 2020). This process

catalyzes the student’s professional role identity formation, consistent with the process of

identity regulation noted in the conceptual framework developed for this study (Alvesson &

Willmott, 2002).
 48

The identity regulation processes in physical therapy education are tightly regulated and

assessed. The Commission on Accreditation of Physical Therapy Education (CAPTE) has

specific standards and required elements governing the accreditation of physical therapy

educational programs (Commission on Accreditation of Physical Therapy Education, n.d.).

Among these are standards dictating the assessment of student performance. While CAPTE does

not typically mandate the use of specific assessment tools, specific assessment tools have been

studied and widely-adopted within the physical therapy education community. These tools

include the Professional Behaviors for the 21st Century (Duke Doctor of Physical Therapy, n.d.)

as well as standardized assessment tools for clinical education such as the Clinical Performance

Instrument (American Physical Therapy Association, 2019) and the Physical Therapist Manual

for the Assessment of Clinical Skills (Texas Consortium for Physical Therapy Clinical Education,

n.d.). These assessment tools provide defined standards against which students are assessed in

their progression through the socialization process of a physical therapy education. This process

constrains the formation of a student’s professional role identity by restricting the options for

acceptable professional conduct and practice as well as restricting the options by which a student

may self-assess in the individualized process of professional role identity formation (Foord-May

& May, 2007; Santasier & Plack, 2007; Shahr et al., 2019; Teschendorf & Nemshick, 2000).

Professional Role Identity as an On-going Narrative of Self

Historically, professional role identity has been viewed from a positivist perspective as

something which is acquired, and once acquired, marks the entry of an individual into the

profession (Nesbit & Fitzsimmons, 2021). More recently, professional role identity has been

recognized as malleable and a construct which healthcare providers, including physical

therapists, may continually develop and refine over time (Hammond, 2013; Nesbit &
 49

Fitzsimmons, 2021; Stiller, 2000; Volpe et al., 2019). Despite the significant influence of identity

regulation exerted by educational programs over the development of healthcare professionals’

role identities, research has recognized professional role identity formation as a cyclical and

interactive process. Both the profession and the individual bend to accommodate each other,

resulting in the intertwining of the individual and the profession in a process extending well into

the working life of the individual (Shahr et al., 2019; Thomas & Hardy, 2011; Volpe et al.,

2019).

Earlier research on the development of a physical therapist professional role identity

described an identity crisis due to physical therapy’s perceived inability to differentiate itself

from the medical profession through exclusive knowledge and content (O’Hearn, 2002). As the

physical therapy profession has developed, the literature has recognized the process of

professional identity formation not simply as a process of differentiation and exclusion, but as a

dynamic and ongoing process by which physical therapists are in a continual state of reflection

and revision (Echternach, 2003; Hammond, 2013; Nesbit & Fitzsimmons, 2021; Stiller, 2000).

The physical therapy education community has, at times, struggled to keep pace with the

changing professional role identity of physical therapists in clinical practice. This struggle stands

as evidence of the physical therapist professional role identity as a malleable construct, the

revision of which extends well beyond the powerful initial socialization process of PT education

(Tschoepe et al., 2021). Furthermore, this recognition indicates a degree of agency of the

individual in response to efforts at identity regulation.

Identity Work as a Response to Professional Socialization

While the process of identity regulation via professional socialization in academic

preparation may utilize standardized assessments and be subject to regulation (American

 50

Physical Therapy Association, 2019; Commission on the Accreditation of Physical Therapy

Education, n.d.; Duke Doctor of Physical Therapy Program, n.d.; Texas Consortium for Physical

Therapy Clinical Education, n.d.), students are not passive participants in the professional role

identity formation process. In contrast, healthcare professional students are active participants,

exercising agency over the process and drawing upon unique and at times individualized

processes of identity work in the formation of their professional role identity (Fitzgerald, 2020;

Perez, 2016; Shahr et al., 2019; Volpe et al., 2019).

Healthcare professional students do not arrive in a professional education program as

blank slates. Nor is the educational program the first exposure of many healthcare professions

students to the beliefs and values which are considered an important part of professional role

identity formation (Fitzgerald, 2020). Students have multiple social identities they bring with

them to a professional education program, and multiple social identities they occupy while in

training (Komives et al., 2005). Furthermore, individuals are often drawn to a particular

healthcare or helping profession because the espoused values and beliefs of the profession are

consistent with their existing self-image and belief system (Cowin et al., 2013; Perez, 2016). The

fact that students possess some of the profession’s espoused values and beliefs before presenting

to a professional education program is evidence of identity work occurring prior to the onset of

identity regulation. These findings suggest students may in fact be actively involved in identity

work before matriculation and thus exert agency over the identity regulation process by self-

selecting the pool of potential applicants for admission into a profession (Cowin et al., 2013;

Perez, 2016).

The selection of a healthcare profession consistent with an existing value and beliefs

system and consistent with existing social identities (Cowin et al. 2013; Komives et al., 2005;
 51

Perez, 2016) means the healthcare profession student begins the socialization process with an

ego-centric professional role identity already intact (Hamilton, 2008). As the student moves

through the socialization process, they begin to identify with the group identity of their chosen

profession, developing a professional role identity in which their existing self-identity and the

commonly accepted aspects of the professional role identity become intertwined and inseparable

from one another (Fitzgerald, 2020; Hamilton, 2008; Kreindler et al., 2012; Vivekananda-

Schmidt et al., 2015; Volpe et al., 2019). The development of this unique blend of professional

and self-identity through identity work exemplifies how healthcare professional students exercise

agency over and influence the identity regulation process.

The blending of existing and developing identities is not the only example of identity

work and the exercise of agency over the identity regulation process. The process of identity

regulation via professional socialization is applied in a relatively uniform manner across a

student body in the form of a structured curriculum. In contrast to the uniformity of the identity

regulation process, the process of identity work by helping professionals is unique by individual.

Fitzgerald (2020) conducted a literature review and conceptual analysis and concluded that

professional role identity is formed from the unique perspective of the individual. Perez (2016)

drew heavily on the helping professions when developing a conceptual model of professional

socialization in student affairs graduate students. Perez (2016) found students in the helping

professions were drawn to their field by its espoused values and tended to hold on to an idealized

view of the profession based on the socialization process of their educational preparation.

However, when helping professionals encountered discrepancies between this identity and

experiences in the workplace or fieldwork assignments, they would engage in processes of

sensemaking and self-authorship to reduce the dissonance. These processes may be viewed as
 52

forms of identity work, in which the individual exercises agency over both the identity regulation

efforts resulting from the organizational context in which the dissonance occurs, but also over

the existing role identity which has now been challenged (Perez, 2016).

Student relied on several resources in the process of sensemaking. Some processes were

internal, such as referencing existing role identities and past experiences which helped form

them. Some processes drew on the external rules and resources made available to them in the

organizational setting, including social context and salient cues given to them by other

professionals or individuals in authority (Perez, 2016). Student would then use these resources to

enact a variety of potential professional role identities in an attempt to find a plausible

explanation for the challenge to their existing professional role identity. This process is similar to

the use of provisional selves identified by Ibarra (1999).

Interestingly, Perez’s (2016) conceptual model recognized the uniqueness of an

individual student or professional’s approach to identity work. Individual students did not draw

on all resources equally. Instead, students drew heavily on particular resources while ignoring or

minimizing other resources. The result was a role identity which was plausible but not

necessarily accurate (Perez, 2016). Students drawing upon social context and salient cues were

more accepting of identity regulation efforts. These individuals tended to align a modified

professional role identity more closely with organizational goals and norms (Perez, 2016). In

contrast, individuals drawing largely on internal cues such as experiences, values, and beliefs

sought to preserve the existing idealized professional role identity, rejecting the organizational

efforts at identity regulation (Perez, 2016). Ultimately, individuals who successfully engaged in

sensemaking and self-authorship, or identity work, were able to minimize discrepancy and leave
 53

graduate preparation in student affairs having achieved the desired socialization outcomes, a

product of identity regulation (Perez, 2016).

Research in the professional role identity formation from healthcare professions such as

medicine, dentistry, nursing, and psychology support Perez’s (2016) concept of professional

socialization as a unique and individual process of identity co-creation (Fitzgerald, 2020;

Komives et al, 2005; Shahr et al., 2019; Vivekananda-Schmidt et al., 2015; Volpe et al., 2019).

In contrast, the literature on identity regulation and identity work in professional role identity

formation by physical therapy students and professionals is more limited. While earlier work on

the professional socialization process of physical therapists did recognize the role of identifying

oneself with the profession via history, experiences, and challenges (Plack, 2006), the physical

therapy community has largely viewed professionalism in a positivistic manner (Nesbit &

Fitzsimmons, 2021).

Hammond (2013) did recognize how physiotherapists will engage in an ongoing process

of identity work, continually developing and refining their professional identity over the course

of a career. This identity work may occur both consciously and unconsciously and may be

triggered by episodes of non-coherence between their perceived self-narrative and the perceived

experience in the workplace (Hammond, 2013). Physiotherapists will continually co-construct

professional identity through discussion with other PTs, family, and friends, as well as

referencing other identities comprising their self-concept (Hammond, 2013). In a follow-up

qualitative study, Hammond et al. (2016) described physiotherapists’ professional role identity as

an on-going construction, influenced by personal feelings and how one makes sense of the

interaction between professional and personal experiences. The results of Hammond et al.’s

(2016) study suggested physiotherapists regularly exercise agency over their professional role
 54

identity, strengthening their role identity over time through a reflexive capacity to envision and

adopt alternative professional selves in response to change. The physical therapy profession has

begun to recognize professional role identity as an on-going process of co-construction

(Hammond, 2013; Hammond et al., 2016; Nesbit & Fitzsimmons, 2021). Nevertheless, the

physical therapy profession, and PT education in particular, has struggled to keep pace with this

changing notion of professional role identity (Tschoepe et al., 2021). Further examination of the

co-construction of professional role identity from alternative philosophical frameworks and

through the interplay of identity work and identity regulation is necessary for the physical

therapy professional role identity to respond to the needs of modern healthcare (Green-Wilson,

2011; Hammond et al., 2021; Tschoepe et al., 2021).

The conceptual framework of Alvesson and Willmott (2002) provides a useful means of

conceptualizing the process of professional role identity formation. Understanding the strength of

the healthcare professional’s role identity and how it becomes interwoven with the professional’s

overall self-identity provides a foundation for better understanding the part played by

professional role identity, and role conflict, in the clinician to leadership transition.

Role Conflict in the Clinician to Leader Transition

The transition from individual contributor to leader or manager is recognized as a

difficult role transition in fields as diverse as business, science, education, law, and

manufacturing as well as healthcare (Hardin et al., 2018; Maurer & London, 2018; Schyns et al.,

2020; Settles, 2004). Recent research on role transitions in other professions has identified some

common themes. First, the strength of the individual contributor role identity may impact the

transition to leadership or management (Crane, 2021; Fitzpatrick & Queenan, 2021; Maurer &

London, 2018; Niessen et al., 2010; Settles, 2004). Over the course of their education and early
 55

to mid-careers, professionals work hard to nurture and grow their professional role identities as

strong, individual contributors (Maurer & London, 2018; Settles, 2004). The result is a narrative

of self in which the professional identity is interwoven with their personal identity and the

identity of the working group with which they identify (Fitzpatrick & Queenan, 2021; Hardin et

al., 2018; Maurer & London, 2018). The individual’s strong performance in this role is often a

reason for their promotion to leadership or management roles in the first place (Crane, 2021).

However, the psychological attachment to this existing role identity has been cited as a limitation

to successful role transition in executive masters of business administration students, lawyers,

scientific researchers, and new business owners (Fitzpatrick & Queenan, 2021; Maurer &

London, 2018; Niessen et al, 2010; Schweiger et al. 2020).

In business, the transition to a leadership or management position represents the shift

from a role defined by one’s individual performance to a role defined by performance within the

larger organizational bureaucracy (Hardin et al., 2018; Maurer & London, 2018). The transition

may create a period of role conflict in which dissonance occurs between an individually-

cultivated and valued prior identity and the attempts of an organization to cultivate a new

organizationally-focused role identity (Hardin et al., 2018; Maurer & London, 2018).

The success of role transitions in other professional fields has been linked to the presence

of leadership as a component of the original professional role identity (Maurer & London, 2018;

Settles, 2004), the identity work undertaken by the individual in response to role conflict (Maurer

& London, 2018; Niessen et al., 2010; Settles, 2004), and the manner in which an organization

engages in identity regulation at various stages in an individual’s career (Maurer & London,

2018). This section will explore the current status of the literature concerning role conflict in the

healthcare professions when transitioning from an individual professional contributor to a

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leadership or management role. More specifically, this section will discuss whether leadership is

typically a component of the healthcare professional’s role identity, how healthcare leadership

positions represent an organizational identity and thus cause role identity conflict, and the

variable ways in which clinicians engage in identity work as a response to identity regulation and

professional role identity conflict.

Leadership as a Component of Healthcare Professional Role Identity

Healthcare professionals typically do not perceive themselves as leaders, nor is leadership

or management included in their professional role identity. The lack of recognition or self-

perception of leadership spans multiple healthcare professional disciplines in the limited research

on this topic (Brocklehurst et al., 2013; Greathouse et al., 2018; Heard, 2014; Mitchell, 2019;

Phillips et al., 2018; Pitts, 2020; Young et al., 2011).

The clinician identity is central to the professional role identity of nurses, physicians,

dentists, and occupational therapists (Brocklehurst et al., 2013; Greathouse et al., 2018; Heard,

2014; Mitchell, 2019; Phillips et al., 2018; Pitts, 2020; Sonnino, 2016; Young et al., 2011). A

lack of integration of leadership into the professional role identity of physicians and nurses may

result in feelings of inadequacy when transitioning into a leadership role (Mitchell, 2019; Spehar

et al., 2012). Furthermore, a lack of recognition of leadership or management as legitimate career

paths and a commonplace view of managerialism as a threat to clinical identity limit physicians’

consideration or willingness to enter leadership and management in the first place (Aggarwal &

Swanwick, 2015; Kippist & Fitzgerald, 2009; Schyns et al., 2020). Nurses and dentists may not

recognize themselves as leaders and may require structured leadership training and reflective

activities in order to recognize existing skills, traits, and job requirements consistent with
 57

leadership and management behaviors (Brocklehurst et al., 2013; Phillips et al., 2018; Schyns et

al, 2020; Spehar et al. 2012; Young et al., 2011).

Occupational therapy is a profession with many similarities to physical therapy. While

the research on leadership as a component of professional role identity in many other professions

demonstrates relatively consistent findings, research on leadership self-perception in

occupational therapy presents conflicting findings. According to Heard (2014) and Pitts (2020),

leadership is not considered a strong component of the occupational therapist’s professional role

identity. Greathouse et al. (2018) noted an increase in leadership self-awareness as a result of a

phenomenological and grounded theory study, indicating the need for occupational therapists to

engage in reflective activities in order to improve leadership self-perception.

In contrast, Fleming-Castaldy and Patro (2012) found occupational therapists perceived

of themselves as leaders and felt they possessed characteristics which predisposed themselves to

leadership positions. This finding may be viewed cautiously as Fleming-Castaldy and Patro

(2012) conducted their study on occupational therapist already occupying leadership positions.

Shams et al. (2019) investigated the lived experience of occupational therapists transitioning into

leadership roles. In contrast to findings from other healthcare professions, the occupational

therapists in the study expressed strong intrinsic motivation to enter leadership (Shams et al.,

2019).

Despite conflicting results regarding occupational therapists’ self-perception of

leadership one common finding existed between the studies noted above. The centrality and

strength of the clinician professional role identity was a theme in each study (Greathouse et al.,

2018; Heard, 2014; Krishnasamy et al., 2019; Pitts, 2020). Leadership roles were often framed in

terms of the clinician identity. The occupational therapist clinician role was felt to be a pre-
 58

requisite to entering leadership with occupational therapists citing their transition into clinical

leadership and clinical teaching roles as part of an effort to become a better clinician rather than

an effort to lead from an organizational standpoint (Greathouse et al., 2018; Heard, 2014;

Krishnasamy et al., 2019). While the centrality of the clinician identity is consistent with

research from other fields, occupational therapists in one study specifically cited their experience

as a clinician as necessary preparation for leadership (Shams et al., 2019). This finding stands in

contrast to the research from other healthcare fields.

The lack of leadership self-perception in many healthcare professions may be linked to

the socialization process and the significant role it plays in the development of a professional

role identity (Barrow et al., 2011; Cowin et al., 2013; Hamilton, 2008; Shahr et al., 2019; Volpe

et al., 2019). As noted previously, individuals within the helping professions make a career

choice linked to existing self-perceptions (Cowin et al, 2013; Perez, 2016). Through the

socialization process of professional education, this sense of self becomes even more intertwined

with their professional role identity (Volpe et al., 2019). The professional role identity formed

during this socialization process may not include leadership and management however (Antony,

2021; Boothman & Hickson, 2021; Heard, 2014; Langendyk et al., 2015; Pitts, 2020; Schemm &

Bross, 1995; Shams et al., 2019; Sonnino, 2016; Spehar et al., 2012).

Physician and nurse training is strong on clinical skills with leadership and management

content often minimal or absent (Antony, 2021; Boothman & Hickson, 2021; Sonnino, 2016).

Furthermore, nursing and medical training will tend to promote a uniprofessional and exclusive

role identity focused on certainty in the micro-level patient decision making process (Boothman

& Hickson, 2021; Fitzgerald, 2020; Langendyk et al., 2015). This narrow and exclusive

professional role identity may actually be antithetical to the mindset and role identity needed in
 59

leadership and management, leaving physicians and nurses who undergo such a transition feeling

unprepared and unsupported in their new role (Boothman & Hickson, 2021; Spehar et al., 2012).

The occupational therapy research similarly notes a lack of leadership content in the socialization

process (Heard, 2014; Schemmer &Bross, 1995; Shams et al., 2019; Pitts, 2020). Greathouse et

al. (2018) suggested future research into the role of leadership self-perception in occupational

therapy.

Leadership and Management Positions as Organizational Identities

Given the lack of leadership and management as components of healthcare professional

role identities, the transition to a leadership/management position within an organization may be

considered a definitive role change. The clinician role identity is formed during the socialization

process, bestowed upon the individual by the profession through graduation and licensure, and is

retained by the professional even when changing employers or organizational affiliations

(Kriendler et al., 2012). In contrast, a leadership or management role is bestowed upon the

individual professional by their employer and, as such, may be considered an organizational

identity (Salvatore et al., 2018). Thus, in transitioning to an organizationally-oriented position,

the clinician is subject to organizational efforts at identity regulation.

Taking a leadership or management position represents a fundamental shift from the

uniprofessional and highly autonomous role identity to a focus on the performance of a team

(Cowin et al., 2013; Steffens et al., 2014). The medical workplace has transitioned from a

conglomeration of individual professionals working in silos to a more collaborative and

interprofessional model of care delivery (Barrow et al., 2011; Brocklehurst et al., 2013;

Langendyk et al., 2015). This shift from a professionally-anchored model of care to a

collaborative care team at all levels of the organization poses a challenge to the healthcare
 60

professional’s previously established and developed role identity (Barrow et al., 2011). New

healthcare leaders/managers are faced with organizational expectations which attempt to regulate

their professional role identity. The organization no longer expects high individual performance

with its corresponding high level of autonomy. Instead, the organization expects a

leader/manager to perform as part of a work group, with strict organizational boundaries and

constraints placed on them by organizational bureaucracy (Langendyk et al., 2015; Masoumi,

2019; Sofritti, 2020). The desired end result of the organization is a role shift in which

professional role identity becomes anchored as part of the organizational team instead of the

profession into which the clinician was originally socialized (Barrow et al., 2011).

Successful attempts at identity regulation on the part of the organization result in a

transition from individual healthcare professional contributor to a productive leader and

manager. Organizations which allow healthcare leaders more autonomy and input into

organizational decision-making facilitate the transition to an organizational role identity from a

professional role identity (Salvatore et al., 2018). Organizations which actively work to

incorporate the individual healthcare professional role identities into an organizational role

identity which recognizes the individual professional contributions to overall team performance

also enjoy more successful clinician to leader transition (Antony, 2021; Kreindler et al. 2012;

Reay et al., 2017). Cummings et al. (2020) found the most effective nursing leadership

development interventions were done within the context of the organizational structure. While

these examples from the literature show how organizational attempts at identity regulation may

be successful, the transition from clinician to leader may also be punctuated by identity

disequilibrium and role conflict which may threaten the success of the clinician to

leader/manager transition (Machin et al., 2011; Masoumi, 2019).

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Role Conflict in the Leadership/Management Transition

In a systematic review, Masoumi (2019) found role identity conflict to be one of the

issues determining first-time clinician manager effectiveness. Often times, new clinician

managers are not provided options or time to re-align their values and goals to the organization’s

before taking on management duties (Masoumi, 2019). This results in clinician managers/leaders

who retain strong clinical identities instead of developing a new organizational identity

(Kreindler et al., 2012; Masoumi, 2019). Thrusting healthcare professionals into leadership and

management roles without sufficient preparation leads to role conflict (Spehar et al., 2012;

Thompson & Henwood, 2016; Young et al., 2011). Central to this role conflict is the fact that

new healthcare professional clinician leaders/managers are expected to occupy roles with

competing logics, the logic of professionalism and the logic of leadership or managerialism

(Masoumi, 2019; Sofritti, 2019; Wikstrom & Dellve, 2009). This presents a situation in which

the new healthcare leader/manager, particularly those engaged in hybrid clinician-

leader/manager roles, are attempting to fill two competing roles simultaneously (Masoumi, 2019;

Sofritti, 2019). Often times, these new leader/managers will attempt to retain a strong clinical

professional identity, returning to or maintaining clinical work to remain competent in the eyes

of their fellow professionals, to continue feeling connected to the ideals which drew them to

clinical work, or as an escape from the new logics of managerialism and leadership in which they

find themselves (Camilleri, 2020; Cantillon et al., 2019; Spehar et al, 2012; Mitchell, 2019;

Thompson & Henwood, 2016). Unfortunately, the retention of a strong clinician identity has

been found to be an aspect of on-going role conflict, ultimately resulting in the clinician failing

to meet the requirements of either role effectively, leaving them feeling ostracized from the
 62

clinical community (Cantillon et al., 2019; Masoumi, 2019: Shams et al, 2019; Spehar et al.,

2012).

The interaction between organizational attempts at identity regulation and an existing

professional role identity can trigger role conflict in the clinician undergoing a transition to

leadership and management (Cowin et al., 2013; Langendyk et al, 2015; Masoumi, 2019; Sofritti,

2019; Spehar et al., 2012; Steffens et al., 2014; Thompson & Henwood, 2016; Wikstrom &

Dellve, 2009; Young et al., 2016). Consistent with the conceptual framework of this study, the

professional turned leader/manager will respond to this role conflict by conducting identity work

(Alvesson & Willmott, 2002).

Identity Work as a Response to Role Conflict

Historically, the research community has viewed the choice between professionalism and

managerialism as a dichotomous one (Andersson & Liff, 2018; Salvatore et al., 2018).

Healthcare professionals either succumb to the regulatory efforts of managerialism entirely or

reject these efforts outright in order to maintain their existing commitment to professionalism

(Andersson & Liff, 2018). This dichotomous choice between outright acquiescence to or

rejection of managerialism does hint at the presence of agency on the part of the healthcare

professional. However, it presents a rather positivistic view which is inconsistent with the

contemporary conceptualization of professional role identity as a nuanced and malleable

construct subject to alteration, adaptation, and change (Alvesson & Willmott, 2002). This

historic view also limits the options for identity work to a dichotomous choice instead of a

process response to organizational efforts at identity regulation.

Recent research supports identity work as a more nuanced, individualized, and contextual

response to the inherent identity regulation efforts that come with taking a leadership or
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management role (Andersson & Liff, 2018; Lega & Sartirana, 2016; Magill, 2020; McGivern et

al., 2015; Perez, 2016; Reay et al., 2017; Yip et al., 2020). Successful leaders in multiple

professional fields typically practice self-awareness, self-regulation, and metacognition and work

to construct and integrate a new leader identity with other valued identities (Magill, 2020; Yip et

al., 2020). Research in healthcare leadership transitions supports this view. Masoumi (2019)

found successful clinician to manager transitions were marked by clinicians who learn the

cultures of multiple stakeholder groups and ultimately align personal goals and values with those

of the organization. Lega & Sartirana (2016) found Italian physicians possessed both the capacity

and inclination to recreate their professional role identities to include leadership and management

roles. Reay et al. (2017) supported this finding in a study of Canadian general practitioners’

response to the healthcare system’s attempt to alter their professional role. Canadian general

practitioners possessed a highly autonomous professional role identity. In an effort to reduce

costs and improve quality, the Canadian healthcare system introduced other professionals into

the daily workflows of the general practitioners. This posed an organizational regulatory

challenge to the role identity of the general practitioners. Ultimately, after engaging in deliberate

identity work, the Canadian general practitioners emerged with a professional role identity which

included their role as the head of a healthcare team (Reay et al., 2017). This research supports the

notion of identity work as a contextual and individualized process which may result in new,

updated, or integrated professional role identities. Reay et al.’s (2017) findings counter the

historic concept of full acceptance or rejection of organizational attempts to regulate identity

(Andersson & Liff, 2018). Healthcare professionals may engage in identity work differently and

come to different end results when transitioning from clinical to leadership or management

positions (McGivern et al., 2015). This section will describe healthcare professional identity
 64

work spanning a continuum between the two historical options of full rejection or acceptance of

organizational identity regulation.

Rejection of the Organizational Identity

While the dichotomous view of rejection or acquiescence to organizational identity

regulation may fail to recognize the gradations in potential responses, the two extremes of the

continuum have been noted as potential results of identity work in healthcare professionals.

Sofritti (2020) noted the delegitimization and rejection of managerialism as one of the possible

responses to attempts at changing healthcare delivery and physician workflows in Italy. In a

similar situation, the British National Health Service (NHS) sought to alter the expectations and

priorities of health visitors in the United Kingdom (Machin et al., 2011). This role change

resulted in role identity conflict. In response to this conflict, some health visitors held more

strongly to their central professional role identity as nurses instead of embracing the NHS’s new

health visitor role identity. The fear of rejection by clinicians led radiography managers to revert

back to a strict clinician identity, foregoing a manager identity (Thompson & Henwood, 2016).

In a uniquely personal account of their experience as a leader in an academic medical center,

Mitchell (2019) describes how she prioritized concern for clinical and research responsibilities

over those of leadership after being asked to take a leadership position. This ultimately resulted

in leaving the position and taking a sabbatical to revive her research.

While the outright rejection of an organization’s attempts to regulate professional role

identity represents only one extreme outcome on the identity work continuum, its presence is

noted in both the leadership research at large, and the healthcare leadership research more

specifically (Andersson & Liff, 2018; Machin et al., 2011; Mitchell, 2019; Noordegraaf, 2015;

Salvatore et al., 2018; Sartirana, 2019; Sofritti, 2020; Thompson & Henwood, 2015). An outright
 65

rejection of the leadership or management role identity has been noted as a factor in clinician

manager ineffectiveness (Masoumi, 2019).

Removal of the Existing Professional Role Identity

The removal or de-stabilization of an existing professional role identity in order to

accommodate a new leadership or management role identity is another potential response to

organizational identity regulation. This response occupies the opposite end of the spectrum of

identity work outcomes. The removal or de-stabilization of an existing professional role identity

has been noted in the general leadership and business literature as a means of dealing with role

conflict, particularly if the conflict results from previous friendships with subordinates (Hardin et

al., 2018; Yip et al., 2020). Kreindler et al. (2012) found physician managers often fail to fully

resolve role identity conflict. This ultimately resulted in physician managers making a

dichotomous choice of one identity over the other. After doing so, the physician managers

resisting the discarded role identity more vigorously, even if the discarded role was clinical

(Kreindler et al., 2012). While the removal or de-stabilization of a clinician identity in favor of a

leadership identity is a possibility, it is uncommon in the healthcare leadership literature. This is

likely due to the strength of the professional socialization process, the centrality of the clinician

identity, and the on-going perceived need to remain clinically-competent in the eyes of fellow

professionals (Barrow et al., 2011; Cowin et al., 2013; Hamilton, 2008; Masoumi, 2019; Shahr et

al., 2019; Spehar et al., 2012; Thompson & Henwood, 2016; Volpe et al., 2019).

Occupation of Multiple Professional Role Identities

The occupation of more than one role identity, dependent on time and context, represents

a third potential outcome of identity work (Noordegraaf, 2015). In this more contemporary

reaction to identity regulation, professionals may accept a managed professionalism in which

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professional services are delivered within the framework of the organization without the

professional accepting, rejecting, or integrating the organizational leadership identity into their

existing professional role identity (Noordegraaf, 2015).

This outcome has been noted in healthcare professionals who take positions in leadership

and management. Ibarra’s (1999) foundational work on professional role identity described the

use of provisional selves, temporary role identities which are trialed in an effort to resolve role

conflict during a transition. These provisional selves were linked to previous research on how

healthcare professionals resolve role conflict (Ibarra, 1999). Spehar et al. (2012) noted how

healthcare managers must learn new terminology for every different management task. While put

forth as a difficulty facing healthcare professionals turned leaders, this finding also highlights

how some healthcare leaders learn to occupy different role identities dependent upon the context

they find themselves in (Spehar et al., 2012). Wikstrom and Dellve (2009) also found that

healthcare managers who do not integrate the two logics of professionalism and management can

still be effective by moving between the two logics.

In studying hybrid physician managers in Italy, Sofritti (2020) discovered this response to

identity work as well. Some hybrid physician managers would recognize the co-existence of

organizational and professional logics and attempt to mediate them, stopping short of altering

their professional role identity to either convert to an organizational identity or integrate

components of the organizational identity into an updated professional role identity (Sofritti,

2020). In an investigation of physicians transitioning from trainee to fully-trained status, Gordon

et al. (2020) noted how some physician-trainees used identity work to compare their current self

with possible future selves. While this state was temporary for some, other physicians chose to

occupy a perpetual state of liminality, moving between possible role identities in order to
 67

effectively manage role identity crises (Gordon et al., 2020). While Ibarra (1999), Sofritti (2020),

Wikstrom and Dellve (2009), and Gordon et al. (2020) portray this response as effective,

Masoumi (2019) noted the failure to transition to a leadership role and the long-term occupation

of a hybrid or liminal state as a reason for first-time clinician manager ineffectiveness.

Conflicting research on this result of identity work leaves unanswered questions concerning the

effectiveness of this response, the contextual nature of the response, and whether this response is

effective in short and long-term situations.

Co-opting Organizational Identity to Sustain Professional Identity

Co-opting components of an organizational identity to advance the interest of one’s

professional role identity is a fourth potential response to organizational efforts at identity

regulation (Andersson & Liff, 2018; Noordegraaf, 2015). When co-opting organizational

identities, the healthcare professional neither accepts nor rejects the efforts to regulate identity.

Likewise, the healthcare professional does not accept the co-existence of two identities and

choose to move between them in order to be effective (Gordon et al., 2020; Ibarra, 1999; Sofritti,

2020, Wikstrom & Dellve, 2009). Instead, the healthcare professional retains their professional

role identity while selectively co-opting specific aspects of the organizational identity in order to

specifically advance the cause of the profession and protect professional spaces from the impact

of leadership and managerialism (Andersson & Liff, 2018; Noordegraaf, 2015).

Sofritti (2020) described this phenomenon in Italian physicians who retain their

professional role identity but integrate selective organizational objectives into it. Andersson and

Liff (2018) observed a more specific case in which psychiatrists co-opted specific aspects of

managerial oversight in order to support their decisions to accept or deny specific patients for

admission to a mental health unit. Finally, any healthcare professional who transitions to
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leadership or management specifically to protect their profession from the impact of that very

same management/leadership bureaucracy could be seen as co-opting these organizational

identities for the protection and advancement of their profession (Daly et al., 2014; McGivern et

al., 2015).

Role Identity Integration and Hybridization

A final outcome of identity work noted in the general leadership literature is the

hybridization of role identities, or more specifically, the integration of an organizational identity

into an existing identity, creating a new professional role identity which retains the core elements

of the professional role identity while incorporating the organizational identity as well

(Noordegraaf, 2015; Yip et al., 2020). Yip et al. (2020) described how the ultimate integration of

a new role identity into an existing role identity may represent the final outcome of identity

work, often times preceded by some of the previous identity work outcomes already mentioned.

A new leader lacks a coherent sense of self or a strong leadership identity due the role conflict

brought on by the transition. This stimulates identity work, which consists of the destabilization

and potential loss of meaningful role identities, followed by a period of liminality, ultimately

concluding with the integration of the organizational identity and creation a new hybridized

professional role identity (Yip et al., 2020).

The integration of a leader or manager identity into an existing professional role identity

is a phenomenon observed in healthcare professionals specifically. Several studies note how

healthcare professionals may successfully integrate leader/manager and clinical role identities as

a response to organizational identity regulation (Andersson & Liff, 2018; Cantillon et al., 2019;

Kippist & Fitzgerald, 2009; Sartirana, 2019; Salvatore et al., 2018; Sofritti, 2020). Healthcare

professionals who find consistency between the organizational identity and the professional role
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identity, or who readily identify with the administrative aspects of leadership and management

are more likely to integrate the two into a new professional role identity (McGivern et al., 2015;

Sartirana, 2019; Sofritti, 2020). Research on role conflict in nurse educators echoes these

findings. Nurses who find the teaching identity as a reinforcement to their clinical identity, and

thus successfully integrate the two identities, tend to remain in nurse educator roles (Cantillon et

al., 2019; Kippist & Fitzgerald, 2009).

As noted previously, a systematic review of the literature on first-time clinician manager

effectiveness found that hybrid clinician-managers were often ineffective, suffered significant

role identity conflict, and failed to project a strong leadership persona (Masoumi, 2019). While

this may appear to represent a conflicting result, Masoumi’s (2019) findings may in fact support

the idea of role identity integration. Masoumi (2019) may be using the term “hybrid” clinician-

managers to describe their assigned job titles within an organizational and professional

bureaucracy, not their professional role identity. The presence of on-going role conflict in these

individuals seems to suggest an absence of successful identity work. If this is the case, these

individuals still occupy a position of liminality and role conflict, explaining their ineffectiveness.

Masoumi’s (2019) findings may in fact support the findings of Sofritti (2020) and Sartirana

(2019) who noted the successful integration of role identities as a precursor to success in their

new positions and in the organization as a whole.

Summary

The integration of clinicians into leadership and management is important to the

performance of healthcare organizations (Barrow et al., 2011; Brocklehurst et al., 2013;

Desveaux, 2015; Gilmartin & D’Aunno, 2007; Kreindler et al., 2012; Masoumi, 2019;

Spyridonidis & Currie, 2016). The transition from a clinical position to a leadership or
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management position may be difficult for healthcare professionals, however. Role conflict is one

factor which can affect the clinician to leader transition (Masoumi, 2019). More specifically,

how the clinician responds to role conflict and the ultimate outcome of their identity work may

impact the success of the transition (Harviksen, 2021; Masoumi, 2019; Sofritti, 2020;

Spyridonidis & Currie, 2016).

Physical therapy has an important role to play in a new healthcare environment which

seeks to reduce costs and improve patient outcomes (Burge et al., 2016; Garrity et al., 2019; Hon

et al., 2021; Vore, 2019). Achieving these goals requires physical therapy leaders. Leadership

remains an understudied phenomenon in the physical therapy research (McGowan & Stokes,

2015; McGowan & Stokes, 2017; Sebelski, 2020; Vore, 2019). Research on the transition from a

physical therapist clinical position to a leadership position and the effect of this transition on the

physical therapist’s professional role identity remains almost non-existent.

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CHAPTER 3

METHODOLOGY

A well-designed research study will seek to answer the proposed research question using

appropriate methods which are consistent with the philosophical assumptions underpinning the

study’s purpose and conceptual framework (Creswell & Poth, 2018; Lochmiller & Lester, 2017;

Merriam & Tisdell, 2016; Mertens, 2010). Linking epistemological and theoretical assumptions,

theoretical perspective, methodology, and methods improves the rigor of a proposed research

study and helps ensure that the methods employed will yield the appropriate data necessary to

realize the purpose of the study (Crotty, 1998). The purpose of this study was to investigate how

physical therapists make meaning of their professional role identity when transitioning from

clinician to leadership positions. Given the focus of the research, a qualitative research approach

was utilized. This chapter will discuss the qualitative approach to research, the philosophical

assumptions which informed the study, the methodology, and the methods of data collection and

analysis used in this study. Additionally, this chapter will also discuss efforts to ensure goodness

and trustworthiness as well as delimitations and limitations of the study.

Qualitative Approach to Research

This study utilized a qualitative approach. Qualitative research seeks to understand how

individuals make sense of, interpret, and assign meaning to their lives and experiences (Creswell

& Poth, 2018; Merriam & Tisdell, 2016). Understanding a phenomenon or experience from the

perspective of the individual in their natural setting is a key focus of qualitative research

(Creswell & Poth, 2018; Merriam & Tisdell, 2016). The naturalistic focus of qualitative inquiry

requires the researcher to embrace ambiguity, differences, and investigate and richly describe the

context of the individual’s experience with the phenomenon rather than attempt to control for
 72

them (Creswell & Poth, 2018; Merriam & Tisdell, 2016). This study investigated how physical

therapists make meaning of their professional role identity when transitioning from clinical to

leadership positions. Contemporary theories of leadership and professional role identity

recognize these phenomena as social constructs (Antonakis & Day, 2018). The focus on

individual perception of a social construct in this study made qualitative research the most

appropriate approach to answer the research question.

Philosophical Assumptions and Research Design

Designing a qualitative research study begins by understanding one’s philosophical

assumptions. In qualitative inquiry, the researcher is considered the primary instrument of data

collection and a co-constructer of knowledge along with study participants (Creswell & Poth,

2018; Crotty, 1998; Merriam & Tisdell, 2016). An explicit explanation of the researcher’s

philosophical stance on reality and the nature of knowledge is required to produce a well-

designed study which is methodologically sound and consistent (Creswell & Poth, 2018; Crotty,

1998; Lochmiller & Lester, 2017; Merriam & Tisdell, 2016). This study was informed by a

constructionist epistemology and a basic interpretivist theoretical perspective.

Epistemology: Constructionism

Constructionism views meaning as a construction which humans assign to an object or

phenomenon (Crotty, 1998). A constructionist epistemology allows for the recognition of objects

and phenomena in the world. While constructionism acknowledges an objective substance to the

world, the meaning attached to that substance is inherently the product of human interpretation

(Crotty, 1998). Under constructionism, it is the interactions of the human mind with objects and

phenomena, and the interpretation and meaning assigned to them, which constitutes knowledge
 73

(Crotty, 1998). A constructionist epistemology will inform all subsequent philosophical

assumptions in this study.

The knowledge constructed as humans interact with phenomena may result from

interaction on both an individual and a societal level (Mertens, 2010). Crotty (1998) describes

constructionism as an overall epistemological stance, while describing social constructionism

and constructivism as sub-categories of constructionism. Constructivism may be viewed as the

creation of meaning on an individual level while social constructionism views the creation of

meaning as a social process (Crotty, 1998). While the terms constructivism and constructionism

are often used interchangeably (Kezar, 2006; Mertens, 2010), for the purposes of this research

study, constructionism was used to describe the epistemological belief that meaning is a human

construction, with constructivism describing this process on the individual level rather than a

social level (Crotty, 1998). Given the nature of the proposed research question, the individual

process of meaning making in relation to a phenomenon, this study was informed by a

constructionist epistemology and constructivist sub-epistemology (Crotty, 1998).

Theoretical Perspective: Interpretivism

In keeping with the constructionist epistemology informing this study, a basic interpretive

theoretical perspective informed the methodology and methods. Interpretivism seeks to

understand the meaning assigned to an object or phenomena from the human perspective,

making it consistent with a constructionist epistemology and ideally suited to inform the

methodology and methods used to describe and interpret the meaning assigned by physical

therapists to their professional role identity (Crotty, 1998; Scotland, 2012).

While epistemology describes one’s belief in the type of knowledge possible, theoretical

perspective informs a researcher on how to go about discovering such knowledge (Crotty, 1998).
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Interpretivism seeks to understand phenomena from an individual’s perspective (Crotty, 1998;

Scotland, 2012). Furthermore, interpretivist practice considers how people construct their worlds

and what objects, phenomena, and configurations of life inform and shape that reality making

process (Gubrium & Holstein, 2000). This dual subjective/objective focus of interpretive practice

guides the researcher toward a focus on both the phenomenon itself and the interpretation of how

meaning is made from the lived experience with the phenomenon (Crotty, 1998).

Methodological Approach

Phenomenology was chosen as the methodology for this study as it focuses on the lived

experience of a phenomenon and the process of making meaning during this experience

(Creswell & Poth, 2018; Merriam & Tisdell, 2016). Phenomenology has been identified as a

philosophy, a theoretical perspective within interpretivism, as well as a methodology (Crotty,

1998; Gubrium & Holstein, 2000; Moustakas, 1994; Tuohy et al., 2013). For the purposes of this

study, phenomenology was considered a methodology.

A phenomenological methodological approach seeks to describe an objective

phenomenon and the subjective interpretation and meaning the individual assigns to the

phenomenon (Creswell & Poth, 2018; Merriam & Tisdell, 2016). This duality is consistent with

both the interpretivist theoretical perspective and the constructionist epistemology which

informed this study.

Edmund Husserl is often considered the founder of phenomenology (Gubrium &

Holstein, 2000). In developing the phenomenological perspective, Husserl aimed to refocus

scientific inquiry toward the phenomena themselves by asserting the relationship between

objects of the world and human perception of them was not passive, but indeed a dynamic

process of interpretation worthy of deeper examination (Gubrium & Holstein, 2000). Key to
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understanding Husserl’s phenomenology are the concepts of consciousness, intentionality, the

natural attitude, and the role of examining and eliminating pre-supposition in the development of

a phenomenological attitude.

Intentionality, Consciousness, and the Natural Attitude.

In order to understand phenomenology’s respect for the subjective and objective aspects

of human experience, the concepts of consciousness and intentionality must be examined.

Husserl (1970b) argued that the separation of psychological and natural sciences was an artificial

separation. In contrast to purely objectivist or subjectivist views, Husserl (1970b) countered that

human consciousness could not be separated from the objects of the world toward which such

consciousness was directed. Instead, phenomenological philosophy considers all human

consciousness as intentional (Husserl, 1970b, Husserl, 1982; Moustakas, 1994; Sokolowski,

2000). The concept of intentionality describes human consciousness as being, by necessity,

conscious of “something.” Human consciousness is directed outward rather than the prevailing

philosophy in Husserl’s time which viewed human consciousness as consciousness of the inner

self only (Husserl, 1970b; Merleau-Ponty, 1962; Moustakas, 1994; Sokolowski, 2000). In the

phenomenological perspective, the natural world is the setting toward which human thought and

perception are directed and from which human experience and development of meaning stem

(Merleau-Ponty, 1962).

The concept of intentionality of consciousness leads to a second key concept in

phenomenology, the natural attitude. The natural attitude humans hold toward the world may be

described as our default setting (Sokolowski, 2000). The natural attitude is based on a world-

directed stance from which our original perceptions were formed. Humans will naturally

experience the phenomena of the world based not on empirical or critical development of
 76

knowledge, but based on intuition, belief, and the cultural framework in which those beliefs were

founded (Crotty, 1998; Husserl, 1982, Moustakas, 1994; Sokolowski, 2000). This view of

objects and phenomena of the world is locked in egocentrism (Sokolowski, 2000). The natural

attitude limits what we are capable of perceiving to the confines of our own minds (Sokolowski,

2000). The natural attitude also restricts the development of new meaning or understanding to

the historical and learned framework housed within our own mind or within the scientific

discipline in which a researcher has trained and practiced (Husserl, 1982; Kuhn, 2012;

Sokolowski, 2000). Furthermore, the natural attitude and its egocentric predicament prevent

researchers from viewing the world from another’s perspective and from uncovering any other

potential meaning an object or phenomenon may hold (Husserl, 1982; Sokolowski, 2000).

The Phenomenological Attitude and Bracketing of Pre-supposition.

The natural attitude represents a person’s current understanding of meaning and

knowledge as constructed by interaction with the objects and phenomena of the given world

(Husserl, 1982; Sokolowski, 2000). In order to free oneself from the confines of egocentrism and

engage in a pure phenomenological investigation, the researcher must strip away the historical,

cultural, and learned pre-suppositions which framed the original experience with a given

phenomenon (Creswell & Poth, 2018; Husserl, 1970a; Merleau-Ponty, 1962; Sokolowski, 2000).

The process of discussing one’s philosophical assumptions and identifying potential biases and

pre-suppositions regarding a phenomenon is known as bracketing (Creswell & Poth, 2018;

Merleau-Ponty, 1962; Sokolowski, 2000). Bracketing is a key step in the development of a

phenomenological attitude. The phenomenological attitude is transcendental in that it frees the

researcher from the bounds of egocentrism, pre-supposition, and the restrictive focus of

paradigmatic training. Development of a phenomenological attitude allows for a more direct

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description of experience as it truly occurs (Creswell & Poth, 2018; Husserl, 1970a; Kuhn, 2012;

Merleau-Ponty, 1962; Merriam & Tisdell, 2016; Sokolowski, 2000). Given that the focus of

phenomenological methodology is a description of the lived experience of a phenomenon and a

return to the phenomenon itself, the switch from a natural attitude to a phenomenological attitude

is a foundational shift needed in order to engage in a true phenomenological investigation

(Creswell & Poth, 2018; Husserl, 1970a; Kuhn, 2012; Merleau-Ponty, 1962; Merriam & Tisdell,

2016; Sokolowski, 2000).

As a methodology, phenomenology focuses on the individual lived experiences of a

phenomenon with respect for the object or phenomenon and the subjective experience of the

study’s participants (Creswell & Poth, 2018; Merriam & Tisdell, 2016). A phenomenological

research study seeks to describe what was experienced, how it was experienced, and the essence

of the phenomenon (Creswell & Poth, 2018; Crotty, 1998; Merleau-Ponty, 1962; Merriam &

Tisdell, 2016). As stated previously, a goal of phenomenological inquiry is to develop this

description from a transcendental point of view. Rather than relying strictly on restrictive a priori

knowledge and developed methods of inquiry common to the scientific method,

phenomenological inquiry requires methods that free a researcher from pre-supposition in order

to develop a description of a phenomenon which respects the essence of the phenomenon

(Husserl, 1982; Kuhn, 2012).

Spiegelberg (1982) described several steps of phenomenological research method,

including three general steps which are commonly accepted despite the wide range of methods

spawned by phenomenological philosophy. First, the researcher engages in intentional analysis.

Consistent with the philosophical concept of intentionality, this initial step involves the

researcher engaging intensely with the phenomenon through the collected participant data. The
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researcher considers each experience singularly in and of itself (Moustakas, 1994). The role of

bracketing is key during intentional analysis to ensure the researcher is viewing the phenomenon

in its totality and from a transcendent point of view (Gubrium & Holstein, 2000; Moustakas,

1994; Spiegelberg, 1982). This process is known as the phenomenological reduction, the general

classification or description of identified characteristics of the phenomenon resulting in textural

and structural descriptions (Creswell & Poth, 2018; Moustakas, 1994; Spiegelberg, 2000).

The researcher then works to identify the characteristics of the phenomenon that cluster

together and make up the essence of the phenomenon. The act of identifying the essence of the

phenomenon is known as the eidetic reduction. It represents a synthesis of the analyzed data into

a composite description of the phenomenon as it was experienced by the study’s participants

(Creswell & Poth, 2018; Moustakas, 1994; Spiegelberg, 1982).

Through bracketing, the researcher ideally is capable of taking a transcendent view of the

collected data, free from their own pre-suppositions and the pre-suppositions of the study’s

participants (Moustakas, 1994). While phenomenology may use a number of different data

collection methods, its focus on participant experience makes qualitative interviewing the

primary means of data collection in phenomenology (Creswell & Poth, 2018; Merriam & Tisdell,

2016).

Application of Phenomenological Methods to this Study

The focus of intentional analysis in this study was the physical therapist’s professional

role identity. The phenomenological reduction resulted in a description of the physical therapists’

professional role identity during a transition from clinical to leadership roles. How physical

therapists make meaning of this role identity while living through the experience of transitioning

from clinician to leadership positions was the focus of the eidetic reduction. The end result of
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both the phenomenological and eidetic reductions formed the essence statement, a description of

the lived experience of physical therapists making meaning of their professional role identity

while transitioning from clinical to leadership positions.

Participants and Sampling

Participants in this study were physical therapists who have transitioned from full-time

clinical positions to leadership positions. Physical therapists serving in full-time leadership

positions and those serving in hybrid clinician/leader positions were considered as potential

participants in this study. While there exists no definitive timeframe by which to define a

leadership “transition,” participants had a minimum of three-quarter’s year and a maximum of

four years in their leadership position to ensure sufficient experience with the phenomenon.

Participant sampling within qualitative research is theoretically driven and focused on the

recruitment of participants who allow the researcher to best answer the research question

(Merriam & Tisdell, 2016; Miles et al., 2014). Additionally, Moustakas (1994) considered

participant experience with the phenomenon and an intense interest in its nature and meaning as

two of the essential criteria in the selection of phenomenological study participants. As a result,

random sampling could not be considered an appropriate sampling procedure for the qualitative

phenomenological study (Merriam & Tisdell, 2016; Miles et al., 2014). Purposeful sampling was

used to recruit a participant sample from which the most could be learned about the research

topic (Merriam & Tisdell, 2016). Maximum variation sampling is described by Merriam and

Tisdell (2016) as a type of purposeful sampling designed to identify and seek out participants

with a wide range of characteristics. Maximum variation sampling was used to recruit a more

diverse participant sample to improve the likelihood of uncovering emergent themes which held

interest and value to a broader pool of physical therapists (Merriam & Tisdell, 2016).
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Participant recruitment began via professional contacts in the physical therapy

community. Professional contacts from across the United States were engaged for participant

recruitment in order to improve maximum variation. Physical therapists with whom the

researcher had an existing personal or professional relationship were excluded from the

participant sample given the potential power gradient between researcher and participant, to

reduce any potential political or personal risk to the participant, and to reduce the likelihood that

the researcher’s own personal experience with the phenomenon in question could influence data

collection and analysis (Creswell & Poth, 2018). Additional study participants were recruited

using a snowball sampling method until eight participants were recruited (Merriam & Tisdell,

2016). The eight participants met the previously stated criteria and were willing to participate in

a lengthy three-part interview and provided consent to record and publish the findings of the

study (Moustakas, 1994). Participant recruitment materials are attached as Appendices A, AA,

and B.

Data Collection Procedures

Qualitative research seeks to understand the meaning assigned by a person or group to a

given phenomenon (Creswell & Poth, 2018). Qualitative research is conducted in a natural

setting using data collection methods which seek to minimize the distance between the

researcher, the participants, and the phenomena under study (Creswell & Poth, 2018; Merriam &

Tisdell, 2016). The constructionist epistemology and interpretivist theoretical perspective

underpinning this study required the researcher to engage directly with study participants to

collect and interpret data and co-construct knowledge with the participants (Creswell & Poth,

2018; Crotty, 1998). To achieve this effect in qualitative research, the researcher served as the

primary instrument of data collection (Creswell & Poth, 2018).

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Qualitative Interviews

A phenomenological study may use any means of data collection consistent with the

phenomenological methodology and the epistemology and theoretical perspectives which inform

it (Crotty, 1998). The most common means of data collection in phenomenological inquiry is the

qualitative interview (Creswell & Poth, 2018). This section will examine why interviewing was

an appropriate means of data collection for the study, review the basic structural and design

aspects of a qualitative interview, and discuss common challenges and considerations when

utilizing interviews to collect data.

Interviewing in Qualitative Inquiry and Phenomenology

The link between phenomenological methodology and the constructionist epistemology

and interpretivist theoretical perspective has been established. Given these philosophical

assumptions, qualitative inquiry, and phenomenological methodology specifically, recognize

meaning as a human construction and require a data collection method which allows context and

meaning to be examined and understood (Esterberg, 2002; Kaliber, 2019; Rubin & Rubin, 2005;

Seidman, 2019).

The interview is an appropriate means of data collection in qualitative inquiry because it

accesses the type of data needed (Kaliber, 2019; Merriam & Tisdell, 2015). Data collected

through surveys and the scientific method are appropriate in quantitative analyses for the

acquisition of statistically significant data. This type of data is insufficient to answer the types of

research questions posed in qualitative inquiry however (Kaliber, 2019; Rubin & Rubin, 2005).

A researcher cannot simply observe or measure how people interpret their world and the

phenomena within it (Merriam & Tisdell, 2015). Seidman (2019) described how the interview

aligns with the philosophical assumptions of qualitative inquiry. If, under a constructionist
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epistemology, humans construct meaning, then the focus of data collection should be the

individual participant with the goal being to attain an understanding of the constructed meaning

(Seidman, 2019). Given that human experience and meaning are the focus of qualitative inquiry,

and given that humans are capable of communication, interviewing makes a logical and effective

means of data collection when operating from a constructionist perspective (Seidman, 2019).

In addition to being consistent with the philosophical assumptions of qualitative inquiry,

the use of interviewing improves the credibility of a study’s findings. When completing a study,

it is important to take steps to ensure that the method of data collection is actually accessing the

type of data it is intended to access (Creswell & Poth, 2018; Merriam & Tisdell, 2016). The

qualitative interview provides a direct link between the researcher and the participant. In this

way, the qualitative interview is a highly credible means of data collection as the researcher is

capable of interacting directly with the participant without the introduction of a human-derived

construction such as a measurement tool, survey, or piece of data collection equipment as is

common in the scientific method (Creswell & Poth, 2018, Kaliber, 2019; Merriam & Tisdell,

2016). Interviews allow the researcher access to experiences, perceptions, and attitudes in their

natural setting in a way that would be less accessible by other methods (Kaliber, 2019; Rubin &

Rubin, 2005).

Interviews as Structured Conversation

Individuals strive to comprehend the world in which they live. This attempt to make

meaning is rooted in the learning process, which is often informal and heavily influenced by

social interactions and culture (Rubin & Rubin, 2005). This learning is important but also

restrictive and rarely analyzed critically by the individual. In order to seek the deeper level of

understanding desired in qualitative inquiry, a more systematic method is required (Rubin &
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Rubin, 2005). As a form of structured conversation, the interview provides the systematic data

collection method needed to access experience, perception, attitude, and meaning at a deeper

level (Rubin & Rubin, 2005).

The qualitative interview has been described as both a social situation and a conversation

with structure and purpose (Fontana & Frey, 2000; Kaliber, 2019; Merriam & Tisdell, 2016;

Seidman, 2019). Both descriptions are important for understanding the value of interviewing as a

data collection method. Fontana and Frey (2000), Kaliber (2019), and Seidman (2019) all

describe the interview as a social process, one in which researcher and participant are

conversational partners in the construction of meaning. Qualitative interviewing represents an

extension of ordinary conversation. Typical conversations do not go methodically down a list of

questions but are fluid and flexible. Likewise, qualitative interviews are also fluid, flexible, and

to some extent reinvented each time they are completed (Rubin & Rubin, 2005). Nonetheless,

qualitative interviews are more structured, involving well-developed questions, probes, and

follow-up questions which are focused on the overall research question and arranged and

delivered with the guidance of the researcher. Thus, a greater depth of understanding may be

achieved through the structure provided by the qualitative interview (Rubin & Rubin, 2005).

Basic Interview Structure

As a means of data collection, interviews fall on a continuum from highly structured to

highly flexible, focused to unfocused, and topical to cultural (Rubin & Rubin, 2005). The ability

to design and adapt interview structure to match the research question and the philosophical

underpinnings of a qualitative research study is one of the strengths of interviewing as a method

of data collection when using a phenomenological methodology (Creswell & Poth, 2018;

Merriam & Tisdell, 2016; Rubin & Rubin, 2005).

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Structured, semi-structured, and unstructured interviews are three predominant types of

qualitative interviews (Dempsey et al., 2016; Fontana & Frey, 2000; Merriam & Tisdell, 2015).

Structured interviews utilize a more rigid structure, asking the same questions of each

participant, in the same order, with little to no flexibility afforded the interviewer or interviewee.

The structured interview is often thought of as an oral form of a survey, allows for a narrow

scope of inquiry, and is often used in qualitative research to acquire demographic data from

participants (Fontana & Frey, 2000; Merriam & Tisdell, 2015; Rubin & Rubin, 2005). In

contrast, unstructured interviews allow a broad scope of inquiry. Unstructured interviews will

allow a greater depth and breadth, will respond to participant questions, and will allow personal

feelings to influence the interview process (Fontana & Frey, 2000). Semi-structured interviews

occupy the middle ground on a continuum of flexibility and structure. Semi-structured interviews

will operate from an interview guide. The guide allows flexibility in which questions to ask and

the order in which to ask them (Dempsey et al., 2016; Merriam & Tisdell, 2016; Seidman, 2019).

However, the semi-structured interview also provides sufficient structure to ensure that specific

data is obtained in order to answer the research questions (Esterberg, 2002; Merriam & Tisdell,

2016). Phenomenology seeks to answer specific questions regarding what phenomena are

experienced and how they are experienced while ensuring the effects of culture are sufficiently

bracketed. For these reasons, semi-structured interviews were the interview method utilized in

this phenomenological research study (Creswell & Poth, 2018; Moustakas, 1994).

Constructing the Semi-Structured Interview Guide

In order for the qualitative phenomenological interview to fulfill this need, the interview

questions must be properly crafted both individually and in an interview guide, so as to provide

the researcher sufficient balance between flexibility and structure (Creswell & Poth, 2018; Rubin
 85

& Rubin, 2005). Good interview questions will stem directly from the research question

(Creswell & Poth, 2018). In general, qualitative research is focused on experience, feelings,

knowledge, and how knowledge is constructed (Merriam & Tisdell, 2016). Phenomenology

focuses on the lived experience of participants with regard to a specific object or phenomenon

(Crotty, 1998). Thus, good interview questions in phenomenological research focus on

experience, behaviors, opinions/values, feelings, and sensory experiences (Merriam & Tisdell,

2016). Good qualitative interview questions remain open-ended and ask “how” questions to yield

descriptive data (Merriam & Tisdell, 2016; Seidman, 2019). In contrast, qualitative interview

questions should avoid seeking causation through the asking of “why” questions and avoid

posing the exact research question directly. Additionally, multiple, leading, and yes/no questions

are insufficient in producing the depth and breadth of response needed to answer most qualitative

research questions (Creswell & Poth, 2018; Merriam & Tisdell, 2016, Rubin & Rubin, 2005).

The interview guide should serve as an interview template, progressing from questions

designed to show empathy and build rapport, to questions designed to achieve the required depth

of data collection. However, at no time should the interview guide be considered a script to be

followed and the qualitative researcher must remain flexible in order to respond to the needs of

the participant and the unfolding circumstances of the interview (Creswell & Poth, 2018;

Merriam & Tisdell, 2016; Rubin & Rubin, 2005; Seidman, 2019).

The Three-Interview Process

Seidman’s (2019) three-part process of phenomenological interviewing was used as a

framework for construction of the interview guide in this study. Seidman (2019) contends the

single interview format limits contact with the participant and provides only a thin

contextualization of the phenomenon and how it was experienced. The three-part interview
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process allows for a deeper level of contact so as to immerse the researcher more fully in the

lived experience of the participant (Seidman, 2019).

The first interview focused on the context and life history of the participant. The focus

was on the participant’s experience with developing their identity as a professional physical

therapist. Within the conceptual framework for this study, the formation of this initial

professional role identity is a co-creative process resulting from the identity work spurred by the

interaction between an existing student self-identity and the process of professional socialization

during their physical therapy education (Plack, 2006; Plack & Driscoll, 2017; Stiller, 2000). The

resultant physical therapist professional role identity represented their default narrative of self

when entering a leadership position (Alvesson & Willmott, 2002). The first interview examined

the influences on their clinician identity development, their experience with professional

socialization, their reactions to these influences, and their opinions, beliefs, and values related to

this experience (Seidman, 2019). The participant’s personal background and experience of

working as a physical therapist clinician was also explored (Esterberg, 2002).

In keeping with the recommendations of Seidman (2019) and Esterberg (2002), the

second interview focused on the lived experience of professional role identity construction while

transitioning from a full-time patient care role to a leadership role. Consistent with the

conceptual framework for this study (Alvesson & Willmott, 2002), a leadership position was

considered an organizational identity and a transition to this position a type of role transition by

the participant. As such, the second interview attempted to gain an understanding of how this

transition impacted the participant’s existing clinician role identity, the effects of any

organizational identity regulation efforts on this clinician identity, and how the participant

reacted to these efforts through identity work. How the participant experienced the transition, the
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influence of their organization, and their feelings, opinions, and responses to this transition and

its influences were also explored.

The third and final interview focused on how the participants made meaning of their

experience with role identity construction during the transition. Alvesson and Willmott (2002)

described the professional role identity as a precarious outcome of identity work in response to

an effort at identity regulation. The third interview explored the participant’s opinions, values,

and concepts of identity and how participants perceived the effects of the transition on their

professional identity. The conceptual framework for this study also recognizes the interactive

process of professional role identity construction as having potential impact on the organization

and the organizational role as well (Alvesson & Willmott, 2002). The third interview also

explored how study participants may have impacted the organization and the leadership role

through the identity work process. The semi-structured interview guide developed for this

phenomenological study is attached as Appendix C.

Qualitative Interview Location and Recording

The collection of data in a natural setting as opposed to a controlled laboratory setting is a

key aspect of qualitative research (Merriam & Tisdell, 2016; Creswell & Poth, 2018).

Conducting qualitative interviews in the participants’ office or clinical setting may be ideal in

terms of conducting simultaneous field observations. Traveling to each individual participant’s

location presented a barrier to the recruitment of a more diverse participant sample via maximum

variation sampling techniques, however. Given the desire to recruit participants from multiple

geographic areas, qualitative interviews were conducted using the videoconference application

Zoom. Despite the historic consideration of face-to-face interviewing as the gold standard,

videoconferencing has been found to be an acceptable, and at times superior, alternative to the
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traditional face-to-face qualitative interview (Archibald et al., 2019; Gray et al., 2020; Irani,

2019; Lobe et al., 2020; Mirick & Wladkowski, 2019). Participants and researchers have found

interviewing via the Zoom platform to be a positive experience and have rated it superior to other

videoconference platforms due to its ease of use, low cost, and functionality (Archibald et al.,

2019; Gray et al., 2020).

Collection of Demographic Information

Qualitative phenomenological research is conducted with the intent of describing the

participants’ lived experience of a phenomenon in the natural setting (Creswell & Poth, 2018;

Merriam & Tisdell, 2016). As a result, the product of a qualitative phenomenological research

study must be richly descriptive (Merriam & Tisdell, 2016). Additionally, rich, thick descriptions

of study participants, their natural environment, and the research setting serve to improve

goodness and trustworthiness by improving transferability. To aid in the creation of rich, thick

descriptions, detailed descriptive and demographic information was collected from study

participants. Information collected included age, gender identity, racial/ethnic background,

educational background, previous positions held, descriptions of their current position, current

employer, current practice setting, prior practice settings, additional professional

credentials/certifications, years of experience in clinical practice, areas of clinical specialization,

years of experience in leadership positions, and number of direct/indirect reports.

Document and Audiovisual Material Analysis and Post-Interview Notes

Qualitative interviewing is considered a primary means of data collection in

phenomenological research (Creswell & Poth, 2018; Merriam & Tisdell, 2016; Moustakas,

1994). However, additional qualitative data collection methods were employed to better

understand and describe the essence of the phenomenon and to allow for data triangulation and
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improved credibility (Anfara et al., 2002; Creswell & Poth, 2018; Moustakas, 1994; Spiegelberg,

1982). Participants’ employer websites, mission/vision statements, organizational charts (if

available), professional job description (if available), curriculum vitae or resume’, physical

therapy educational program website and curricula, and curricula for any leader development

courses taken (if available) were examined.

Additionally, detailed post-interview field notes were taken immediately following each

interview. Post-interview notes included any contextual information concerning the environment

and circumstances of the interview as well as notations of any non-verbal communication which

may have been lost during the interview transcription process. Field notations also noted initial

thoughts, reactions, and emotions of the researcher following the interview, serving as an audit

trail and an initial act of reflexive practice in order to improve goodness and trustworthiness

(Anfara et al., 2002; Miles et al., 2014).

Ethical Considerations

Qualitative interviewing does not presume objectivity or distance on the part of the

researcher. In contrast, qualitative interviewing is recognized as a social process, a structured

variant of normal conversation, and one in which the researcher and participant are co-

constructors of knowledge (Fontana & Frey, 2000; Kaliber, 2019; Merriam & Tisdell, 2016;

Seidman, 2019). While these characteristics make interviewing an ideal data collection method

for many qualitative methodologies, they also create challenges and considerations for the

qualitative researcher (Dempsey et al., 2016; Fontana & Frey, 2000; Kaliber, 2019; Mellor et al.,

2014; Rubin & Rubin, 2005; Seidman, 2019).

Building Trust and Rapport

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Given the researcher’s role in the social process that is qualitative interviewing,

developing rapport with the study participant is a key consideration. Interviewing is chosen as a

primary means of data collection in qualitative inquiry precisely because it provides access to the

experiences of a participant that are not accessible by other means (Kaliber, 2019; Rubin &

Rubin, 2005). However, it is the study participant who ultimately provides the researcher access

to this data through their responses to the interview questions. Gaining access to this data

requires the researcher to develop a rapport with the participant and develop trust between them

(Dempsey et al., 2016; Mellor et al., 2014; Seidman, 2019). Proper research design and planning,

which includes consideration of ethical conflicts as well as proper reflection on the potential

benefit, harm, or marginalization of participants was required (Fontana & Frey, 2000; Mellor et

al., 2014; Seidman, 2019). Defining the rights and roles of the researcher and participant, being

transparent in how data will be collected, used, and shared, and how the rights and anonymity of

the participant will be protected are also key to developing trust and building initial rapport

(Fontana & Frey, 2000; Mellor et al., 2014; Rubin & Rubin, 2005; Seidman, 2019). A properly

designed interview guide with a proper progression of interview questions will also contribute to

the building of trust and rapport and help the researcher maintain focus on the participant, not

themselves (Creswell & Poth, 2018; Esterberg, 2002; Merriam & Tisdell, 2016; Rubin & Rubin,

2005; Seidman, 2019).

Practicing Self-management and Reflexivity

Practicing self-management and reflexivity are essential for the qualitative researcher to

complete interviews which are focused on participant experience while reducing the potential for

bias (Kaliber, 2019; Rubin & Rubin, 2005; Seidman, 2019). Practicing reflexivity is important

for all qualitative methodologies, but particularly for phenomenology, in which the researcher is
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focused on setting aside previous social or cultural influences to return to a deeper examination

of the lived experience of a phenomenon (Husserl, 1970b; Merleau-Ponty, 1962; Moustakas,

1994; Sokolowski, 2000). As a researcher, taking active steps to recognize and bracket one’s

own biases and presuppositions increases the likelihood that the researcher will design and

complete qualitative interviews which obtain data on the experience of the participant and the

phenomenon under research, not simply reproduce the experience of the researcher with a

phenomenon (Creswell & Poth, 2017; Merriam & Tisdell, 2015; Seidman, 2019). Understanding

and bracketing presuppositions will also diminish the researcher’s blind spots, allowing the

researcher to recognize unanticipated sources of depth and detail and to pursue these deeper

insights using probes, prompts, and follow-up questions (Kaliber, 2019; Mellor et al., 2014;

Rubin & Rubin, 2005).

As a researcher, managing one’s personality is important for developing trust, rapport,

and maintaining focus on the participant’s experience (Creswell & Poth, 2017; Mellor et al.,

2014; Rubin & Rubin, 2005; Seidman, 2019). Practicing self-management may be particularly

helpful in maintaining an empathic distance when working with topics which hold personal

interest or meaning to the researcher (Dempsey et al., 2016; Kaliber, 2019; Mellor et al., 2014).

Institutional Review Board

This study was presented to the Drake University Institutional Review Board to ensure

compliance with all ethical guidelines for human subjects research in the social and behavioral

sciences. The researcher completed training in the social and behavioral responsible conduct of

research through the Collaborative Institutional Training Initiative on September 4, 2019. The

completion of this training serves as evidence of the researcher’s knowledge of the ethical

guidelines for conducting this research study. Institutional Review Board approval was received
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on November 12, 2021. All recommended changes to the study design were completed before

the initiation of data collection.

Informed Consent

Study participants were asked to sign an informed consent (see Appendix D) outlining

the purpose of the study, guidelines for participation, and their rights as participants in this study.

The informed consent included an outline of privacy protections, the right of participants to

withdraw from the study at any time, an acknowledgement of any risks to the participant, an

acknowledgement of the researcher’s right to control data analysis, and potential benefits of the

study.

Confidentiality

Qualitative research involves the direct engagement of the researcher with study

participants in their natural setting (Creswell & Poth, 2018). Furthermore, qualitative research’s

consideration of situation and context requires the collection of data which may be personal and

sensitive. The maintenance of privacy and confidentiality in qualitative research is of the utmost

importance to comply with ethical guidelines for the completion of a qualitative research study

and to create the necessary confidence between participants and the researcher (Creswell & Poth,

2018; Merriam & Tisdell, 2016). All personal identifying information for each participant was

altered for the final presentation of data. This included the use of pseudonyms to replace

participant names and the alteration of any specific demographic information to more general

forms in order to allow for rich, thick descriptions without providing the consumers of this

dissertation with specific information by which study participants could be identified. All data

collected for this study was housed on a password protected computer. Backup files were saved

on a second password protected computer. Upon the completion of qualitative interview

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transcriptions, backup recordings were deleted from the password protected cell phone on which

they were recorded. According to IRB guidelines, data will be stored for a minimum of three

years and after that destroyed once it is deemed no longer useful for research purposes.

Data Analysis and Procedures

A research study completed in the transcendental tradition of Husserl (1970a, 1982)

involves the bracketing of presuppositions by the researcher, followed by a step-wise process

leading to an essence statement which describes the phenomenon and how it was experienced by

the study’s participants (Creswell & Poth, 2018). Creswell and Poth (2018) described the step-

wise process for conducting a phenomenological research study leading to the construction of the

essence statement.

1. Identify the phenomenon and describe it

2. Bracket presuppositions: A transcendental approach requires fresh perceptions.

3. Specify philosophical assumptions

4. Collect the data

5. Generate themes from the data using progressive coding steps

6. Develop both a textural and structural description of the phenomenon and how it was

experienced by study participants

7. Report the essence of the phenomenon using a composite description involving both the

textural and structural descriptions

8. Present the essence in written form.

This section will describe the specific methods used to analyze the collected data in order to

develop the textural and structural descriptions needed to compose the essence statement.

Interview Transcription and Memoing

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Each recorded interview was transcribed by the researcher with line numbers inserted for

easy identification of identified text items. Each transcript was then read in its entirety several

times and memos completed in the margins. Memos served as an initial data synthesis activity

and an opportunity to identify emergent ideas. Furthermore, memos served as an audit trail and

an initial opportunity to practice reflexivity to ensure sufficient bracketing of presuppositions

(Creswell & Poth, 2018; Merriam & Tisdell, 2016). Memos were compared and triangulated

with the researcher’s post-interview field notes as an additional step to ensure proper bracketing

of the researcher’s prior experience with the phenomenon.

Coding

After several overall readings, open codes were assigned within each transcript and a

master list of open codes compiled. The master open code list was organized by participant with

representative quotations and line number references and was housed in a Microsoft Excel

format.

From the master list, focused/analytical codes were developed. The chosen conceptual

framework served as a guide in the development of the focused/analytical codes (Miles et al.,

2014). Focused codes were housed in the same Excel file under a different tab. Each focused

code included subheadings for the open codes which were used in its creation, along with the

representative quotations for each. The focused codes were subsequently developed into themes

consistent with the process outlined by Merriam and Tisdell (2016) and Esterberg (2002).

Themes were assessed to ensure they were exhaustive and in clear connection to the proposed

research question (Merriam & Tisdell, 2016).

Document and Audiovisual Material Analyses

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Documents and audiovisual analyses were also collected and analyzed. These materials

served to provide rich, thick descriptions of the participants. Additionally, the audiovisual and

documents collected for each participant were reviewed during the development of open codes.

This additional source of data assisted in the development of focused codes and provided context

to the open codes identified in the participant interview transcripts (Merriam & Tisdell, 2016).

Design Issues – Goodness and Trustworthiness

Qualitative research requires distinct methods to assess quality and rigor (Anfara et al.,

2002). These methods are necessary to ensure credibility, transferability, and consistency while

assuring the reader that findings were not unduly influenced by the researcher’s personal beliefs

or biases (Anfara et al., 2002; Merriam & Tisdell, 2015).

Credibility

Credibility in qualitative research refers to measuring what the study intends to measure.

Credibility is linked to the epistemological beliefs underpinning qualitative research. The

researcher is seeking to study participants’ constructions or perceptions of reality (Merriam &

Tisdell, 2016). The credibility of this qualitative research study was ensured through prolonged

immersion with the data, triangulation, peer debriefing, member checks and by practicing

bracketing, positionality, and reflexivity (Merriam & Tisdell, 2016).

A research journal was kept throughout the completion of this qualitative study to

document immersion with the data, create an audit trail of the researcher’s thoughts and

processes as a researcher, and to promote reflexive practice continuously throughout the study’s

completion (Anfara et al., 2002; Merriam & Tisdell, 2015).

Triangulation involves using multiple sources of data collection and comparing them

against one another as an additional means of improving credibility (Anfara et al., 2002;
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Merriam & Tisdell, 2015). While the qualitative interview served as the primary data source in

this study, the codes and emerging themes developed during the data analysis process were

triangulated against the demographic information and audiovisual media collected and reviewed

as supplemental sources of data.

Credibility may also be improved by checking a study’s findings with peers and

participants. Peer debriefing offers an outsider’s perspective on the credibility of the researcher

and member checks help improve credibility by confirming data analysis directly with study

participants (Anfara et al., 2002). Peer debriefs were conducted with the dissertation advisor.

Member checks were conducted upon the completion of themes. Six of the eight participants

responded to the request for a member check. One participant posed questions about the naming

of a subtheme which led to a modest change in subtheme name to provide clarity. All six

participants who responded voiced agreement with the themes and subthemes developed.

Transferability

Transferability is the ability to transfer a study’s findings to the broader population. There

exist conflicting views on the transferability of qualitative research findings (Anfara et al., 2002).

Some perceive the lack of control of study participants and the natural setting of data collection

as barriers to transferability. In contrast, others perceive the naturalistic observation of study

participants as improving the transferability to other natural settings (Merriam & Tisdell, 2016).

To improve transferability, a researcher can provide rich, thick participant descriptions and

engage in purposive sampling, choosing participants based on their ability to help the researcher

answer the specific research questions (Anfara et al., 2002). Transferability was improved in this

study through the use of purposive sampling, specifically a maximum variation sampling

procedure.
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Consistency

Given the naturalistic nature of qualitative research and the contextualized environment

from which data are collected, the ability to reproduce a study’s findings is not considered a goal

of qualitative inquiry (Merriam & Tisdell, 2016). Instead, qualitative researchers seek to

demonstrate that results are consistent with the data collected (Merriam & Tisdell, 2016).

Consistency is demonstrated through an audit trail which tracks the process of data collection

and analysis while practicing triangulation amongst multiple data sources (Anfara et al., 2015;

Merriam & Tisdell, 2016). As described previously, a research journal was kept as an audit trail

and data triangulation was practiced by comparing the developing codes and emerging themes

from the qualitative interview data against the supplemental sources of data obtained.

Delimitations

This study was delimited to focus on how physical therapists made meaning of their

professional role identity when transitioning from a clinician to a leadership role. Other

healthcare professionals were not considered in the recruitment process given this focus and in

keeping with the need to fill the gap in the research on this topic as it pertains specifically to

physical therapists. Participants were recruited from within the United States and were required

to be in their first leadership position. “First” leadership position was defined as the first position

with substantial leadership/management duties. Participants who held prior positions which

included nominal leadership or management duties, but whose role remained primarily clinical,

were allowed to participate in the study. Only physical therapists with a formal title conferring a

recognized leadership role within their organization were considered. While leadership in

physical therapy may take many forms, the formal recognition of a leadership role as evidenced

by organizational job title is necessary to remain consistent with the conceptual framework
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informing this study. As a result, profession-wide designations such as clinical instructors and

site coordinators of clinical education recognized by the profession but not necessarily by the

organization were excluded. The assumption of a formally defined leadership role aided in

defining the beginning of the transition period which was a key focus of this study. Hybrid

clinician-leaders were considered for this study if patient care responsibilities did not exceed

60% of their time in the position.

Limitations

A key limitation in this study was the lack of separation of management and leadership

roles in participant recruitment and in the data collection and analysis. Management and

leadership are recognized as separate constructs (Antonakis & Day, 2018; Green-Wilson &

Zeigler, 2020; Page, 2015). However, many positions within an organizational hierarchy consist

of both management and leadership responsibilities, particularly those positions taken on by first

time manager-leaders transitioning out of clinical physical therapy practice (Page, 2015).

Nonetheless, the lack of separation of these two constructs may limit the application of the

study’s findings to further the understanding of how management and leadership are experienced

in the physical therapy profession.

Summary

This chapter outlined the philosophical underpinnings of the proposed study, including a

constructionist epistemology and basic interpretivist theoretical perspective. The

phenomenological methodology was also presented along with methods of data collection and

analysis. Procedures to ensure goodness and trustworthiness along with ethical considerations,

delimitations, and limitations were also discussed.

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CHAPTER 4

PARTICIPANT PROFILES

Qualitative research is conducted in a natural setting and is, therefore, context-dependent

(Creswell & Poth, 2018). A thorough description of study participants and the circumstances of a

researcher’s interactions with them are important for providing such context (Creswell & Poth,

2018; Merriam & Tisdell, 2016). More specifically, phenomenological study seeks to provide a

deep understanding of a phenomenon as experienced by multiple individuals (Creswell & Poth,

2018). All participants in a phenomenological study must have experienced the phenomenon in

in order for the researcher to effectively develop themes, first through the phenomenological and

ultimately through the eidetic reductions (Moustakas, 1994). The use of rich, thick participant

descriptions provided this context while also serving as evidence of a maximum variation

sampling technique by the researcher. Maximum variation sampling was a key quality

component utilized in this study to ensure goodness and trustworthiness by improving

transferability (Anfara et al., 2002; Merriam & Tisdell, 2016).

This section provides rich, thick descriptions of each study participant, as well as the

participant’s education, training, and key descriptions of their employer and current position.

Participant descriptions were created through the compilation, examination, and triangulation of

data from the qualitative interviews, demographic information collection, written and audiovisual

materials, and detailed post-interview notes completed by the researcher. Pseudonyms were

assigned to each participant and key details of the participant’s employer and educational

background have been altered to protect the participants’ identities.

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General Participant Demographics

Eight individuals participated in this study. Six of the participants identified as female

and two participants identified as male. All eight participants identified their racial/ethnic

background as white-Caucasian. The participants ranged in age from 29 to 50 years old. All eight

participants were serving in their first leadership position, defined as consisting of no more than

60% patient care responsibilities. The participants ranged from 9 months to 4 years of experience

in their leadership position. The homogeneity of participants’ racial/ethnic background

resembled the physical therapy profession as a whole. The male to female ratio of the

participants did as well. The 2016 American Physical Therapy Association (APTA) member

demographic profile indicated white members comprised 88.5% of membership, while female

members made up 69.4% of APTA membership compared to 30.6% of members identifying as

males (American Physical Therapy Association, 2019b). Physical therapists from several regions

of the United States were recruited, although a majority of the participants were from the

Midwest. The Northeastern region of the United States was not represented. The demographic

details of the participants are provided in Table 4.1.

Table 4.1

Participant Demographics

Name Age Gender Region Clinical Years in Years in

Specialty Practice Leadership
Amanda 39 F Midwest/Urban Acute Care 14 2
Melissa 29 F Midwest/Suburban Neurology 5 3
Doug 49 M West Coast/Mid-Size City Neurology 24 2
Nicole 34 F Midwest/Mid-Size City Orthopedics 9 0.75
Sports/
Sarah 39 F Midwest/Suburban Orthopedics 15 4
Katelynn 37 F Southeast/Urban Neurology 12 1
Bryan 38 M Midwest/Suburban Orthopedics 15 2.5
Stacy 50 F Midwest/Suburban ------ 27 3.5
Notes: F=Female, M=Male
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The following profiles provide rich, thick descriptions of the participants’ practice setting,

personality, background, education and training, current employer, and current position.

Amanda

Amanda is a 39-year-old physical therapist. Amanda identifies as female and of white-

Caucasian descent. Amanda’s current practice setting is in a long-term acute care hospital,

although she previously held positions in acute care and outpatient pediatric physical therapy.

Amanda describes her current area of specialty as acute care. Amanda has been a physical

therapist for 14 years and has served in a leadership position for two years.

The Zoom meeting access available to Amanda did not allow for a video link. As a result,

the researcher was not able to observe non-verbal behaviors during the qualitative interview.

During the three-part interview, Amanda presented herself as confident, strong-willed, and

passionate in her drive to provide holistic and comprehensive care to her patients. Throughout

the interview, Amanda described periods in her academic preparation and work career in which

her strong will was needed in order to advocate for herself, her profession, and most notably, her

patients. On multiple occasions, she describes herself as “different-minded” and not afraid to

voice her thoughts or opinions. She also describes herself as “type A.” Throughout the three-part

interview, Amanda spoke to the ways in which her communication style and strong-willed

approach have evolved over the years in order to be more selective in terms of which “hill to die

on.”

Employer

Amanda currently works for a private, national healthcare corporation. The parent

corporation operates long-term acute care and critical care hospital services in 27 states. The

long-term acute care/critical illness recovery division’s website does not contain a specific
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mission or vision statement for the organization. However, the website makes frequent

references to the key components of critical illness rehabilitation that unify the standard of care

amongst the corporation’s multiple locations. The key components of rehabilitation listed

highlight what appears to be a second core tenet of the organization, interdisciplinary practice.

Each of the components is consistent with essential functional skills or activities of daily living

which require the input of multiple healthcare disciplines in order to achieve. This

interdisciplinary focus is further highlighted by repeated references on the corporation’s website

to the team of specially trained providers at each location, including physicians, nursing staff,

occupational and physical therapists, speech-language pathologists, respiratory therapists,

pharmacists, and dieticians.

The specific location in which Amanda practices has 26 beds and is housed in a larger

parent hospital. This location’s leadership hierarchy consists of a chief executive officer (CEO),

chief nursing office (CNO), and chief medical officer (CMO). Amanda describes the leadership

hierarchy as consisting of a group of directors or managers reporting directly to the CEO. The

site was not visited as part of this study. However, the website for Amanda’s specific location

includes site photos revealing a stereotypical inpatient physical therapy gym and office equipped

with a mat table, parallel bars, training stairs, assistive devices, and basic exercise equipment.

Education and Training

Amanda holds a bachelor’s degree from a large state university in the Midwest. Amanda

earned her Doctor of Physical Therapy degree from a smaller private university, also in the

Midwest. Amanda describes the program as having a strong orthopedic component to the

curriculum which was inconsistent with her primary interest in neurological physical therapy. As

a result, Amanda made several references to the effort she put into shaping her clinical education
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experiences to meet her desired career path upon graduation. Review of her university’s DPT

program website reveals no direct reference to a stronger orthopedic focus. Review of her DPT

program’s curriculum does reveal additional coursework in advanced musculoskeletal treatment

and evaluation techniques. Advanced evaluation and treatment technique courses are not

included for other body systems in the curriculum.

Amanda described receiving formal and informal leadership training and mentorship as

she transitioned into her current leadership role. Interim mentorship came in the form of

informal, topic-specific meetings with chief nursing and quality offices. Once she was promoted

from interim to full-time rehabilitation manager, she met regularly in the first year with her CEO.

Additionally, her employer offered continuing education on a variety of leadership topics

including communication, interviewing, diversity, business management, and leadership

competencies.

Current Position

Amanda currently works as the rehabilitation manager. The position is her first

leadership/management position. She came to her current employer from a different organization

and worked alongside the existing rehabilitation manager at the time. After the existing manager

departed their role, Amanda served in the interim manager position under the guidance of the

CEO until receiving a permanent promotion to the position.

She oversees a team of physical therapist assistants (PTAs), one occupational therapist

(OT), one certified occupational therapist assistant (COTA), and a speech-language pathologist

(SLP). She continues to provide physical therapy services to patients on the long-term acute care

unit, completing all physical therapy evaluations and re-evaluations along with a limited volume

of scheduled patient care sessions. Her clinical work typically comprises approximately 60
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percent of her daily workload with management accounting for approximately 40 percent,

although these volumes may fluctuate. Amanda’s position is salaried and often times completion

of the full range of her job duties requires working a greater number of hours than the other

therapists in her department.

Amanda’s role as rehabilitation manager includes a variety of duties. She is responsible

for monitoring the completion of patient mobility programming. She attends patient rounds with

unit physicians, including rounds with the pulmonologist in which the weaning of patients on

mechanical ventilation is discussed. Amanda also attends weekly interdisciplinary team meetings

to work on discharge planning for patients on the unit. Her job description cites her responsibility

for oversight and coordination of all duties of the rehabilitation department and makes frequent

references to interdisciplinary coordination. In addition to these regular management duties,

Amanda is also involved in an outcome measures research project and serves as the safety

committee co-chair for the unit.

Amanda reports directly to the CEO. Amanda’s position is unique in that she is employed

at a manager level and continues to engage in patient care, yet reports directly to the CEO and

participates in interdisciplinary care coordination with others who are employed at the director

level.

Melissa

Melissa is a 29-year-old physical therapist. Melissa identifies as female and of white-

Caucasian descent. Melissa’s current practice setting is outpatient neurological physical therapy.

Melissa has been a physical therapist for five years and has served in a leadership position for

close to three years. Melissa has been employed by the same organization since graduating from

physical therapy school. Melissa also worked briefly as a per diem physical therapist on an acute
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inpatient rehabilitation unit in addition to her primary employment. She describes her specialty

as neurological physical therapy. Melissa holds board certifications as a neurological certified

specialist (NCS) and geriatric certified specialist (GCS) from the American Board of Physical

Therapy Specialties (ABPTS). She also holds certifications in specific treatment protocols for

individuals with Parkinson’s disease and is active in her state physical therapy association

chapter.

Melissa presented herself as friendly, easy-going, and thoughtful. She chose her words

and responses carefully, but shared them openly once chosen. Melissa described herself as “more

laid back” and “relaxed” than many other members of the leadership team at her organization.

She prefers to serve as the “quiet voice” at the end of the meeting who is respected for making

well thought out contributions after absorbing all the information.

Melissa’s passion for her work as a physical therapist, and more specifically her role in

caring for individuals with neurological diagnoses, was apparent throughout the interview

process. Melissa displayed her love and passion for working with these patients when describing

her clinical practice and the pride she takes in starting three different community-based wellness

programs for patients with neurological diagnoses.

Employer

Melissa currently works for a large, not for profit healthcare organization. The

organization is affiliated with a religious institution and operates 12 hospitals and over 200

outpatient/ambulatory care facilities in over 45 counties in the Midwest. The organization

employs over 35,000 people in a wide variety of hospital, outpatient, specialty, and support

capacities. The organization’s mission, vision, and core values are clearly stated on the website.

The mission, vision, and values are centered around a focus on clinical excellence and
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compassion and indicates a commitment to both patient and employee satisfaction. These

organizational statements are referenced by Melissa during the three-part interview and appear

consistent with Melissa’s focus in her work.

The organization markets its neurological care expertise, including physician and

rehabilitation expertise, and stresses the interdisciplinary nature of its neuroscience care

programs. The website stresses the physical therapy department’s use of advanced techniques

and equipment for the care of a wide variety of patients with neurological diagnoses, as well as

the department’s focus on individualized care and patient outcomes.

Education and Training

Melissa earned a bachelor’s degree from a large state university in the Midwest. She

received her doctor of physical therapy (DPT) degree from a large state university in the

Midwest as well. Melissa credited her training and work experience in a tech position at an

inpatient neurological rehabilitation unit as formative in her decision to pursue neurological

physical therapy. Melissa described the tech position as an opportunity to “have eyes on the

patient and what every minute of their day looked like.” Melissa stated the tech position “was the

thing that really kind of gave me that identity” and went on to describe how her clinical

experiences solidified her decision to enter neurological physical therapy.

Melissa has completed extensive continuing education and independent study in

preparation for her board certification examinations in both neurology and geriatrics. Melissa has

also completed formal leadership development training through her state physical therapy

chapter. Melissa completed a leadership practicum during her physical therapy training with an

individual who currently holds a leadership position in her healthcare organization. Melissa

credited the mentorship of this individual as influential in her development as well.

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Current Position

Melissa is currently employed as an associate manager of neurological and pediatric

rehabilitation. She oversees four neurological therapy locations and is currently overseeing the

opening of a fifth site. Melissa has been involved in the growth and development of the

neurological physical therapy service line since serving as a staff physical therapist. She has also

been involved in the renovation of one of the existing neurological PT clinics.

The associate manager role is primarily a management and leadership role. Melissa is

responsible for setting the direction of the clinics, overseeing clinic operations, attending

operational meetings, and mentoring the clinicians she oversees. She currently has 10 to 15 direct

reports and four indirect reports. Despite being only five years out of physical therapy school,

Melissa finds herself “focused on a lot of mentorship from a leadership perspective,” noting that

this has always been the case because of her experience as a specialist. Melissa is responsible for

monitoring key performance metrics such as budget, patient satisfaction, and associate

satisfaction. She is also responsible for building and maintaining departmental culture and

keeping this culture in alignment with that of the broader organization. Melissa reports directly

to the rehabilitation director.

Doug

Doug is a 49-year-old physical therapist located on the west coast of the United States.

Doug identifies as male and of white-Caucasian descent. Doug currently practices in inpatient

acute rehabilitation. He describes his area of specialty as neurology with an emphasis in post-

spinal cord injury care. Doug also holds a certification as a credentialed clinical instructor (CCI)

through the American Physical Therapy Association (APTA). Doug has been a physical therapist

for 24 years, the majority of which he has spent employed with his current organization. For two
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years, Doug did hold a split acute care and outpatient physical therapy position. Doug took that

position for practical reasons, but quickly returned to inpatient acute rehabilitation because he

“wasn’t fulfilled at all” in the job. He returned to the organization which he currently works for

and has remained there since. Doug previously held a lead therapist position which included

some minor administrative duties but remained primarily a patient care position. Doug has been

in a leadership position for two and half years.

During the three-part interview, Doug presented himself as open, talkative, and highly

engaged with the researcher. He shared freely of his thoughts and willingly offered answers with

little prompting. Doug described himself as “even-keeled” and a “stabilizing force” on his team.

Doug exuded pride in his work and his organization, but also in his family and his role as a

father. Doug frequently wove mention of his children into his interview responses. Doug

described how he would tell his children about his days treating patients and “see the excitement

on their faces for what I was doing at work.” Doug appeared to place a high value on personal

relationships and a strong sense of pride in the physical therapy profession. Doug described a

desire to “have fun on the job” and enjoys quoting movies and playing games with patients and

fellow staff alike. He described his therapy team as a family and appeared to care deeply for

them, much the way he cares deeply for his own family. Doug described his therapy team by

stating “we really feel that we’re family in general, genuinely like each other, and love what we

do.”

Employer

Doug currently works for a mid-sized, not-for-profit healthcare organization on the west

coast. The organization operates five hospitals and over 20 clinic locations offering a variety of

general as well as specialty medical services. This includes the location at which Doug practices,
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which includes inpatient acute rehabilitation services. The organization’s website clearly

articulates its mission, vision, and core values, all of which center around core tenets of quality,

compassion, and integrity. These core values are linked to important organizational initiatives in

terms of quality patient care, transparency in cost and billing, and a commitment to patient

satisfaction and the health of the communities served. The website includes descriptions of the

rehabilitation services provided with an emphasis on the interdisciplinary and team approach to

patient care.

Education and Training

Doug received bachelor’s and master’s degrees, both in physical therapy, from a mid-

sized state university in the western United States. Doug reports taking on-going continuing

education over his 24-year career but provides little detail given the lengthy timeframe. Since

taking his leadership position, Doug has pursued on-going training in leadership and

management including topics such as peer interviewing, motivation, innovation, strengths-based

leadership, and resiliency in the workplace. Doug also took the initiative to complete a leadership

training program through his church. Doug also credited informal mentorship from his director,

also a physical therapist. He cited peer relationships with other rehab managers in the

organization as influential in the learning process in his new role, stating his, “co-manager has 30

plus years’ experience with this organization and probably 20 to 25 of them are in management,

so I have learned a ton from her as well.”

Current Position

Doug currently serves as a manager of therapy services. His duties include providing

oversight to the inpatient rehabilitation department as well as outpatient physical therapy

services, psychology services, and speech-language pathology. Doug oversees a team of 40

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direct reports including physical therapists, speech-language pathologists, and clinical

psychologists and his job description indicates the position may include supervision of

occupational therapists and recreational therapists as well. His position is primarily

administrative. Doug continues to see patients at a low volume, something he negotiated into the

job description. Doug describes this split as 95% administration and 5% patient care.

Doug’s job duties include oversight of daily operations, facilitating communication and

problem solving, maintaining service quality and safety, personnel management, and fiscal

planning and oversight. Doug described his daily work as “putting out fires,” maintaining safety

standards, and managing staff issues. He described his weekly and long-term work as centered

around progressing the agendas of a variety of committees and task forces of which he is a part.

Doug reports directly to the director of therapy services, who is also a physical therapist.

Nicole

Nicole is a 33-year-old physical therapist. Nicole identifies as female and of white-

Caucasian descent. Nicole has been a physical therapist for eight years and has served in a

leadership position for 9 months. She has held positions with the same employer since

graduating from physical therapy school, where she completed her final clinical experience and

was offered a position upon graduation. Nicole described her specialty as orthopedic physical

therapy, and she is a board certified orthopedic certified specialist (OCS) by the American Board

of Physical Therapy Specialties (ABPTS). Nicole also possesses a certification in manual

therapy and is a credential clinical instructor (CCI) by the American Physical Therapy

Association (APTA).

Nicole presented herself as outgoing, confident, and relaxed. She laughed frequently

throughout the three-part interview. Nicole shared thoughts, insights, and opinions readily and
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displayed a strong degree of self-awareness and self-reflection. Throughout the interviews,

Nicole displayed a strong interest and commitment to the well-being of other people, including

family, friends, co-workers, and patients. She regularly referenced personal relationships as

meaningful and described herself as “engrossed in the people that I’m around in my circle of

influence and how can I like make those people just love their life.” These personal relationships

were often the source of positive experiences in her training and work life. A strong sense of

community and belonging appear important to Nicole. As a result, a strong sense of

responsibility is important to her as well.

Nicole links these commitments and preferences to her upbringing and being the oldest

child. When discussing her ethical views as a professional, Nicole stated:

I think physical therapy met me personally in a place that was very relevant to me. I just

have this probably personal family background or upbringing, it’s always been extremely

important to me that I am first and foremost honest, genuine, authentic.

Nicole seemed to enjoy meeting and learning about other people out of a genuine interest. She

did not seem to enjoy doing so for superficial reasons or out of a need for self-promotion.

Employer

Nicole currently works for a mid-sized, physical therapist owned, private practice in the

Midwest. The practice owns and operates over 60 clinic locations in three states and markets a

wide variety of specialty physical therapy services on its website. The practice also offers a

variety of health and wellness services to individual and corporate clients.

Physical therapist ownership is an important part of the practice’s identity. Almost the

entire senior leadership team are physical therapists, including the chief executive officer (CEO),

the chief operations officer (COO), and the chief financial officer (CFO). Additionally, leaders at
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all levels of the organization continue to treat patients to some degree in the course of their work

responsibilities. Nicole described this as “intentional” and a part of the culture of the

organization.

The practice’s website includes a mission and vision statement which highlights this

culture and focuses on being therapist-owned and providing patient-centered care. The website

also emphasizes a commitment to the communities in which its clinics reside. The employment

section of the company’s website seeks physical therapists with skills in communication,

leadership, and independent thinking. These qualities appear consistent with Nicole’s description

of herself and her workplace.

Education and Training

Nicole holds a bachelor’s degree in biology from a small, private college in the Midwest.

Nicole earned her doctor of physical therapy (DPT) degree from a large state university, also in

the Midwest. At the start of her career, Nicole participated in an intensive clinical mentorship

program at her current employer, which she describes as similar to a physical therapy residency

training. This intensive mentorship program was a formative experience for Nicole because she

perceived it as “a large upfront investment by my company within me.” Nicole’s resume also

lists extensive continuing education with a focus on orthopedic evaluation and treatment. Nicole

did not mention specific leadership education or training programs as part of her preparation for

or transition to her leadership role. Nicole did reference strong, albeit informal, mentoring

relationships she has had. These relationships included a clinical instructor who promoted the

development of her communication skills as a student, working clinically alongside senior

leadership members in her first position, and a strong level of personal and professional support

from her direct supervisor when she transitioned to her leadership position.
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Current Position

Nicole currently works as a regional manager. The position is Nicole’s first leadership

position. Nicole was promoted from a senior therapist position within her organization. Nicole’s

regional manager position involves oversight of six clinics within a particular geographic region

of the practice. Each clinic has a site manager who reports directly to Nicole. These six site

managers represent her direct reports. The six clinic sites employ approximately 40 therapists

which constitute Nicole’s indirect reports.

The regional manager is a hybrid position with an approximately even split of 50%

patient care and 50% leadership and management responsibilities. The division of time between

these two sets of responsibilities fluctuates depending upon the needs of the clinical sites, site

managers, and patient volumes. In addition to oversight of the individual site managers, Nicole is

also responsible for tracking key performance indicators including patient satisfaction, referral

data, and outcomes data. Nicole reports directly to the COO who, as noted previously, is also a

physical therapist.

Sarah

Sarah is a 39-year-old physical therapist. Sarah identifies as female and of white-

Caucasian descent. Sarah’s current practice setting is outpatient physical therapy with an

emphasis on orthopedics and sports medicine. Sarah has been employed by her current

organization since graduating from physical therapy school. She currently practices in the

suburbs of a city in the Midwest. She is board certified as a sports certified specialist (SCS)

through the American Board of Physical Therapy Specialties (ABPTS) and holds additional

certifications in dry needling and augmented/instrumented assisted soft tissue mobilization

techniques. Sarah has been a physical therapist for 15 years and has served in a leadership
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position for the last four years. Earlier in her career, Sarah completed a brief stint as a clinic

manager, which involved administrative duties on top of full-time patient care. Sarah left that

position to return to a staff therapist position after less than a year. She indicates she “knew right

away that that was not meant for me” and “one of the reasons I hated it is because it was

smaller…I didn’t have you know colleagues to bounce ideas off of.”

Sarah presented herself as confident, open, and outgoing both in her verbal and non-

verbal expressions. She frequently smiled and laughed during the course of the three-part

interview. Sarah described herself as goal-oriented and calm under pressure, traits she feels are

intrinsic to her personality since childhood. She has always seen herself as a healer and projected

a strong self-image and clear sense of purpose in her life. As a child, Sarah described herself as,

“always very calm and collected, even when I was little, and like I knew that this is what I was

meant to do, to take care of people.” Sarah also values loyalty and possesses an intrinsic drive to

learn and improve. She enjoys work environments which are upbeat, team-oriented, and

possessing “great energy.”

Employer

Sarah currently works for a large, private, corporate physical therapy practice with a

presence in over 20 states. The practice is focused on the delivery of outpatient physical therapy

services. The corporation offers a variety of clinical specialty programs for its therapists. These

clinical specialty programs are featured on the corporation’s website and are marketed to

potential patients and potential employees. The corporation also features its use of outcome

tracking to monitor patient outcomes throughout its multitude of clinical sites. A focus on

community partnerships and service are also featured on the corporation’s website.
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Sarah’s current location is housed in the corporate headquarters but her worked is

essentially decentralized, involving work with other associates at multiple sites. She remains

involved in patient care serving as a mentor for residents in the company’s orthopedic and sports

residency programs.

Education and Training

Sarah holds a bachelor’s degree in exercise science and a master’s degree in physical

therapy from a mid-sized private university in the Midwest. Sarah went on to receive a post-

professional doctorate in physical therapy from the same university after finishing her master’s

degree. Over her years of practice, Sarah described a consistent focus on learning and education,

frequently pursuing continuing education credits in excess of those required by her state’s

licensure board. The focus of this self-directed learning has been primarily in the specialty areas

of orthopedic and sports physical therapy practice. More specifically, Sarah has chosen to focus

on hip and knee pathology, an area she developed into a sub-specialty. She is recognized as a

resource in this sub-specialty within her organization.

Sarah described a general lack of orientation and training to her leadership role in the

organization. She cited no specific leadership training or development opportunities as part of

her transition to leadership and described the whole position as not “very well defined” and

arriving at her first week of training and thinking “is there any training or anything right? No, it

was just do your stuff.” Sarah did describe informal learning and networking opportunities which

stemmed from her active participation in the state physical therapy chapter, however.

Current Position

Sarah currently serves as a manager over the organization’s clinical programs. This

position involves managing all of the corporation’s specialty training programs, including
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specialized techniques such as dry needling and augmented soft tissue mobilization, as well as

specialty learning programs, including the orthopedic and sports residency programs. Each of

these programs has a manager. These program managers have their own direct managers or

directors at their individual locations. Sarah’s role involves overseeing the program managers’

performance regarding the educational programs only. As such, Sarah described having 27

indirect reports and only one direct report. This is Sarah’s first leadership position. Initially, the

position was 50% patient care and 50% administration. Over time, the position transitioned to

full-time administrative work. This marks the first time Sarah has held a position which did not

involve a significant amount of direct patient care.

Katelynn

Katelynn is a 37-year-old physical therapist. Katelynn identifies as female and of white-

Caucasian descent. Katelynn currently practices in a critical illness recovery hospital located in

an urban area in the southeastern United States. Katelynn described the setting as if an “ICU and

a SNF had a baby.” Katelynn held a previous position as a full-time physical therapist at an

inpatient rehabilitation facility where she worked extensively with patients who had sustained

spinal cord injuries, traumatic brain injuries, and cerebrovascular accidents. Katelynn also spent

time working as a per diem physical therapist at a skilled nursing facility prior to working at the

critical illness recovery hospital. Katelynn has been a physical therapist for 12 years. She holds a

certification in neurodevelopmental treatment (NDT) and identifies her specialty area as

neurology.

Katelynn presented herself as confident, particularly in her clinical skills and ability to

care for patients effectively. Katelynn loves “trying to figure out what pathway is still intact,

what can we do different, tactics to make something work.” This willingness to keep trying and
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to never give up on patients is key to Katelynn’s view of herself and the physical therapy

profession as a whole. She views this “follow through” as a key aspect of her professional

integrity, one she shares with the other physical therapist with whom she has worked. Katelynn

stated she “really tried to make it creative and think of creative ways” to help patients achieve

their goals.

Katelynn willingly shared thoughts and opinions in the interviews and gave the

impression this willingness extends into her work life as well. In clinical care, Katelynn’s

willingness to share thoughts and opinions manifests itself as a strong belief in physical

therapists as key patient advocates. Patient advocacy is another key component of integrity for

Katelynn, even if it is “difficult or takes more time.” To Katelynn, a willingness to be outspoken

and determined in the pursuit of patient advocacy means physical therapists “won’t settle for just

mediocre,” even if that may “ruffle some feathers” with other providers. That being said,

Katelynn also noted a recognition of the need to channel the determination and advocacy on the

part of the patient in order to work as part of a team and ultimately achieve the best outcome for

a patient through teamwork and collaboration.

Employer

Katelynn is currently employed by a national healthcare corporation which operates long-

term acute care and critical illness recovery hospitals in over 20 states. The corporation’s website

focuses on the role of interdisciplinary rehabilitation of key functions including mobility,

respiratory function, speech, and cognition. The interdisciplinary nature of rehabilitation is

emphasized as a key component of care which is shared amongst its many facilities. The

corporation’s website also references the team of specially trained providers at each location,
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including physicians, nursing staff, occupational and physical therapists, speech-language

pathologists, respiratory therapists, pharmacists, and dieticians.

Katelynn’s specific practice location has 35 beds. The location’s leadership hierarchy

consists of a chief executive officer (CEO), chief nursing office (CNO), and chief medical officer

(CMO). In her role, Katelynn regularly interacts with the CNO and the respiratory therapy

manager to ensure they are getting “patients safely to home or to a SNF or inpatient rehab”

facility. Statements such as this underscore the value of interdisciplinary practice to Katelynn’s

organization and its care providers.

Education and Training

Katelynn holds a bachelor’s degree from a large, state university in the southeastern

United States. Katelynn earned a doctor of physical therapy degree from a large, state university

in the southeastern United States as well. Formal and informal mentorship have been a strong

component of Katelynn’s professional development in both her clinical and her leadership roles.

As a new graduate, Katelynn was mentored by a more senior clinician, an experience she

credited with the development of strong clinical skills, particularly in treating patients with spinal

cord injuries. The value of mentorship in Katelynn’s professional development extends to her

leadership position as well, where she credits her previous supervisor as being “vital in the

success and kind of setting me up for success over here.”

Katelynn’s current organization also provided leadership training on the form of online

educational modules covering management topics such as conflict resolution, performance

evaluations, and writing action plans. Katelynn described these as “informative,” but “not

anything that was completely earth shattering.” Overall, Katelynn found the modules helpful

when she could “glean one little nugget of info from each module.”
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Current Position

Katelynn is currently employed as the rehabilitation manager. Her role includes oversight

of the physical therapy, occupational therapy, and speech-language pathology services at her

location. Overall, 10 to 11 associates report directly to Katelynn. This position represents

Katelynn's first leadership role, a position she has occupied for one year. Katelynn is also

responsible for providing direct physical therapy care to patients in the form of initial evaluations

and periodic follow ups in the form of treatment sessions and patient re-evaluations. Katelynn

did note she periodically takes responsibility for the full course of rehabilitation of specific

patients if their complexity level requires her specific skill set, noting, “maybe my NDT

certification is going to help them progress, then I kind of take them on.” Patient care comprises

roughly 60% of Katelynn’s current workload with leadership and management responsibilities

comprising 40%.

Katelynn described her leadership and management duties as centered around staffing

and making sure “we meet the business plan.” She also oversees patient scheduling to ensure all

patients are seen by at least one of the three therapy disciplines every day and that organizational

goals for patient mobility are monitored and achieved. Katelynn is also responsible for educating

nursing staff on patient handling and positioning along with ensuring a safe working

environment for all staff. Finally, Katelynn described her role as “the fixer,” solving problems as

quickly as possible so “we’re not spinning our wheels.”

Bryan

Bryan is a 38-year-old physical therapist. Bryan identifies as male and of white-

Caucasian descent. Bryan’s current practice setting is outpatient physical therapy, primarily

orthopedics. He is board certified in orthopedics by the ABPTS. He also holds certifications in

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manual therapy and augmented/instrument-assisted soft tissue mobilization techniques. He

practices in a suburban area in the Midwest. Bryan has been a physical therapist for 15 years and

has practiced exclusively in outpatient private practice physical therapy for four different

organizations during this time. Bryan did enter into a site manager position after his second year

of clinical practice and has held site or clinic manager positions for 13 of his 15 years of practice.

Bryan described each of these positions as being primarily patient care positions, none of which

exceeded 10-20% management or administrative duties.

Bryan presented himself as easy-going and confident. He was talkative and shared

thoughts, feelings, and insights freely with the researcher during all three interviews. According

to Bryan, colleagues at his former clinic site described the environment as “so much quieter”

after he left. Despite Bryan’s outgoing and confident demeanor, he described his default setting

as feeling he “could always be doing better.” Bryan also described himself as “outgoing and

engaging,” but “quiet enough” to give others a “chance to speak.” These seemingly contrasting

observations and statements gave the impression of Bryan as an individual who is in fact

outgoing and confident but who also possesses a high tendency toward introspection. Bryan

credited this healthy sense of introspection with helping him learn “where maybe you’re not as

comfortable and how can I remedy that.”

Employer

Bryan’s current employer is a multi-disciplinary physician-owned private practice. The

practice provides primary care, pediatric, urgent care, and specialty care services at over 150

locations in a number of different suburban communities. The practice employs over 1000

providers representing 43 medical specialties, including physical therapy. The practice’s website

markets the variety of specialties available to healthcare consumers and focuses on the types of
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care available, convenience in terms of locations, and the bios of individual providers who

deliver care for the organization. The practice’s website also emphasizes the multi- and

interdisciplinary practice patterns of the organization, an emphasis supported by statements made

by Bryan concerning recent initiatives in the organization. One such example is a recent move to

create a clinical pathway for patients with lower back pain:

I’ve been tasked with by this company to kind of create a lower back pain pathway. So,

they want to look at patients instead of looking at them that they enter at this branch of

healthcare or medicine, how do all these practices of healthcare work together for this

specific patient.

Education and Training

Bryan holds a master’s degree in physical therapy from a mid-sized university in the

Midwest. He also earned a post-professional doctorate in physical therapy from the same

university after graduation. Much of Bryan’s training in management and leadership has been

obtained through on-the-job experience or informal mentorship. Bryan’s current employer has

begun to invest in leadership training however, bringing in an outside consultant to provide

leadership and management training as the size of the organization has increased. Bryan also

described informal mentorship from his director as well as the vice-president who oversees his

service line, both of whom are also physical therapists. Bryan has taken the initiative to seek out

additional training on his own and recently joined the American College of Healthcare

Executives (ACHE) to further his development.

Current Position

Bryan is currently employed as a senior manager. He answers directly to an executive

director who oversees physical therapy but also one of the medical specialties. Bryan supervises
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nine physical therapy locations and eight individual site managers who constitute his direct

reports. As a result, Bryan oversees 58-60 therapists indirectly among these various locations.

While Bryan has held site or clinic manager positions in the past, this position represents the first

position which has been primarily administrative. His position is currently full-time

administration, although Bryan continues to see patients approximately six hours per week on

top of his administrative duties. These administrative duties include supervising the individual

site managers, setting and monitoring key performance indicators such as patient volumes, visit,

and billed units, as well as patient and employee satisfaction scores. Bryan has also recently been

tasked with supervising the chiropractic service line and with spearheading the development of

interdisciplinary treatment pathways for individuals with low back pain. Bryan described his

daily responsibilities as dealing with “whatever fire pops up,” as well as being a “conduit of

information” as part of a big company. He described having other large projects, such as the back

pain pathway, going on that involve a long-term commitment of time.

Stacy

Stacy is a 50-year-old physical therapist. Stacy identifies as female and of white-

Caucasian descent. Stacy’s current practice setting is outpatient physical therapy. She currently

practices in a suburban area in the Midwestern United States. Stacy has been a physical therapist

for 27 years. Over the course of her career, Stacy has practiced in a wide variety of settings

throughout the Midwest and the southern United States. Stacy spent a portion of her early career

working as a travel or contract physical therapist. As a result, Stacy has worked in inpatient,

outpatient, skilled nursing, and inpatient rehabilitation settings. She has treated a wide variety of

orthopedic and neurological patient caseloads as well as provided wound care. Her contract

therapy work allowed her to provide care throughout urban, suburban, and rural areas of the
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southern United States, including many areas which were medically underserved. Stacy credited

this experience as formative in the way it taught her “so much about culture and appreciating

other cultures.” Stacy also credited this early experience with teaching her how to “pull up your

bootstraps and get to work.”

Stacy has worked for her current employer for over 20 years, first in the staffing pool, a

position in which she filled specific staffing shortages at several locations. She then moved into a

regularly scheduled position, followed by a lead physical therapist position. The lead physical

therapist position developed into a clinic supervisor position. The lead and supervisor positions

together occupied approximately 12 years. While these positions did involve some limited

leadership and management responsibilities, the roles remained primarily patient care. Stacy

reported her most recent clinic supervisor position never exceeded 20% management duties.

Stacy presented herself as thoughtful and introspective with a strong internal drive to

work hard and produce quality outcomes. Stacy credited her upbringing, her experiences in

physical therapy school, and her early career experiences as influential in the development of a

strong work ethic. These early experiences took “some inner gumption” to “stick it out and not

walk away.” When dealing with challenging circumstances, Stacy described an intrinsic

motivation to succeed and do well, recognizing that failure and walking away from challenges

was “not really me, so I would have to figure out a way to be successful.” Stacy was cautious

and thoughtful in her responses, responses which display a strong sense of self and a strong

belief in her ability to be successful, even when circumstances may not lend themselves to such

success. These beliefs seem to be born of challenging educational and work assignments which

Stacy has been able to overcome.

Employer
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Stacy’s current employer is a hospital system located in a suburban area in the

Midwestern United States. The organization’s website does not clearly or prominently display a

mission, vision, or set of core values. The website does place immediate emphasis on the

locations and medical services provided. While a variety of medical services are offered by the

organization, the website features primary care, cancer care, heart and vascular care, orthopedics,

and neurology services. The employer operates three acute care hospitals and a rehabilitation

hospital, nine urgent care clinics, and 14 provider clinics in a variety of suburban locations.

Stacy’s employer also operates 16 rehabilitation locations. Some rehabilitation locations are free-

standing, and some are located within the organization’s hospital facilities. Several of the free-

standing locations are located within health and wellness centers and one location offers

pediatric therapy. The organization’s website also features bios of healthcare providers,

including physical therapists.

Education and Training

Stacy holds a bachelor of science degree in physical therapy from a large state university

in the Midwest. She also holds a master’s degree in healthcare administration and management

from a large state university in the southern United States. In addition to formal leadership and

management training in her master’s program, Stacy has also taken advantage of a variety of

formal leadership and management training opportunities through her employer as well as the

American Physical Therapy Association (APTA). The formal training through her organization

included a performance improvement training program which provided education and practical

skill application in project management and performance improvement. The organization also

required Stacy to complete learning modules and classes on a variety of leadership and

management topics. Despite these formal learning opportunities, Stacy still described her
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leadership and management training as “more on the job,” not a formal structured process where

the organization shows “you the ins and outs,” but instead, “It was…here’s your job.”

Current Position

Stacy is currently employed as the manager of outpatient therapy services. The position is

entirely administrative and does not include patient care. Stacy oversees 14 outpatient therapy

clinics and 10 supervisors. Stacy also oversees 15 athletic trainers which provide sports medicine

outreach services to area high schools as well as an area college. Stacy oversees a large number

of therapists indirectly among these various locations. While Stacy held lead therapist and

supervisor positions in the past, this position represents her first position which has been

primarily administrative. Stacy’s job duties include oversight of clinic operations, financial

productivity measures, clinical mentorship programs, continuing education opportunities,

staffing considerations including interviews and hiring, and new clinical program development.

She has been involved in the conversion of billing from hospital-based to clinic-based billing, the

development of a centralized scheduling service for therapies, the opening of a new pediatric

therapy clinic, and the development of a neonatal intensive care unit outpatient follow up

program. With myriad responsibilities of her job, Stacy describes herself as “the knowledge

holder of so many things.”

Summary

This chapter described the eight physical therapists who participated in this study. Each

participant summary included a personal description and background information as well as

descriptions of the participant’s current employer, education and training, and current position.

The participants represented most major geographic areas of the country with the exception of
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the northeastern United States and the overall demographic makeup of the participants resembled

the physical therapy profession as a whole.

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CHAPTER 5

FINDINGS

The purpose of this study was to understand how physical therapists make meaning of

their professional role identity when transitioning from clinical to leadership positions. An

integrated conceptual framework derived from the work of Alvesson and Willmott (2002) and

Fitzgerald (2020) informed the collection and analysis of data in this study. An inductive method

of qualitative data analysis was used to develop themes which answered this study’s overarching

research question: How do physical therapists make meaning of their professional role identity

when transitioning from a clinical to a leadership position?

After interview transcription was completed, each transcript was read multiple times with

the researcher making initial memos in the margins. Data analysis began by assigning open

codes to the transcripts of each qualitative interview. Open codes were then grouped into focused

codes. Using the conceptual framework as a guide, focused codes were developed into emergent

themes, including subthemes within each emergent theme. Emergent themes were triangulated

against the researcher’s original memos, research journal, and post-interview notes. Using the

conceptual framework, the emergent themes and subthemes were further refined and named.

Participant statements from the interview transcripts were referenced in the naming of the themes

and subthemes. Member checks were conducted to solicit feedback from participants. Six of the

eight participants responded and voiced agreement with the final developed themes. The data

analysis process yielded six overarching themes which answered the research question. The six

themes which emerged from the data analysis are as follows:

Theme 1: Beginning with a strong role identity focused on more than clinical skills

a. A focus on affective and interpersonal skills

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b. A focus on growth, flexibility, and an ever-expanding identity

c. Alignment between self-identity, clinical identity, and a leader identity

d. Identification with their organization

Theme 2: Accepting the role of discomfort during the transition process

a. Feeling overwhelmed

b. Adjusting to the loss of patient care

c. Using past experiences to embrace discomfort

d. Separating management from leadership in identity construction

Theme 3: Focusing on relationships

a. Work relationships

b. Mentoring relationships

Theme 4: Exercising agency over the construction of their leader identity

a. Responding to a lack of organizational identity regulation

b. Charting their own path

b. Getting things done

Theme 5: Recognizing consistency between physical therapist and leader roles

a. Recognizing their clinical skill set is applicable to leadership

b. Recognizing clinical work and leadership work both focus on service to others

c. Recognizing alignment of organizational, clinical, and personal values

Theme 6: Establishing a professional identity informed by, but not bound by, their

physical therapist identity

a. Becoming the “go to” person

b. Having a foot in both worlds

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c. Redefining success in their new role

d. Expanding their focus

This chapter will discuss each of the six themes and their subthemes. Representative

quotes will be used in the discussion of each theme. Additionally, each theme and subtheme will

be discussed in relation to the integrated conceptual framework used to guide this study

(Alvesson & Willmott, 2002; Fitzgerald, 2020). A visual representation of the six overarching

themes and subthemes situated within the conceptual framework for this study is presented in

Figure 5.1.

Figure 5.1

Themes and Subthemes Situated Within the Integrated Conceptual Framework

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Theme 1: Beginning With a Strong Role Identity Focused On More Than Clinical Skills

The physical therapists in this study all possessed a strong role identity prior to their

transition from full-time clinical work into their leadership/management positions. The

participants all described this role identity in a broad scope which exceeded a more simplistic

role identity focused exclusively on clinical skills. The participants all identified the importance

of affective and interpersonal skills, a focus on growth, flexibility, and an ever-expanding

identity, alignment between self-identity, clinical identity, and leadership identity, and alignment

with their organization.

A Focus on Affective and Interpersonal Skills

The possession of exclusive knowledge and clinical skills, and the acts of using the

knowledge and performing the skills in the presence of fellow professionals, has been identified

as a component of healthcare professional role identities (Fitzgerald, 2020). The participants in

this study, however, referenced clinical knowledge, skills, and scope of practice of physical

therapists only briefly when describing their PT professional role identities prior to transitioning

to leadership/management. Stacy did describe physical therapists as “anatomical and

biomechanical experts,” while other participants referenced the knowledge-base and academic

preparation of physical therapists as a given rather than a defining aspect of their professional

identity. Instead, the participants in this study focused on the affective and interpersonal skills as

necessary skill sets for a physical therapist to possess.

Nicole noted how the academic preparation of the physical therapist was considered a

pre-requisite rather than the defining aspect of her professional role identity as a physical

therapist:
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You need to have, like, all this pre-requisite content and academic capacity … but it’s not

even close to meaningful if you can’t put it in a language that somebody’s going to

understand. So, you have to have good communication skills.

Bryan also considered academic capacity a pre-requisite rather than a defining factor of the PT

professional role identity when he stated, “I kind of expect the science stuff, but I want to see

what kind of mentality that person has … I need to know that they know how to connect with

people.” When asked which skills were necessary for a physical therapist to possess, Bryan

responded by stating, “You need to have someone who has strong interpersonal skills because so

much of our job is education and understanding patients.” Bryan went on to describe a moment

in his training when he became aware of the importance of affective and interpersonal skills as a

component of his physical therapist identity:

The PT starts his subjective and he’s sort of going through and he's got a paper in front of

him and he's going through his checklist, and I realized after about three or four minutes

he never actually looked at the patient. He's just sort of rattling off questions to the point

where I'm looking at the patient and I can see him like trying to get his head down to

maybe the level where he could maybe make the therapist look up at him and I remember

that so vividly…just thinking that person just wanted the therapist to make eye contact

with him, just to sort of acknowledge him as a human being and not a checklist. And I

remember that was my first interaction saying boy that's an important piece of this.

Sarah confirmed the importance of affective and interpersonal skills to a physical therapist’s

professional role identity, stating, “I think there’s a lot of intangible skills, you know as far as

just being able to have a conversation.” When considering the importance of communication to

her PT role identity, Sarah went on to say, “I think that was probably what got me further than all
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the continuing ed courses was just the ability to read patients’ moods and figure out what other

psychological things were going on.” Doug described these skills as “intangibles,” stating,

“What you can’t teach is personality, you can’t teach the ability to relate to patients, you can’t

teach the intangible things.” Katelynn stated this more directly when she noted, “you have to be a

people person, I don’t think it matters what setting you’re in.”

By identifying key affective skills such as communication and being aware of another

person’s emotional status, the participants in this study spoke to the importance of interpersonal

skills as key to success in their patient care careers. To Amanda, successful patient evaluations

were not the exclusive result of excellent clinical skills, but a result of getting people to “feel like

they can trust you and connect with you,” and noting how she was able “to build those rapports. I

had those abilities to have those life conversations with people and I, and I saw how important

that was to them.” The possession of affective skills and the application of these skills in the

development of interpersonal relationships was key to Stacy’s PT professional role identity as

well. Stacy, “wanted people to really feel like they were cared for and heard. That was probably

my most important thing.” For Doug, his PT professional role identity was perceived in the form

of patient narratives which resulted from his ability to meet them on a personal level. For Doug,

“being a PT and helping people overcome overwhelming obstacles they don’t have any idea they

can overcome, the best thing that comes out of that for me is the stories we get about the human

spirit.”

The value of affective and interpersonal skills as a key component of the physical

therapist professional role identity was not confined only to the therapist-patient relationship. It

was also key to the participants’ development of their professional role identity during training.

During undergraduate observations and work in a hospital setting, Melissa viewed the “therapist
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as the person who is really kind of spending the bulk of their time direct patient-facing and

having that opportunity.” The strength of a physical therapist’s affective and interpersonal skills

began to shape Melissa’s professional role identity from early on in her training, while her early

patient care experiences solidified their place in her PT role identity. Melissa identified with how

a physical therapist’s:

approach and their knowledge can ultimately influence the outcome of a patient and how

much true ownership we have in building those relationships, that inspiring others. I think

that was the thing that really kind of gave me that identity and clinicals really solidified

it.

The affective skills and interpersonal capacities of physical therapists also molded the

professional role identities of Katelynn and Stacy during training. Katelynn noted how her

relationships with clinical instructors and PTs “helped mold you during your clinic experiences

and then your first year,” while Stacy’s identity began to form during a “great first experience

and a great team of nurturing therapists.”

The development of personal relationships was key in the construction of the physical

therapist identity for each of the study’s participants. This stands in contrast to the integrated

conceptual framework used in this study, specifically the key components of professional role

identity identified by Fitzgerald’s (2020) conceptual analysis. Fitzgerald (2020) described a

profession’s extant knowledge obtained via the formal education and certification processes as a

defining factor in the professional identity. In contrast, the physical therapists in this study

presented very little in terms of the physical therapist’s specific knowledge base as influential in

the formation of their professional role identity in training. The participants in this study

indicated this knowledge was a given, assuming any and all physical therapists having
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successfully completed a physical therapy program would be in possession of it. Instead, when

asked what knowledge and skills were needed by a physical therapist, the participants in this

study regularly referenced affective skills such as emotional intelligence and communication

skills. These skills were identified by the physical therapists in this study as the defining skill set

in the construction of their physical therapist professional role identity. Furthermore, many

participants felt these skills were not necessarily taught in their professional training program,

but instead were either encouraged or developed through the personal relationships they

developed during clinical experiences as opposed to their didactic coursework.

Most notably, the ability to develop personal relationships was influential both in the

development of their professional PT identity via relationships with their clinical instructors,

professors, and peers, but also perceived as the most important skills in need of acquisition in

order to be a successful physical therapist. This subtheme also conflicts with Fitzgerald’s (2020)

“actions and beliefs” components of professional role identity in healthcare providers, which

states that professionals develop their professional identity by doing the tasks of the profession.

None of the participants referenced specific tasks, techniques, treatments, evaluations, or

interventions when describing their PT identity. Instead, the participants referenced affective

skills of communication and relationship development as most important.

A Focus on Growth, Flexibility, and an Ever-expanding Identity

When describing their professional role identity as full-time clinicians, the physical

therapists also noted a degree of malleability. The participants viewed growth and learning and a

willingness to be flexible and expansive in their self-view as PTs as key to their clinician

identities. For the participants in this study, the ability to be flexible in their approach to patient

care and adapt to a variety of circumstances were not only viewed as admirable, but necessary to
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providing quality patient care. Furthermore, the participants viewed this adaptability, flexibility,

and growth-oriented mentality as key uniquities which separated them from other professions.

Katelynn described her early experiences with physical therapists on her first job. She

“admired how they really thought outside the box” when devising ways to connect with and treat

patients with significant neurological injuries. Doug also noted how “PTs need to be dynamic.

They need to be able to think on the fly.” Amanda also noted the ability to adjust on a moment’s

notice as key when working in the hospital when she stated, “knowing what your day is going to

look like, obviously in the hospital it could look one way and five seconds later, something

completely different.” To Stacy, it was “flexibility, an ability to move … change is going to be

very difficult for people who don’t have kind of that innate ability.”

While flexibility and a focus on growth and expansion were perceived as clinical skills,

other participants noted this same focus as key in their original PT professional role identity from

a formational standpoint. Bryan noted how being flexible and growth-minded helped him gain a

more expansive view as a clinician by, “Going down to a city and doing rotations throughout the

Midwest helped broaden my horizons from a personal interaction perspective. I did clinical

rotations in Louisiana, Wisconsin, all over, in downtown Chicago.” Likewise, Stacy noted,

“being open to new experiences, but that probably was foundational for me.”

The focus on growth, flexibility, and an ever-expanding identity played out for several

participants in their clinical work and how they approached their progressive development as

clinicians. Amanda and Melissa both noted how a flexible, growth-minded, and expansive

identity as a physical therapist was important to their clinical approach to patient care. Amanda

noted how, for her, being a PT involved “looking at it as a life view versus just the task view,”

and “looking past the immediate physical tasks and looking what else can you incorporate,”
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while Melissa noted how she had to “understand all of those pieces of the puzzle that occur

outside of your specific discipline then to most effectively treat the patient.” This view of a

physical therapist’s clinical identity as dynamic, flexible, and ever-expanding was viewed by all

participants as not only necessary, but also a positive and unique characteristic of the profession.

Sarah summarized this best when describing how she enjoyed her first clinical position after

physical therapy school. In describing her first job, she stated, “that’s kind of what I remember

from those early years is that energy and that hunger to learn more.”

This subtheme was consistent with Alvesson and Willmott’s (2002) description of role

identity. Role identity is described as the precarious outcome of identity work, indicating that

role identity is not static, but instead open to constant interpretation and reinterpretation based on

exposure to challenges such as attempts at identity regulation via professional or organizational

socialization. In describing their PT professional role identity before entering their leadership

positions, all participants referenced the need to be flexible and adaptable. These statements

paint a picture of PT professional role identity as growth-oriented and focused on learning and

growth, not as a static identity which, once achieved via training, does not continue to expand,

develop, mature, and grow.

Alignment Between Self-identity, Clinical Identity, and a Leader Identity

The participants in this study all reported alignment between their self-identity, clinical

identity as a physical therapist, and the possession of a leader identity. This alignment was

present prior to making a transition from full-time clinical work to a formal

leadership/management position. For the participants in this study, the desire to help others and

the drive to lead presented as components of the participants’ self-identity which were consistent

with how they perceived themselves as physical therapists.

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Nicole stated this plainly by noting, “Physical therapy met me personally in a place that

was very relevant to me” when she was an undergraduate making career path decisions.

Likewise, Doug noted, “One of the things that being a PT at rehab has allowed me to do is to be

myself.” Doug worked a short time in an acute care physical therapy setting, leaving after two

years. He left the position because “I felt like I couldn’t be myself.” For Sarah, the alignment

between her self-identity and clinical identity existed even prior to her training:

As a healer for sure…this is going to sound very, like, awkward, but like growing up I

always felt like I had this, not a superpower, but I was like, there’s something in me that,

like, even as a young kid…I was always very calm and collected…I knew that this is

what I was meant to do, was to take care of people.

Melissa described a very similar alignment between her self-identity and identity as a physical

therapist. Working as a technician at a rehab hospital during her undergraduate education, she

“knew once I got the job that was it … I knew going into PT school that I was going to do neuro

rehab.”

For each participant, this alignment between self-identity and clinician identity was

described as an emotional connection. The alignment was felt as opposed to being developed or

cultivated through training and professional practice. This feeling extended to a view of physical

therapists, and by default themselves, as leaders. Amanda described a previous position in acute

care physical therapy:

The dynamics at the acute care hospital I was at was, it was, there was a couple of PTs

who had been there a long time and they obviously were the go-to, de facto leaders kind

of it, and … PT just generally tends to lead a little bit more.

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Amanda went on to describe how, when those physical therapists, the “de facto leaders,” moved

into different positions, she took the reins of clinical leadership in their place. Amanda “became

that leadership role in acute care.” Being the person people could go to “kind of started that

desire to be more in a leadership role” for Amanda. Similar to Amanda, Katelynn also felt an

intrinsic desire to lead, stating she “always wanted to move up.” Once again, Katelynn described

the alignment between her self-identity, clinical identity, and leader identity as a feeling rather

than a result of development or socialization:

As you kind of mature as a clinician I feel like you either become complacent, or you’re

the person where you’re like I wish I could make these decisions because I would want to

do XYZ, and I was that person.

In a similar manner, Bryan “always sort of had an eye for management” and Sarah “always saw

myself as that staff PT, but being a leader, both, in the clinic.” Like the other participants, for

Sarah, this perception was consistent with her self-identity. Playing high school and college

sports, Sarah “was a captain a lot, and it was kind of a…jump on my back and here we go.”

The alignment between self-identity, physical therapist identity, and an identity as a

leader fits Alvesson and Willmott’s (2002) components of self-identity as well as Fitzgerald’s

(2020) components of professional role identity. Alvesson and Willmott (2002) described the

presence of a central life interest as a key component of self-identity. The participants in this

study described the profession of physical therapy as a key component of their self-identity,

often linking their professional identity inextricably with their identity of self. Additionally,

Fitzgerald’s (2020) conceptual analysis of professional role identity in healthcare workers

includes concepts of personal identity and group identity. According to Fitzgerald (2020), the

development of professional role identity involves a process by which a professional internalizes

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the characteristics, values, and norms of a profession and begins to think, feel, and act as a

member of the profession. Viewed through the lens of the conceptual framework of this study,

the values, characteristics, and norms of the PT profession were consistent with the participants’

existing self-identity.

The identity consistencies of the study participants were not limited to consistency

between self and clinical identities, however. The participant responses also indicated a

consistency between their self and clinical identities and the possession of a leader identity. The

leader identity pre-dates the transition of these PTs into their respective leadership positions. The

data analysis revealed the presence of leadership identity as a component of self and a

component of their identity as a clinician.

Identification with Their Organization

Identifying with their organization or employer was a hallmark of the physical therapists’

professional role identity even before taking a leadership or management position with the

organization. Group identity has been found to be a component of healthcare professional role

identity (Fitzgerald, 2020). As noted in the previous subtheme, the participants in this study felt a

strong connection between their self-identity and their identity as a physical therapist in clinical

practice. Despite this strong connection, the participants did not appear to share this connection

with the physical therapy profession at large. In other words, group identification with the PT

profession was not a component of their strong professional role identity. Instead, the

participants’ sense of group identity was with their organization.

This organizational identification manifested differently amongst the participants despite

being a consistent theme. For some participants, the organizational identification was on a local

scale, identifying with the organization in terms of their immediate work environment. For
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example, when serving in her full-time clinical role, Nicole identified “as a member of my team,

but often don’t find myself identifying as like a representative of our profession.” Nicole went on

to state:

I think I am much more passionate about being a part of that and I identify as part of that.

I chose that, and what, again, as opposed to necessarily having this like big identity as a

clinician or as a physical therapist.

Likewise, Melissa noted a strong identification with the organization for whom she has worked

since graduating from physical therapy school. This organizational identification began during

her clinical experiences and was the reason for turning down another position in her preferred

area of practice. Melissa recalled how having:

my old clinical instructor there as a mentor and then also you know the boss who I really

looked up to and admired, and they're a really solid program, so it seemed to identify

with a lot of the things I was looking to get started in my career.

As a result, when asked whether she identified more strongly with the PT profession or her

organization when working in full-time patient care, Melissa responded, “I have to probably say

more strongly with my role in the organization.”

For other participants, identifying with their role as a physical therapist and identifying

with their organization were not viewed as mutually exclusive options. Doug related “more to

my role as a PT, but the organization that I started with…the work they did, the camaraderies,

um, I related to that piece as well.” Doug went on the state how his identification with being a

PT and his identification with the organization were very close, stating, “I relate to the

organization that I worked for and, not that, not equal amounts as to being a PT, but I think it’s

not that far behind.” Katelynn had a similar experience, noting how she felt she identified with
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“Both of them. I feel the organization and the PT profession. I don’t feel like they were

conflicting.”

Sarah’s responses provided an even stronger example of how identifying with the

organization was integral to her professional role identity even before taking on a leadership or

management position. Sarah spoke of how her identification with the PT profession was

maintained more out of a sense of obligation than as a true component of her identity:

I've always been an APTA member and always pretty active with [state] physical therapy

association, so I think that identity has always been there, just as a you know…guilt, like

you gotta stay true to your profession and help give back to your profession.

In contrast, Sarah’s true feeling of identification in relation to her own personal and professional

role identity more closely aligned with her organization as her clinical career progressed. Sarah

stated she began:

identifying more with the organization than with [state chapter] because there are so

many sections of PT, and yes, I was active in ortho and sports, but this was, the company

was always, here is my vision, where I want to go.

Bryan and Stacy present a contrast to some of the other participants in that they have not

necessarily worked for the same organization for the entirety of their clinical careers. Bryan

specifically left a previous employer after they were bought out by a competitor specifically

because the new employer’s value system and style of doing business was not consistent with his

identity, values, and preferred way of doing business and providing care. In this way, Bryan’s

lived experience confirms this subtheme by demonstrating how participants in this study valued

identification with their organizations as part of their strong professional role identity even prior

to transitioning into leadership.

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Stacy’s experience is even more representative of this trend. Stacy worked as a traveling

physical therapist for years before settling at her current employer. Because she never worked at

a particular organization for very long, her role as a physical therapist was a strong central

component of her professional role identity which she carried from temporary position to

temporary position. Despite this, Stacy reported:

If I had a long-term assignment and I really felt like I was representing that organization,

I might be you know at a, at a job for nine months and I definitely was there to represent

and to bring good quality care and support the reputation of that hospital even if it weren't

my long-term job.

Much like Bryan, Stacy also recognized the importance of organizational identification to

her clinician role identity when contrasting experiences between a previous employer and her

current employer. Stacy took one position after leaving her travel PT position due to her non-

compete agreement. Working there, Stacy found “more of what I learned in my identity you

know I would never do work like this. I never treat anyone like this.” In contrast to that

experience, Stacy described how strongly she identified with her current employer as part of her

role identity, stating, “Definitely with this organization I really wanted to work with this

organization because I felt like I identified with it.”

According to Fitzgerald (2020), group identity is a component of professional role

identity in healthcare professionals. Fitzgerald (2020) speaks to group identity in terms of

identifying with the profession, internalizing its beliefs, values, and norms. While, in general, the

physical therapists in this study felt a personal connection with the profession of physical

therapy, they also identified strongly with their organization. According to Alvesson & Willmott

(2002), it is the role conflict produced by differences in the existing self-identity (in this case a
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physical therapist professional role identity) and the organizational identity (the leader identity)

which triggers identity work to resolve the dissonance. This subtheme appears to contradict the

conceptual framework. The physical therapists’ professional role identity included professional

and organizational group identification even before the transition into leadership occurred. Since

this dual identification pre-dated their transition into their current leadership positions, it was not

due to an organizational identity regulation process stimulated by their leader transition.

Theme 2: Accepting the Role of Discomfort During the Transition Process

When engaging in the role transition from full-time clinical work to a leadership or

management position, the participants experienced discomfort in a variety of ways. Encountering

discomfort, as well as recognizing discomfort as a component of the role transition process, was

a common theme expressed by the participants when reflecting upon their transition to date. The

physical therapists in this study not only recognized the discomfort, but embraced it as a

necessary part of transitioning out of clinical work. By recognizing and accepting the role of

discomfort, the participants were able to develop ways of using the discomfort to facilitate their

transition. Discomfort during the transition included feeling overwhelmed, adjusting to the loss

of patient care, using past experiences to embrace the discomfort, and separating leadership from

management while constructing their leader identity.

Feeling Overwhelmed

All participants in this study described feeling overwhelmed when they began the

transition from full-time clinical work to a leadership/management position. Being overwhelmed

was felt in different ways by the physical therapists. Some participants were overwhelmed

simply by an increase in workload. Amanda stated:

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At first it is very overwhelming because you have a lot on your plate, and you are trying

to do everything at the same time. And once you realize you can’t do everything at the

same time, then the stress comes off.

Melissa experienced a similar feeling of being overwhelmed and the effect it had on her

perceived effectiveness:

I know I definitely, like, I play a really important role on the team in the overall program,

but it makes me feel like I’m perhaps not as effective in my role because I don’t have the

same amount of time to build the relationships and work along with everyone that I used

to have.

Nicole and Stacy stated it more plainly. Nicole reported, “swimming from buoy to buoy.” and

Stacy felt “like an island, just trying to stay afloat.”

Other participants felt overwhelmed by the knowledge gap between their experience and

preparation as a clinical physical therapist and their new role as a physical therapist in leadership.

Bryan simply stated he “was not equipped for it whatsoever, it was very much on the job.”

Amanda echoed this sentiment when she stated:

It definitely made me fully aware that I had a lot to learn as the manager. I knew it was

going to be a challenge but it kind of put it all in black and white in front of you, like, this

is a lot and it’s not as easy as you may have thought.

Amanda went on to explain, “One of the more challenging situations is when more things get put

on your plate that you really don’t know anything about, and you just sit and stare at it like, I

don’t even know where to begin.” Part of the discomfort was due to the lack of time to learn the

new skill set required of them as new leaders. Stacy felt she “couldn’t even get immersed in

learning, it was so flying by the seat of my pants, it was chaos.”

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Being overwhelmed in the new role was also a byproduct of an increased sense of need

from team members, a need which the participants never felt in clinical care. Sarah noted how

being a new leader was “a little bit overwhelming because a lot of people now see me as their

resource,” while Stacy found it overwhelming to “always be that up person, when I’m personally

feeling, you know, very just overwhelmed and exhausted, is just hard, it’s hard to be up all the

time.”

Despite the demands of the new position and the gap in knowledge it brought with them,

feeling overwhelmed proved to be a driving force to improve on the part of the participants.

Doug provided a particularly representative example by stating:

I was very, very comfortable as a therapist. I was comfortable who I was as a therapist,

my skill set … There are still things in this role that I have not seen yet and they still

come up on a daily basis and having to deal with that in and of itself, as a side, it’s what

brings you back every day.

Doug’s statement exemplifies how the participants in this study not only recognized their

feelings of being overwhelmed, but also embraced that discomfort as a part of their role

transition.

According to the conceptual framework for this study (Alvesson & Willmott, 2002;

Fitzgerald, 2020), identity work comprises the continual forming, repairing, maintaining, or

revising of a coherent narrative of self. A professional will initiate the process of identity work in

response to a stimulus. Alvesson and Willmott (2002) identify efforts at organizational identity

regulation as a key stimulus for the onset of identity work during role transitions. As an

organization seeks to develop an identity in an employee which is consistent with the

organization’s desired views, this may produce tension in the form of role conflict, requiring the
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individual to work on their role identity in an effort to resolve the tension. In this study, feeling

overwhelmed was an emotion shared by all study participants when transitioning from clinical

PT work to a leadership position. Feeling overwhelmed, learning their leadership responsibilities

on the fly, and a certain sense of being adrift in their initial role transition were common.

Furthermore, each PT appeared cognizant of these feelings and how they served as a catalyst to

advance their knowledge, skills, and performance in their new role in order to make meaning of

their professional role identity through identity work.

Adjusting to the Loss of Patient Care

Discomfort during the leadership/management transition was also brought on by the

departure from full-time patient care. The discomfort brought on by leaving patient care was

experienced in a variety of ways amongst the participants. For some, the loss of the patient

interaction was a source of discomfort. For others, leaving patient care led to a separation from

the clinical team, while still others feared being viewed as less legitimate in the eyes of fellow

physical therapists. Regardless of the source of the discomfort, all participants in this study

needed to adjust to the loss of patient care experienced during their transition.

For Melissa, the loss of the direct patient care interactions and the satisfaction of seeing

patients improve was difficult. In describing this source of discomfort, Melissa stated:

Very challenging for me personally. I love patients and I know it, like, as my role as a

leader I’m helping to grow and develop our program and other clinicians in the team so,

ultimately, we could take care of our patients … definitely hard switching … to just

having that high level of satisfaction and you know, the results that you see treating each

patient.
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Melissa went on to state, “For me personally, the transition from not seeing patients as much was

a lot harder.” This sense of loss was felt by Melissa despite the pride she takes in her work as a

leader. Melissa noted, “there’s things about it I really do love, but miss the patients a lot.”

Doug echoed Melissa’s sense of loss when asked which aspects of his leadership

transition were most challenging. He noted the loss of patient care and no longer being the

person in the rehab gym with the patient. Doug stated, “Going cold turkey on patient care was a

low point. My office is right outside the gym, knowing that it's no longer me, it was an

adjustment, and I would say that's, that's been a low point.” For Amanda, who works in a hybrid

leadership/patient care position, the reduction in patient care time was already identified as a

source of discomfort. Amanda anticipated the discomfort to increase should she ever be required

to reduce her patient care time further:

I don’t mind taking up extra management things but if I start to not know the patients

because I’m not being able to spend the time with them, then that’s a problem for me

personally. I want to be able to know them without having to reference a piece of paper

all the time.

For others, the discomfort brought on by the loss of patient care was felt as guilt or a

sense of abandonment. Sarah stated, “It’s been weird. So, on one hand I have been dealing with a

lot of guilt leaving patients and leaving the clinic, and leaving my team.” Katelynn felt a similar

discomfort due to her ongoing sense of responsibility to her patients. When asked how she was

adjusting to leaving patient care, Katelynn stated, “Sometimes not well. I try to see every patient

on a weekly basis and there are some patients that because of my background I feel almost like a

sense of responsibility with them.” Despite being in a hybrid patient care/leadership position,

Katelynn’s sense of loss and sense of ongoing direct responsibility for patient care remained.
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Finally, adjusting to the loss of patient care for the participants also involved coming to

terms with the possibility of being perceived differently in the eyes of their fellow physical

therapists. Stacy felt this acutely, noting a “disconnect, I feel this awkwardness, how do I solve

this piece of what I know is so important being a PT in my leadership role when I don’t have to

do it.” Stacy experienced the disconnect from front-line clinicians, noting, “There’s that layer

though that exists, while people are like, well you don’t do this anymore.” Bryan experienced a

similar discomfort and expressed the need to remain legitimate in the eyes of the PTs he now

supervised. Bryan reported actively taking steps to make “sure that that identity as a clinician is

still there. And I do think being in the clinic has helped give me some credibility from that

perspective.” Despite his efforts to adjust to the discomfort of leaving patient care by remaining

credible in the eyes of his fellow physical therapists, Bryan did “wonder if I have a new grad

who doesn’t know me as a clinician, they know me as a leader, if they, if there’s extra work I

have to do to kind of help prove that.” Even amongst the staff who worked alongside him

clinically, Bryan needed to adjust, feeling “like folk’s perceptions of me has changed a little bit

from what I used to when I was a site manager.” Sarah felt the weight of a change in perception

amongst her peers as well. Sarah reported how she was now:

Perceived as a suit. I get perceived as a, a, corporate robot. And maybe robot’s not the

right word, but I think there’s a lot of perceptions of clinicians that are out in the field

that see corporate as a negative being.

Both Amanda and Katelynn felt the need to adjust to this sense of loss by altering their

work patterns. Amanda reported taking steps to help others “see that I am not just going to be

sitting at the desk and doing paperwork and actually be there, kind of in the trenches with them.”

For Katelynn, adjusting to the loss of time in patient care meant adjusting to a changed
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relationship with her former peers. After a difficult interaction with a physical therapist whom

she now supervised, Katelynn, “had to kind of make this shift in my brain, and what I mean by

this is, I am not your friend, I’m not your buddy … you know it was just hard for me to make

that shift.”

The feeling of loss associated with leaving full-time patient care was consistent amongst

all participants. Again, this feeling of loss and missing direct patient care appeared to be another

stimulus for identity work. Unlike feeling overwhelmed, the feelings of loss over patient care

does represent a type of role conflict (Alvesson & Willmott, 2002). As noted previously, the

physical therapists in this study felt a link between their overall self-identity and their

professional role identity as physical therapists. Furthermore, the development of patient

relationships was a key factor in how they defined their concept of self as a professional. The

loss of an avenue for the development of these patient-PT relationships represented a source of

tension between their new leadership role within the organization and their prior role as full-time

clinicians. This conflict prompted identity work, as evidenced by statements of the clinicians

who reported adjustments in their perceptions of former colleagues and their relationships with

them.

Using Past Experiences to Embrace Discomfort

The participants in this study needed to embrace discomfort as part of their experience in

transitioning from full-time clinical care into leadership/management. Participants embraced the

discomfort of this transition by referencing past experiences in which they navigated discomfort

successfully. For the participants, their experiences in transitioning from the classroom to the

clinic as students, and transitioning from student to newly independent clinicians, were formative
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and served as learning experiences. These experiences were then referenced in order to deal with

and embrace the discomfort of their current transition.

Nicole noted how her “first long-term rotation was, I was, as uncomfortable as I’ve ever

been for as long as I’ve ever had to be.” This clinical rotation in school helped Nicole learn “how

to function uncomfortable, and that was good for me.” Because of that experience Nicole found

she was better equipped to handle the discomfort of transitioning into leadership, stating:

You spend so much of your first year uncomfortable and I feel like that’s how I’ve lived

again. I’m going through, you know, all the different situations and things … Well, the

things that didn’t go well, I’m just constantly sitting there going…I did this or that or I

should have done this or that or was that always going to happen? But I’m sort of trying

to embrace the discomfort.

Because Nicole “lived through it once,” she was able to adjust and accept her discomfort in the

leadership/management role as “temporary and then … like you shouldn’t try to run away from

it.” For Nicole, this willingness to embrace discomfort is what separates leaders in PT from

others, because “the stuff that makes you a little bit uncomfortable is the stuff that people in your

same peer group won’t even swing the bat at.”

Nicole’s experience was echoed by the other physical therapists in this study. Stacy

described how her PT educational program was in a state of flux while she was there, requiring

the students to handle quite a bit of upheaval and take responsibility for their own progress.

Stacy stated quite plainly, “It was pure insanity and so I guess maybe it set the stage for me to be

like I can do whatever, you know, bring it, I can do it.” Stacy referenced this “bring it on”

attitude to address the discomfort she felt during her transition into a leadership role, when things

in her assigned departments were in a significant period of transition and upheaval. Stacy noted,
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“I would say I still have spent a lot of time uncomfortable, but it reminds me a lot of initiating

clinical practice. So, I’ve made that kind of parallel to myself often.” Likewise, Bryan used his

experience as a student and a new clinician to inform his response to the discomfort of his new

leadership position. Bryan noted how transitioning into clinical practice required him to “get

your head on straight, to take all that school information and all your rotations and now suddenly

you’re expected to be a free-standing clinician.” Having done so helped Bryan learn “having a

healthy sense of introspection helps learning where maybe you’re not as comfortable and how

can I remedy that.” For Bryan, remedying that discomfort in his leadership transition meant

telling "myself to lean into contact just a little bit” instead of avoiding the discomfort. Amanda

was able to link her initial experience as a clinician to her transition as well, noting it was “like

that first realization of, yes, I went to school but I know nothing, there’s a lot more to learn.”

The participants in this study described embracing discomfort and recognizing the role it

played in the development of their leader identity. As noted previously, feelings of discomfort

and being overwhelmed were stimuli for engaging in identity work. The way in which the

physical therapists in this study used past experience with discomfort in order to embrace

discomfort, rather than shy away from it, represents a form of identity work. Identity work is

grounded in self-doubt and openness to change and is stimulated by the liminality which occurs

when structures which typically reinforce self-identity instead challenge it (Alvesson &

Willmott, 2002; Ashforth et al., 2008; Gordon et al., 2020). The statements of study participants

reflected feelings of self-doubt, but also reflected the participants’ prior experience with self-

doubt in their clinical education and early career experiences. Their prior experience in

overcoming these feelings allowed the PTs in this study to further refine their professional
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identity as one consistent with the ability to take on new challenges, embrace the discomfort

associated with them, and emerge successful.

Separating Management from Leadership in Identity Construction

The physical therapists in this study adjusted to the discomfort of transitioning from full-

time clinical care to a leadership position by separating management responsibilities from

leadership responsibilities. The participants in this study possessed an inherent sense of the

difference between a leader and a manager. Furthermore, the physical therapists in this study

were capable of recognizing which aspects of their new roles were leadership-focused and which

were management-focused. The participants were able to separate these job requirements and

compartmentalize them, allowing them to view their position in terms of leadership, with which

they inherently identified as part of their existing identity, and management, which existed

separate from their existing professional role identity. By separating the two constructs, the

participants were able to embrace the discomfort brought on by their role transition and reduce

the components of the new position which were uncomfortable to them, making these

management components easier to embrace and to handle.

For Sarah, recognizing business management skills as only one aspect of her position

made the entirety of her new role easier to embrace. Sarah was able to encapsulate the business

management principles into a confined set of skills and recognize they were not the entirety of

her new position. Sarah’s discomfort with management stemmed from the fact that “we’re not

getting it in school. We’re not learning it and then that ingrained skill of helping people gets in

the way.” Sarah could “understand the intent…but it’s just not as fun as brainstorming and

visions and education.” Ultimately, Sarah’s ability to come to terms with the discomfort posed

by the business side of her job allowed her to also accept the rest of her job as more consistent
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with her existing professional role identity. Sarah described herself as “not a money person. I

understand that this is a business, but it is probably the part that I understand the least and that I

just don’t really care for.”

Melissa was able to separate the business management from the leadership components

of her new position, allowing her to compartmentalize her discomfort to select components of

her new role instead of feeling uncomfortable in the new role entirely:

I find that I’m in a lot more meetings than I thought I would be…when I initially

envisioned the role, something I really love is that kind of face time with the people that

you know that associates in my clinic and that mentorship and the problem-solving …

like that’s really what I saw that person kind of managing and helping through the day to

day and kind of guiding the direction of the clinic. And I find that I’m in a lot of

meetings.

Putting it more simply and directly, Melissa stated, “I didn’t view the management as highly or

the concept of that as highly as I view the concept of leadership.”

Unlike Melissa, Nicole envisioned the new role as being more focused on the business

management aspects, a vision which initially created hesitancy when approached with taking on

the new position. As a clinician Nicole’s focus was on “what were they visibly doing that I

wasn’t, like what’s in this operations meeting, what’s this running over reports, what’s this data

collection.” Adjusting to the discomfort of transitioning for Nicole meant coming to terms with

those business management aspects while also realizing leadership was a key component of her

new position, one which she more closely aligned with.

For Bryan and Stacy, the business management demands of the position were also

uncomfortable. Bryan noted, “from an operational demands perspective you know the shift is
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more that kind of business owner’s sense,” while Stacy noted, “There’s that level of unspoken

expectation that you’re in this role and we expect you to meet your productivity.” For all the

participants in this study, separating management obligations from leadership obligations

allowed them to identify the specific aspects of their position which made them uncomfortable.

This in turn allowed them to address the discomfort by finding ways to address management

demands while staying focused on the leadership tasks they enjoyed.

The physical therapists in this study recognized the discomfort posed by the operational

functions in their new roles, most notably budgetary responsibilities and attendance at business

operations meetings. Within the context of Alvesson and Willmott’s (2002) framework,

responsibility for the management of business operations was a defined expectation of the

organizations employing the study participants. As such, the expectation of their organizations

with regard to business management represents a form of organizational identity regulation. The

business operational management expectations of their new roles produced a role conflict with

their existing professional role identity as physical therapists. This role conflict, in turn, initiated

identity work.

While the leadership requirements of their new roles appeared to resonate and reinforce

the existing PT professional role identity, the management expectations represented a challenge.

Part of the identity work was to maintain the leader component of their existing identity by

separating the leadership and management components of their new roles. Identity work is not

only a response to attempts at identity regulation by an organization, but also a means of

exercising agency over the structures imposed or controlled by the organization (Alvesson &

Willmott, 2002). In the case of the PTs in this study, separating management from leadership

was a means of exercising such agency by defining the job for themselves in a manner that
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allowed for the maintenance of the existing leadership components of their professional role

identity while also allowing that identity to expand and include management. In doing so, the

participants revised their professional role identity in a way which did not result in outright

refusal of the organization’s identity expectations, but instead reshaped their role identity and

also the organizational role itself.

Theme 3: Focusing on Relationships

In order to make meaning of their professional role identity during the transition from

full-time clinical work to leadership, the participants in this study focused on relationships with

others. The ability to form and maintain relationships with others was a key component of their

professional role identity, one which the participants leveraged during their transitions.

Participants focused on past relationships, including relationships with previous mentors, faculty,

fellow students, clinical instructors, and previous leaders. These past relationships provided

reference points for the participants during their transition to leadership. The participants also

focused on current relationships in order to make meaning of their role identity. Whether past or

present, two subthemes emerged with regard to relationships: work relationships and mentoring

relationships.

Work Relationships

The physical therapists in this study focused on work relationships, both past and present,

in order to make meaning of their professional role identity when transitioning into leadership.

Stacy referenced the creation of a therapeutic alliance, a sense of partnership with her patients

when she worked full-time in clinical patient care. Stacy “saw myself as a partner and I prided

myself on creating the therapeutic alliance,” going on to state, “the therapeutic alliance was my

identity.” It came as no surprise when faced with the transition into leadership, Stacy sought the
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input of others in order to aid in her role transition, stating, “I counseled a lot with my

supervisors, they were my peers. I asked questions.” Moreso than any of the other participants,

Stacy’s transition into leadership included significant negative experiences. A significant

contributor to this was the manner in which her new work assignments interfered with the

maintenance and development of work relationships. Stacy noted how “That has challenged my

stamina…I feel a lot of it was just that feeling of not being successful in those human

connections…the way I would have expected previously.” For Stacy, focusing on work

relationships was key in her clinical career, her transition, and remained a key guidepost for her

to work toward as she continued to make meaning of her role identity when transitioning.

Other participants drew the parallel between their experience as clinicians and the value

of work relationships to making meaning of their professional role identity. Katelynn felt her

clinical work as a PT was “the art of finding how can I get this patient to trust me and have a

commonality so that ultimately we’re going towards the same goal,” a mentality she applied to

her team when she became a leader. Amanda experienced a similar commonality between

clinical and leadership work. As a full-time physical therapist in patient care, Amanda liked to

“make those personal connections with patients.” This principle guided how she led her therapy

team. This focus on relationships in her work was evident, as Amanda noted, “Lots of times I

hear from patients you guys, meaning therapy, are the only ones that take the time to stop and

listen.”

For Nicole, the commitment to work relationships was a key component of her work as a

PT which she referenced to make meaning of her identity in a leadership position. As a PT,

Nicole:
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Influenced the people around me in practice, and, so, the next six or seven years that

followed that, I would say most of my actions were driven by how it impacted the people

within my office, people within my clinic, like my circle of influence.

Focusing on work relationships translated to how Nicole saw herself as a developing leader,

stating, “It’s my responsibility to have a good appreciation of what’s going on with the people

that directly report to me.” Ultimately Nicole found as a leader, “People are really important to

me. And so, I’m like these are the people that I’m responsible for taking care of and nothing is

more relevant to me than that.”

Doug and Melissa echoed this sentiment as well. As practicing physical therapists, the

relationship with the patient was paramount. This focus on relationships in one’s daily work as a

PT directly impacted how Doug and Melissa made meaning of their professional role identity in

leadership. Doug noted, “As a team at rehab we want nothing but the best for all of the people

who are here, either patient or employee.” Doug’s focus as a leader was the same as a practicing

clinician, to “show that you actually care about the teams from a personal as well as a

professional level.” Melissa echoed Doug’s sentiment. For Melissa, getting away from meetings

and interacting with her staff was when she felt “in my element and loved it.” Melissa “just

really liked to get to know them, let them know I care a lot about them.” Finally, for Sarah, her

work relationships were the bright spot in her transition to leadership from patient care. Sarah

reported how she loved "meeting with my program managers. I think they are the shining stars,

not only within my world, but also for the whole company.”

Alvesson and Willmott (2002) described identity work as the continual forming,

repairing, maintaining, or revising of a coherent narrative of self. Within the conceptual

framework of this study, identity work is stimulated by some type of challenge or reinforcement
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to the existing professional role identity. All participants in this study reference their focus on

building relationships with the individuals to whom they will report as well as those who report

to them in their new leadership roles. Focusing on relationships within the work environment

represents a form of identity work. As noted, the ability to develop relationships was a key

component of the existing clinical PT identity of the participants. By focusing on relationships

during their transition into leadership, the participants were able to leverage an existing

component of their professional role identity and use it as a reference point to construct their new

identity as a leader.

Mentoring Relationships

Past work relationships with patients and current work relationships with colleagues and

associates were not the only relationships referenced by the physical therapists in this study. The

participants also focused on their relationships with mentors and leaders, both past and present.

For some of the participants, past leaders served as an example of what they did not want to

become in their leader roles. Bryan spoke of how “nothing would frustrate me more than asking

a supervisor a question, and kind of getting a, well, we’ll see.” Bryan described his focus on

always providing an answer or an update to his staff when asked questions. Furthermore, Bryan

used the experience with a leader who failed to provide guidance and resources to directly

inform how he made meaning of his own professional role identity when transitioning to

leadership. Unlike his prior leader, Bryan sees himself “as the mentor, both from a clinical and

an operational perspective.”

Amanda referenced a similar experience with a previous manager she perceived as

disengaged. Amanda recalled how previous leaders of hers were “people who didn't know like
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what was actually going on…people that were removed from the everyday struggles.” Amanda

vowed:

Even if I, someday I’m in a position where I am not doing any clinical work and I'm just

in a leadership role, I still want to, to have the opportunity to be there with my team and

interact with them more on a regular basis and take the time to discuss with them what's

going on with their patients, what are their challenges, how are they working through

those challenges you know, what I can do to help facilitate things

Katelynn also referenced a prior leader when deciding how she did not wish to function in a

leadership position, stating, “I think it’s really important for staff to know they’re appreciated,

having been on the opposite end where you don’t feel appreciated.” Nicole referenced experience

with a prior leader by contrasting that leader’s approach with her own. Nicole’s prior leader

functioned quite differently than her, utilizing different strengths and exhibiting different areas

for improvement than Nicole saw in herself. While she did not always agree with his approach at

the time, reflecting upon this past relationship helped inform her developing leader identity.

Nicole recognized when her own performance may or may not need to be adapted. Nicole

remembered, “Having him taught me a lot about maybe some of my own tendencies, where they

weren’t so good, and then times when the way I would do things is absolutely essential.”

While the participants in this study referenced past mentor or leader relationships as

examples of what not to do, it was more common for the participants to discuss the positive

mentoring relationships which helped them make meaning of their professional role identity

when transitioning into leadership. For Nicole and Melissa, this mentorship paved the way for

them to transition in the first place. Nicole recalled how one leader encouraged her to make the

transition to leadership, even when she doubted it was the right choice:
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So, he called me and was like why didn’t you apply for this [location] Regional Manager

job? I said, well, that, I don’t have any relationships there…I don’t even know it…he’s

like no, I think I need you there, so why don’t you, can you apply? … He gave me this

nudge.

Nicole went on to describe this leader as “somebody that I probably work to emulate a lot more.”

Just as Nicole’s transition to leadership began with a mentoring relationship, so did Melissa’s.

Melissa’s relationship with her mentor was a key influence in her choice of employer and an

inspiration to pursue leadership. It was natural for Melissa to reference the example he set when

making meaning of her own leader identity. Melissa described her mentor and director as

“incredible and such an inspiration to everyone on the team. And I’ve been there with him since I

was a student and he’s the one who really pushed me to pursue leadership. So, he’s been a huge

influence.”

For Stacy, Katelynn, and Doug, the presence of a strong and supportive mentor during

the transition period from clinical to leadership offered a guidepost and a support system for

them to lean on and reference as they made meaning of their professional role identity. For

Katelynn, her “old boss at our sister facility basically mentored me for almost two months…she

has been vital in the success and kind of setting me up for success over here.” Focusing on this

mentoring relationship during a transition was not new for Katelynn. When Katelynn

transitioned from a student into a new graduate position in neurological rehab, she used the same

tactic with a more senior therapist, recalling, “I had a really good mentor. We became good

friends and she, at lunchtime, she would say, hey, do you want me to teach you how to do this

type of transfer?”
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Doug’s experience was similar. When attempting to make meaning of his professional

role identity, Doug focused on relationships with his mentor but also cultivated relationships

with other leaders in the organization. Doug recalled:

In order to figure out all the things I need to know in this role I need to know who to ask.

So, networking with those folks, networking with the director of programs development

for the entire organization … I know who to ask about that, it's not that I have the

information, it's that I know who to ask.

Doug’s relationship with his director, also a physical therapist, was crucial in the development of

his leader identity. Doug’s director “would do the leg work in trying to figure out all of those

who, what, where, when, why, and how questions.”

Stacy’s experience transitioning from clinician to leader was marked by more upheaval

and difficulty than the other participants. Stacy worked her way through this difficult transition

in the same manner as the other participants in this study however, by focusing on the

relationship with her mentor. Stacy described how collaborating with her supervisor and mentor

was “most helpful because she would help me be like well look here, or this is how you do that”

and describes her as “my mentor … I knew I had 100% trust in her to provide for me.” This trust

and support provided Stacy stability from which to make meaning of her professional role

identity during a tumultuous transition. Ultimately, focusing on her mentoring relationship with

her supervisor provided Stacy “a really good perspective … my relationship and that connection

is so important … even when I’m having dark moments, I know she has my back.”

Current and prior mentoring relationships were a focus of the participants during their

transition from clinical to leadership positions. Focusing on mentorship relationships represented

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both a form of identity work as well as a type of identity regulation for participants when viewed

through the conceptual framework of this study (Alvesson & Willmott, 2002; Fitzgerald, 2020).

With regard to identity work, focusing on mentoring relationships, past and present, provided the

participants the opportunity to both maintain and revise components of their professional role

identity while also forming new components. At times, the participants referenced their

experience with prior leaders as examples they wished to emulate, as well as examples they

wished to avoid in the development of their own leader identity. The participants compared and

contrasted both previous and current mentors with their existing professional role identity as a

means of revising the existing professional role identity to include desirable components of these

prior leaders while still maintaining authenticity in the leader they hoped to be. Finally, focusing

on current mentoring relationships was a key component of the transition to a leadership position

as opposed to focusing on skill acquisition.

Mentoring relationships also represented an important form of identity regulation for the

participants in this study. Identity regulation is the act of causing one to identify with the

organization (Alvesson & Willmott, 2002). In the case of this study, the organization attempting

to regulate the professional role identity of the participants was their employer, given their

leadership positions were organizationally bestowed upon them. One means of influencing an

individual’s identity work is by the control of structures. According to Giddens (1984),

“structures” are employed to influence and regulate the self-identity of an individual. Resources

provided by the organizations to the participants in this study are a form of structure. Resources

may often be thought of in terms of tangible resources such as space, financing, or equipment.

Resources may also be thought of as cognitive in the form of training and orientation. However,

resources may also include psychological resources such as emotional feedback and social
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validation (Ibarra, 1999). The participants in this study rarely described the tangible physical or

cognitive resources provided to them as instrumental in maintaining, forming, and revising their

professional role identity to include leadership. They frequently referenced mentoring

relationships as key to the development of their leadership identities and instrumental in their

success, or sometimes survival, of the role transition. In this way, mentoring relationships

represented a form of structure which influenced the participants’ identity work, thus

representing a form of identity regulation (Alvesson & Willmott, 2002).

Theme 4: Exercising Agency Over Construction of Their Leader Identity

The physical therapists in this study made meaning of their professional role identity

when transitioning from clinical to leadership positions by exercising agency over the

construction of their leadership identities. This autonomy was exercised in large part because the

participants’ employers did not place significant organizational pressure on the participants to

comply with a regimented description of a physical therapist leader. Instead, the lack of

formalized efforts by the organization to regulate the participants’ identities produced a need for

the participants to exercise autonomy over the meaning making process themselves. The physical

therapists in this study exercised autonomy over their leadership identity construction by charting

their own paths and simply getting things done.

Responding to a Lack of Formalized Organizational Identity Regulation Efforts

All of the participants described a transition process marked by a lack of strict

organizational direction or attempts to regulate who they were and how they were to see or

present themselves as leaders in their new roles. While their transitions were not devoid of

orientation or training, much of the formal, organizationally-provided input was in the form of
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operational training as opposed to highly formalized attempts to socialize the participants into an

organizational vision of a stereotypical leader.

Bryan summed up this theme well by stating, “The first few months I felt kind of,

pointless. I remember sitting around for a few months going, what am I doing here?” Bryan had

difficulty describing the exact responsibilities of his leadership position, stating, “I didn’t really,

actually I still don’t really have a strong idea, I can’t say I have been given a lot of that

guidance.” For most of the participants, the lack of strict organizational regulation of their job

role and identity was palpable. Stacy noted, “it was more on the job, it was, here’s your job,” and

feeling like her new leadership position was “really baptism by fire.” Melissa was also faced

with the need to engage in on-the-job learning. Despite having positive mentors, her actual job

role transition was punctuated by “a lot of learning on the fly and on the job because, you know,

I’m there at the clinic without another operational leader over me.” For Amanda, the lack of

formal organizational regulation of her identity led to miscommunication and the implementation

of an unsanctioned agenda by the outgoing manager. Amanda recalls, “initially it was a big

challenge … I was told that I was coming in to help change and that was not the case, that was

not what was wanted, that was coming from the manager and not from corporate.”

The lack of organizational attempts to regulate the participants’ identity led to feelings of

dissonance and a need to adjust how they approached their workdays. Sarah noted how she liked:

well-defined stuff. And it’s been a journey to figure out how to use Outlook and look at

my calendar and say, it’s okay, like I have a whole day open, then let me block time with

these tasks so that, you know, you know to get them done.

For Sarah, the lack of structure in her new role meant “every day is a little different. And so, I

am getting better at setting boundaries.” This lack of structure meant Sarah felt a stronger
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internal sense of dissonance, more “self-induced deadlines and self, like, anxiety, self-induced

stress.” Bryan’s experience was similar. For Bryan, everything in his new position felt “a bit

more fluid if you will, because whether it’s devoting some time, blocking myself time to get

some projects done or answer emails or whatever, I don’t really have a set schedule. That’s been

a challenge for me.” While Doug received considerable orientation and opportunities to network

with his leadership colleagues, the reduced organizational structure left him needing to “manage

my time differently and make sure I’m touching those different areas each and every day.” Of his

new leadership position, Doug noted, “the fatigue that I feel is more mental.”

This subtheme stands in contrast to the conceptual framework of this study. According to

Alvesson and Willmott (2002), organizations will seek to regulate one’s identity in order to bring

the role identity more in line with organizational expectations. The societal structures which the

organization controls, including rules and resources, are tools used to determine human behavior

(Giddens, 1984). These attempts to regulate professional role identity may cause tension within

an individual, which then serves as the stimulus for identity work (Alvesson & Willmott, 2002).

In contrast, it appears the participants in this study were not subjected to direct, formal, or

highly structured methods to regulate their leader identity during their transition from clinical to

leadership positions. In contrast, there was a distinct absence noted in terms of the formal

provision or withholding of structures by the organization. In further contrast with the conceptual

framework for this study, it was the absence of highly structured or formalized attempts at

organizational identity regulation which stimulated identity work in the study participants, not

the presence of it.

Charting Their Own Path

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In response to the lack of highly regimented and formal efforts by their organizations to

regulate their leader identities, the study participants were left to chart their own path toward

making meaning of their professional role identities during the transition. For Sarah, her

leadership position was newly created, requiring her to develop her own path toward becoming a

leader. Sarah recalled her position was a “brand new role, so the expectations, even though they

were kind of clear, it was kind of a wild, wild, west.” But for Sarah, instead of this being a cause

for concern, it was an opportunity to develop into what she wanted to be. Sarah recalls the start

of her leadership role as “exciting to come in and exceed those written expectations and get to

meet all new people and be something that clinicians could really see and believe in.” In order to

exceed those written expectations and achieve her vision for the role and her program, Sarah

recognized a “sink or swim situation, and similarly I knew what the priorities were and what

tasks had to be done and it was just kind of like, okay, like, figure out what the priorities are for

today.” Bryan echoed Sarah’s experience. The lack of structure to his new position provided the

opportunity to chart his own path. Bryan responded, “It took me a while to find purpose and

something that go me excited to get up and get going.” Bryan did, however, find his purpose,

albeit on his own terms.

Stacy and Melissa experienced a similar need to chart their own course toward

developing their leader identities. Stacy put in plainly, stating, “I had decided that I needed to

have, I needed to create my own destiny in some way.” For Melissa, charting her own path as a

leader involved taking seemingly mundane management tasks and finding ways to put her own

spin on them. Melissa recalls a time when she needed to implement an outcome tracking measure

in the electronic medical record. Instead of implementing the measure the same way as others in

her organization, Melissa:

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Tried to structure things a different way … used a lot of like humor in congratulating and

calling out people in our interdisciplinary team meeting and kind of it became like a

running joke … I feel like I did it in kind of this relaxed manner that works for the team

… and got us to the target.

Melissa made meaning of her professional role identity by comparing her natural way of doing

things to the predominantly more aggressive styles of her fellow managers. Instead of trying to

be like them, Melissa charted her own path forward by altering the job to fit her strengths.

Ultimately, Melissa reflected, “I’m definitely more of a quieter voice overall, but one that’s

really well respected.” Doug also strove for authenticity when charting his own path during the

leadership transition. Doug reported a close mentoring relationship with the supervisor whose

role he was filling after she was promoted. Despite this close mentoring relationship, Doug felt

the need to chart his own path as a leader, stating, “I let my teams know as soon as I took over

this role and I was not trying to replace her, I can never be who she was, the only thing that I

could be was myself.”

For Amanda, charting her own path came naturally. She had charted her own path before

as a student and as a new graduate. This past experience allowed Amanda to make meaning of

her professional role identity when the transition to a leadership position began with misleading

guidance from the prior manager. Amanda recalled, “just like I had to figure out my path as a

clinician on what I was comfortable with and which way I was going to be a clinician, I had to

do the same thing as the manager.” Amanda, “felt like if I wanted to do something I was going to

figure out a way to do it, even if it was different than what other people were telling me I should

have been looking at.” Ultimately, Amanda stated, “I’m going to do the things that I need to do

to get to where I want to be.”

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For Nicole, charting her own path meant learning to complete her work in a different

way. As a leader, Nicole needed to “learn a different way to do it because just taking it from

them … So, it’s been a very good challenge for me to have to find different avenues to solve

those problems other than … just doing it.” Ultimately, Bryan summed up the subtheme of

charting one’s own path when he stated, “I can’t say I get it or ask for a lot of feedback from my

boss … the reason I left my last company was because they were kind of poking around in my

business too much.”

The participants in this study engaged in identity work by charting their own path during

the transition from clinical to leadership positions. Identity work includes revising an existing

professional role identity in response to a stimulus (Alvesson & Willmott, 2002). In the case of

these PTs, one of the stimuli was a lack of organizational attempts to regulate the participants’

professional role identity through highly structured and formalized use of structures (Giddens,

1984). Instead, a key stimulus for identity work was the lack of such guidance. As a result, the

PTs in this study leveraged their unique and autonomous nature as PTs to chart their own path.

Professional autonomy is a key component of healthcare professional role identity noted by

Fitzgerald (2020). In many ways, the ability to engage in identity work in an autonomous manner

played to the strengths of the participants in this study. This finding is consistent with the

conceptual framework of this study. Alvesson and Willmott (2002) noted the rules of identity

regulation and identity work are improvised rather than scripted, while Ibarra (1999) found

societal regulation and the subsequent identity work which results were a negotiated process. By

charting their own path, the participants in this study were negotiating the process and exercising

autonomy over it.

Getting Things Done

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A final way in which the physical therapists in this study exercised autonomy over the

development of their leadership identity when transitioning out of full-time patient care was

simply putting the work in and getting things done. Finding a way to get things done, to

accomplish one’s work, and to achieve one’s goals was a trait all of the participants saw in

themselves. Several of the participants felt this trait was a direct translation from their time in

clinical care.

For Sarah, the lack of guidance in terms of her leadership position stimulated the need to

get going and figure out a way to get the work finished. Sarah recalled, “That first week, coming

in to sit at my desk and I was like, is there any training or anything, right? No. It was just do your

stuff.” Which is how Sarah opted to navigate the situation. She developed her own workflows,

processes, and curricula. Melissa, despite having a supervisor she respected and felt supported

by, still needed to take the initiative to find a way to complete her work. Obtaining the resources

needed for her team required Melissa “working with other sites to learn where my knowledge

gaps were, and kind of a lot of like self-learning and taking initiative.”

Taking initiative and remaining persistent were key for the participants in this study to

realize success in constructing their leader identities. Stacy reported, “there has to be a tenacity”

when describing physical therapists. Stacy leveraged this tenacity to navigate a difficult

transition which involved opening new clinical sites within her first few months of taking on her

new leadership position. Stacy felt this tenacity and tendency to simply put the work in came

from “doing really hard work” as a clinician. She recalled, “Some of the jobs I had … I can’t

believe I ever did. And I look back and think wow, that took some, really some inner gumption

you to, to just stick it out.”

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Amanda echoed this point, noting how an attitude of getting things done was part of her

physical therapist leader identity which she cultivated. Nurse’s aides on Amanda’s unit often

came to her, because “The aides feel, definitely, I’m not going to let something just kind of sit if

it needs to be done.” Doug felt this mentality was common amongst all the physical therapists he

worked with, stating, “PTs have the mentality of just getting things done.” Like Amanda, Doug

used this mentality when exercising autonomy over the development of his leader identity,

stating, “people know they can come to me they know that I'm going to act on whatever they

need me to act on and I'll follow through.”

Katelynn also noted how not giving up and getting the hard work done was a mentality

she used to construct her leader identity. Like Doug, Katelynn felt “PT in particular is almost like

a pit bull, we don’t give up, we don’t let up, we keep hounding.” Simply getting things done and

not giving up was key to the way Katelynn made meaning of her professional role identity when

transitioning into leadership. Katelynn described an early success in her leadership role. She was

working to reduce extraneous work done by her therapy team so they could focus on seeing more

patients during the day and meeting what Katelynn believed was a reasonable productivity

expectation of their organization. One physical therapist regularly had difficulty meeting the

expectation and even voiced how it was not possible. Katelynn "didn’t let it go … you know like

a dog with a bone … every month, yeah, she’d have to come in my office, and we talked about

it.” Ultimately, the therapist met the expectation and did so with pride and thanks for Katelynn’s

relentless efforts and support. Katelynn made meaning of her leader identity by getting the work

done. As a result, Katelynn viewed herself as “still in the trenches, a doer.”

Getting things done represented a key component of the physical therapist clinical

professional role identity of the participants in this study. The participants consistently
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recognized PTs as the providers on the healthcare team which focus on achieving results and

getting the work done, often with a commitment and tenacity which stood out from others on the

healthcare team. The participants in this study used this component of their existing professional

role identity to inform identity work during their role transition. When faced with a lack of

specific organizational identity regulation, the participants responded by putting in the work,

taking initiative, and remaining committed to getting things done in their leader role in order to

achieve the expected results for their teams and the patients being cared for. In doing so, they

crafted a leadership identity which maintained this component of professional role identity in

their new, provisional leader identity.

Theme 5: Recognizing Consistency Between Physical Therapist and Leader Roles

In order to make meaning of their professional role identity when transitioning from full-

time clinical care to a leadership position, the physical therapists in this study recognized the

consistency between their roles as physical therapists and their roles as leaders. While the

participants recognized the value of their clinical skills in a leadership context, their recognition

of consistency between clinical care and leadership was also noted on a more conceptual level.

The physical therapist’s focus on service and a commitment to values also helped the participants

in this study make connections between their roles in patient care and their roles as new leaders.

In order to make meaning of their professional role identity when transitioning from patient care

to leadership positions, the participants in this study recognized how their clinical skill set was

applicable to organizational leadership, recognized how clinical work and leadership both focus

on service to others, and recognized the alignment between their organization’s values and their

values as a person and as a physical therapist.

Recognizing a Clinical Skill Set is Applicable to Organizational Leadership

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The participants in this study recognized the applicability of their physical therapy

clinical skill set to the leadership positions they transitioned into. More specifically, study

participants recognized core skills which were foundational in the practice of physical therapy,

including strong affective skills, but also a more expansive, functional, inclusive, and global

approach to treating patients made them uniquely prepared to take on leadership roles in their

organizations.

Bryan noted the physical therapy approach to patient care and the manner in which he

was trained to view movement problems was uniquely applicable to a role in leadership. Bryan

noted, “For PTs in this role, we really kind of get the job, get the medicine, and so that helps us

really put a lot of energy into it versus others who maybe don’t as much.” More specifically,

Bryan discussed how physical therapy’s patient-first approach provided him the skills to succeed

in the leadership and business aspects of healthcare. Bryan noted how, “The kind of care we

provide to patients makes ourselves an interesting addition to the business landscape of

healthcare because we see a model that encourages patient empowerment … so I think our

medicine is uniquely positioned.” Stacy echoed Bryan’s thoughts concerning the patient-centered

approach and its applicability to leading others when she noted, “I think those were things that

were most important to me as a PT are collaboration with the patient, collaboration with my

peers, treating everyone with respect you know, no matter what.” Melissa also noted how the

skills she used as a physical therapist were applicable to her role as a leader. Melissa stated, “I’m

using all of my skills as a PT but also as a leader and sitting alongside other directors who don’t

have the background in therapy to help advise on how we bring these programs forward.” For

Melissa, Stacy, and Bryan, their skills as physical therapists in terms of a global and patient-
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centered approach offered them unique preparation to work in multi-disciplinary teams in

healthcare leadership.

In addition to the general mindset and approach to patient care, many participants also

cited specific skill sets which were vital to their success as clinical physical therapists being vital

to their performance as leaders. Bryan noted how “one of the skills I use is conflict resolution,”

drawing a parallel to patient care when he reported, “it’s sort of akin to talking to a patient who

doesn’t want to do their home program.” With clinical preparation being his only formal

educational preparation, Bryan found ways to apply his clinical skillset to leadership. Bryan

noted, “I’ve never been through a business program or an MBA program so … I think everything

I employ probably in some facet has been from my clinical training because that’s all I have.”

Several participants noted the leadership value of the affective skills honed when

providing patient care. When discussing her skills as a leader, Nicole reported, “I think it’s very

similar. I mean it’s all the time, like, it’s just structuring interactions and communications,”

adding, “it’s very similar to how I’ve always viewed it, it’s just on a different scale and with

different audiences.” For Melissa, the affective skills acquired as a practicing PT were uniquely

applicable to her transition into leadership. She noted, “The communication and emotional

intelligence that were really required as a PT I think helped, have influenced a lot of my role as a

leader.” Echoing the observations of Nicole and Melissa, Amanda reported her clinical PT work

prepared her to “be able to have those conversations with a lot of different people that have a lot

of different educational background and knowledge of what you’re talking about.”

Stacy and Katelynn also found additional consistencies in their clinical and leadership

skill sets. Stacy recognized the unique knowledge of billing and coding acquired during clinical

care was a necessity for a PT leader. Katelynn relied on the strong focus of physical therapists as
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patient educators and how it translated into her role as a leader when she stated, “if it’s

education, I definitely rely on my past experience when I was a full-time therapist.”

Ultimately, identity work will produce, alter, or sustain a professional role identity to fit

the new role once a transition has occurred (Alvesson & Willmott, 2002). For the participants in

this study, the applicability of their clinical skill set to their leadership roles sustained a key

component of their previous professional role identity. Fitzgerald (2020) noted that knowledge

and skills were key components of a health care professional’s role identity. Through identity

work, the participants in this study recognized the applicability of their existing clinical skills

within the new role of leader. The result of this recognition was to sustain a key component of

their professional role identity as PTs, and in doing so, cement the acceptance of their new role

as leaders. Because there was a lack of highly structured onboarding, the participants used their

existing skill sets when engaging in identity work. Drawing this parallel between prior role and

new role resulted in a new provisional identity which was not in conflict with their prior, PT

professional role identity.

Recognizing Clinical Work and Leadership Work Focus on Service to Others

While the participants in this study recognized the applicability of specific clinical skill

sets to their leadership roles, they also recognized consistency between their clinical and

leadership roles on a more conceptual level. Specifically, the physical therapists in this study

drew parallels between the service mentality of a clinical PT and the service mentality required

of a healthcare leader.

The role of advocacy was a commonly reported aspect of this subtheme. Stacy reported a

strong focus on advocacy for the profession, for her staff, and for patients. She recognized the

consistency between this approach as a leader and her prior approach as a clinical PT. Stacy
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noted how “people have kind of the same motivations to support their team,” comparing it to the

way in which she was motivated to “support their patients, to be accountable, to be trustworthy.”

As a leader, Stacy saw herself as “An advocate for sure, for, you know, like recognition as far as

access to services … that’s something I am a strong proponent for and will speak out and I

definitely try to engage my staff.”

The theme of advocacy in both patient care and in leadership was also reported by

Katelynn and Amanda. Katelynn described physical therapists by stating, “We don’t settle for

substandard care and we’re big patient advocates.” This statement correlated directly with her

approach as a new leader when she described herself as, “Still a huge advocate, but also an

employee advocate.” As a leader, Katelynn saw one of her core responsibilities as making “staff

to feel like they’re being listened to. I care about what their concerns are. I try to make their lives

easier.” Amanda put in more succinctly when she stated, “Leadership means being, being an

advocate for your staff and for your patients.”

For Nicole, the focus on serving others as a leader was linked more viscerally with what

drove her to become a physical therapist. Nicole described this strong connection:

I’ve really been drawn to alleviating somebody’s anxiety or discontentment. I mean in

clinical practice that’s my favorite thing … and so to like transfer that skill a little bit it’s

like, I mean, my little fix out of watching my clinical manager be like, you helped me …

that is really fun for me.

Melissa and Sarah both drew parallels between the service mentality of PT patient care

and the role it played in strengthening the organization. Melissa described how she truly loved

“influencing the clinic and the culture and seeing what a big difference that has on the ultimate

care that we provide others.” Sarah linked her service mentality as a PT to her service mentality
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as a leader and how a focus on service buffered the focus on business management that her

leadership role required:

I think it comes back to just my values of you know caring and putting patients first. And,

you know, even though it is a business, like, if you keep, you know, taking care of

patients they will come back and take care of you.

Doug provided the clearest example of a service mentality and how it carried over from

his physical therapy clinical practice to his practice as a leader. Doug described how he felt his

service focus was “pretty consistent, because I wanted to be the best clinician for my patients …

My thought process is still the same. I want to be the best leader that I can be and the best

manager that I can be for those that I’m supervising.” Ultimately, Doug wanted to help

“everybody who walks through this door as an employee to experience what I’ve experienced as

a clinician.”

Much like the applicability of clinical skill sets to leadership, the consistent focus on

service to others in both clinical and leadership roles allowed participants to retain an aspect of

their PT professional role identity during the construction of their leadership identities. Unlike

the consistency in skills sets, however, the recognition of consistency in focus on others also

represents a revision of the existing professional role identity as a result of identity work. As the

representative quotations indicate, participants revised their professional role identity to include

their team members under the scope of “others” they are focused on serving. Individuals with

strong and rigid identity beliefs may be more likely to attempt to adjust a role to fit their existing

identity (Ashforth & Saks, 1995; Ashforth et al., 2008). As noted in theme one however, the

physical therapists in this study began with professional identities characterized by flexibility and

adaptability. As a result, once they recognized the consistent focus on serving others between
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their clinical identity and developing leader identity by engaging in identity work, they were able

to revise their existing professional role identity to encompass a broader definition of “others.”

Recognizing the Alignment of Organizational Values with Clinical and Personal Values

The participants in this study also recognized the alignment of their organization’s values

with the values they held as physical therapists and as individuals. For the physical therapists in

this study, clearly stated organizational values which placed the patient at the forefront of all

organizational decisions allowed for consistency in the decision-making process. The

participants also recognized the alignment of a patient-first organizational value system with

their values as physical therapists. In turn, those same values are what led them to their physical

therapy careers originally. The recognition of this alignment was a consistent subtheme amongst

participants as they began to recognize the consistency between their roles as PTs and their roles

as leaders.

For some of the participants, the values of their organization were always present, visible,

and at top of mind as they made meaning of their professional role identity. Melissa stated it

simply when she asked about her organization’s values. Melissa noted, “I’m okay with it. I really

identify with [employer’s] mission. It’s to improve the health of those we serve and that’s

something that I feel really strongly about.” Stacy stated she, “really wanted to work for this

organization because I felt like I identified with it.”

Nicole also noted how the patient-first mentality of her organization “makes a lot of the

decisions clear in terms of when you’re trying to talk about what should we make the standard

be.” When making decisions in her new leadership role, Nicole felt. “If I have those principles

top of mind, that sometimes it does make what feels like a hard decision a little bit easier.”
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Nicole’s comments highlight how the clarity of her organization’s value system and its

alignment with her own have facilitated her development as a leader.

Doug also recognized how his organization’s value system was consistent with his

personal values and his values as a physical therapist. Like Nicole, the value system of Doug’s

organization was consciously present in everything he did. Doug described, “The other thing

that, that I have found in this organization is we have a mantra and that mantra’s ‘patients first.’

So, we really put the needs of the patient at the forefront of everything we do.” Doug went on to

explain how “the values that the hospital has, and my core values are very, very well-aligned.”

Doug’s experience was echoed by Katelynn who described how even the policies and procedures

of her organization allowed for alignment between the values of the organization and her values

as a PT and an individual:

If there’s anything that’s left to interpret or I have to use that clinical judgment, it would

line up with our policy because that’s just how [employer] is. Ultimately, it’s about the

patient and keeping them safe and staff safe.

In describing her organization’s values, Katelynn went on to state, “I think they line up well …

and ultimately as a PT we want the patient to have the best experience.”

Amanda frequently described herself in the interviews as a strong and outspoken patient

advocate. She noted how, at times, her vocal and tenacious patient-first mentality would manifest

as a disagreement with other members of the care team. Amanda drew strength in her leadership

role by recognizing the consistency between her approach and that of her organization:

I think [employer’s] main expectation is for every staff member to do what’s best for the

patient and within our own roles of licensing or, you know, title. That looks different for
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everybody, but from my perspective it’s making sure that the patient’s having any needs

physically are identified.

The response of Amanda’s leadership team to her patient-first approach reinforced the

consistency between her values as a person and a PT and those of her organization:

My CEO has said that if you feel like you’re doing what’s right for the patient, even if it

ends up being something that you may have pushed a little too much you know, you’re,

you’re trying to do what’s best for the patient and you’re never going to be seriously

reprimanded.

For Bryan, it was the lack of consistency between his core personal and professional

values and what he perceived to be the values and behaviors of his employer which led him to

leave a prior position. Bryan recalled how his former employer was bought out by a larger PT

corporation. After only six months, Bryan “realized really quickly it was an environment I didn't

want to be in.” Bryan left and went to work for his current employer where he recognized

consistency between their value system and his own. This consistency has allowed Bryan to

advance to greater leadership responsibilities in the organization.

For Sarah, recognizing the consistency between her values as a person and a PT and the

values of her organization allowed her the freedom to make leadership decisions without needing

to worry about conflicting priorities. In fact, Sarah had difficulty naming her organization’s core

values at first. Instead, the consistency between value sets came naturally. Sarah described how,

“it’s never honestly at the forefront. I mean I think my personal values line up relatively well

with the company’s core values, so I think it’s just something that blends really nicely.”

The recognition of alignment between organizational, clinical, and personal value

represents another result of identity work when viewed from the perspective of the conceptual
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framework of this study (Alvesson & Willmott, 2002). Identity work is stimulated by a role

transition and the outcome of identity work sustains or alters the existing professional role

identity, or produces a new role identity. One means of identity regulation, which influences

identity work, is the control of rules and resources by the organization (Alvesson & Willmott,

2002; Giddens, 1984). In the case of this theme, organizational values are a defined set of rules

which leaders/managers in the organization are expected to exemplify, promote, and possibly

even enforce. As such, the organizational values are a set of rules controlled by the organization

which influence the process of identity work by the physical therapist occupying a new

leadership role. By recognizing the consistency between their personal, clinician, and

organizational value sets, the participants in this study avoided role conflict and accepted the

development of a leader component to their professional role identity while being able to retain

an important aspect of their existing professional role identity as a clinician.

Theme 6: Establishing a Professional Identity Informed By, but not Bound By, Their

Physical Therapist Identity

Ultimately, the physical therapists in this study made meaning of their professional role

identity when transitioning into leadership positions by using their physical therapist identity to

inform but not limit the development of their professional role identity in a leadership position.

The participants’ professional role identity as a physical therapist was not abandoned. Instead,

the participants continued to see themselves as physical therapists, but their role as physical

therapists no longer represented the singular dominant component of their identity. Instead, their

identity as physical therapists formed the foundation upon which the participants developed a

leader identity. The professional role identity established by the study participants as they

transitioned from clinical to leadership positions included becoming the “go to” person for their
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teams, having a foot in both worlds of PT and leadership, redefining what it meant to be

successful in their new role, and expanding their focus beyond the more limited scope of a

physical therapist.

Becoming the “Go To” Person

For the participants in this study, establishing a professional role identity in their

leadership positions meant cultivating and ultimately accepting their role as the “go to” person

for their respective departments. The participants experienced this increased responsibility in

myriad ways. For several participants, being the “go to” person meant an increased sense of

accountability and leading by example. Katelynn described how she “would never ask of them

something that I couldn’t personally do myself.” Katelynn referenced this level of personal

accountability when describing how she led by example and assisted a fellow therapist with

improving her productivity. By demonstrating competency as a clinician and using that

competency to inform her leadership, Katelynn began to “feel like I’m the fixer.” Bryan also

chose to lead by example, an action which helped him cement his reputation as the “go to”

person. Bryan described a good leader as “Someone who, at first, does … who practices what

they preach, whether it’s in the clinic or what have you.” By establishing credibility in this way,

Bryan hoped team members would “be able to come to me … that’s a sign that I’m, that they

trust me a little bit, again, when they’re struggling, or something doesn’t make sense.”

Amanda expressed a similar sentiment. She felt, “As a leader everybody is looking at you

to do the right thing all the time and making the right decisions and being that person that they

look to when they don’t know what to do.” In order to establish a leader identity, Amanda had to:

Find a way to center yourself and regroup without necessarily having that venting cohort

that you had when you were a clinician … It may not be great it may not be going as I
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want but I can't sit here and complain about it. I've got to just do it I've got to figure out a

way to do it.

This increased sense of accountability was confirmed by other participants as well. When asked

about the skills needed in her leadership role, Sarah simply stated, “accountability is a big one,”

while Melissa described how she was now “the person who’s ultimately responsible for

everything that goes on.” Much like Amanda, Stacy also felt the weight of becoming the “go to”

person and how the responsibility and accountability aspects were distinctly different from that

of a clinical PT. Stacy described herself as “the knowledge owner of so many things.” This

responsibility left her feeling like a target, noting, “I’m in leadership and in leadership you’ll

always have a target on your back.” Much like Amanda, who noted the loss of her “venting

cohort” when dealing with the weight of the increased responsibility, Stacy also noted, “As

leaders you’re not given the bandwidth to also struggle, you’re supposed to just carry on.”

Katelynn and Amanda also noted how becoming the “go to” person extended beyond the

scope of their direct reports. They also became “go to” people for all things therapy-related

within the broader leadership structure. Katelynn described how she became “the delegate for the

therapy team,” while Amanda noted how her new leadership identity:

amplifies the expert in our field sort of thing as a leader. Your put more in that

magnifying glass for the knowledge that you have … I am now the go to voice for the

department. There is a little bit more weight I guess that’s put to it in that leadership role.

Ultimately, becoming the “go to” person for their teams and their organizations meant an

acceptance of the increased accountability and acceptance of responsibility for a scope of work

which was greater than that for which they were responsible as practicing clinical physical

therapists. For Doug, this meant becoming “a stabilizing force,” someone who could “stabilize
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the environment, stabilize the feelings around here.” For Nicole, this meant accepting that she

was the best suited individual on the team to step up and become that “go to” person. Nicole felt,

“as long as like I’m the person that’s best suited for that and I’m the, so I have very much felt

that responsibility, like if I’m the best person to go and execute that, I feel really comfortable

there.”

Becoming the “go to” person is one result of the identity work engaged in by the

participants in this study. Identity work produces, alters, or sustains the professional role identity

to fit the new role (Alvesson & Willmott, 2002). In this case, the increased focus on the

participants’ actions as leaders, the increased responsibility, and being accountable for setting the

standard for their respective departments resulted in the production of a new professional role

identity. This new professional role identity was one which challenged the physical therapists in

this study to take responsibility for leadership and actions of an entire team instead of being

limited in responsibility for their individual professional actions. When considered in the realm

of Fitzgerald’s (2020) components of healthcare professional identity, the participants redefined

their personal identity as separate, but still associated with, their professional cohort of physical

therapists.

Having a Foot in Both Worlds

All of the participants in this study recognized the transitional nature of their professional

role identity. While each participant noted their growth, development, and progression beyond

the bounds of an exclusively clinical role into a leader role, their professional role identity

continued to be linked to their identity as physical therapists. This ongoing linkage impacted the

establishment of their new professional role identity by requiring the participants to transition
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back and forth between roles and, often times, inhabit both worlds simultaneously in order to be

effective.

Despite the majority of his time being spent primarily in leadership and management

activities, Bryan felt the ability to retain a foot in both worlds had strengthened the establishment

of his new professional role identity. While trying to stay on top of current concepts, ultimately

Bryan saw himself as “that operations slash clinical person.” He noted how still being “in clinic

adds a unique portion to this because I think that influences a lot of the decisions that I can help

contribute because I have at least the context of how it’ll hit someone working in the trenches.”

Katelynn and Amanda, both working hybrid patient care/leadership positions, noted the

need to inhabit both worlds simultaneously and even float back and forth between their two

identities distinctly. Katelynn noted, “Some days I’m more of a therapist and other days I’m

definitely more managerial.” Likewise, Amanda reported, “There’s times where the leadership

things get pushed to the back burner because the patient care needs to be done.” For both

Katelynn and Amanda, inhabiting both worlds simultaneously required flexibility. Amanda

spoke of how she needed “to be flexible and you have to be able to change gears at a moment’s

notice or do multiple things at the same time,” while Katelynn felt, “like it’s a balancing act

between corporate, their goals, values, and being on model versus the reality of this is what can

be accomplished.” The balancing act of inhabiting two roles simultaneously was a learning

process, one which stimulated the establishment of a new professional role identity. Katelynn

noted, “I still see patients, but I feel like I’m almost more of an educator,” and having one year of

leadership experience meant she was “evolving and maturing as a leader.”

Doug described a similar feeling of inhabiting two different worlds but feeling the

evolution of his professional role identity into something new, something which was no longer
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exclusively within the realm of patient care. Doug described, “Even though I’m still treating

patients, and I still love doing that, my leadership skills right now need to be the focus of what I

do and not so much being a PT.” Doug saw himself “as a growing leader.”

The evolution beyond strictly a clinical focus was shared by the other participants as

well. Sarah cited the “opportunities for growth both personal and business growth” as a stimulus

for establishing an identity still grounded in physical therapy but no longer bound by it. Sarah

described how she was “still learning more about the business and about, you know, how to

manage people and conflict resolution.” While accepting this growth, Sarah retained her footing

in physical therapy as a reference point, seeing herself “As evolving, I, you know, I’ve taken my

PT worlds and my education world and kind of combined those two.”

Nicole, Melissa, and Stacy provided additional examples of how participants in this study

were operating with a foot in both worlds, but also establishing a professional role identity no

longer bound exclusively by their PT identity. Of her new leadership position, Nicole quite

plainly stated, “I thought I would miss my clinical practice a lot more. So that part has been

really good.” Melissa noted how she began to:

put a little more focus more from what I need from my [employer name] side just

because, you know, I’m so new in my role now, but I feel like I’m really focused on that

development … I think more organizationally-focused.

Melissa went on to describe, “at heart I still really view myself as a neurological physical

therapist who has a really strong passion for taking care of patients. I just approach it a little

differently than I used to.”

Stacy also inhabited both worlds as a PT and a leader. However, Stacy’s evolution had

advanced even further toward the establishment of a professional role identity that, while still
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informed by PT, was most certainly not bound by it any longer. Stacy described how she was

“getting a little more distance from, you know, PT.” In fact, Stacy had experimented with no

longer using the acronym “PT” after her name. Stacy noted how:

I, often times, will drop PT after my name in communications. You know, like, I do feel

like I’m more … like I don’t need that little added identity because I’m a manager … my

identity is in this role as manager.

The subtheme “having a foot in both worlds” is consistent with Alvesson and Willmott’s

(2002) description of role identity as a “precarious outcome” of identity work. Within the

conceptual framework of this study, professional role identity is not fixed or permanent, it is

malleable. Professional role identity is consistently exposed to stimuli which may provoke the

onset of identity work to form, repair, maintain, or revise an ongoing narrative of self (Alvesson

& Willmott, 2002). By occupying, and at times moving between, the clinical and the

leadership/management worlds, the participants in this study occupy a liminal state which is not

completely defined by membership in either. Instead, the participants occupy what Ibarra (1999)

described as a “provisional self”, one which the participants try on and assess its fit to the

situation without completely abandoning a prior self completely.

The provisional self, this precarious outcome of identity work, at first may appear to

conflict with a key component of Fitzgerald’s (2020) concept of healthcare professional role

identity, context. Healthcare professional role identity is defined, in part, by what differentiates it

from other groups, the concept of exclusivity in the context of the healthcare team. This concept

of exclusivity may seem to conflict with the subtheme of occupying two different worlds.

However, occupying two different worlds may in fact serve as evidence of a new and updated

professional role identity, given that participants have moved away from their unique physical
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therapist identity and instead are defining themselves as part of a new and separate group, albeit

provisional and evolving in nature.

Redefining Success in Their New Role

For each of the participants, establishing a professional role identity as leaders meant

finding ways to measure success in their new positions. As physical therapists in full-time patient

care, success was measured in terms of patient outcomes and satisfaction. These outcomes were

readily apparent and easy to correlate directly with their actions as a clinical PT. In contrast, the

participants in this study felt the absence of this direct form of feedback in their new positions in

leadership. Given that being goal-oriented and motivated were characteristics which made these

individuals successful clinicians and ultimately led to being recognized as leaders, the absence of

directly visibly measures of success required the participants to redefine how they perceived

success in their new leadership roles.

For several participants, the loss of an immediate measure of success in terms of patient

outcomes was the stimulus for this redefinition. Melissa described this challenge when she

stated:

Some of the progress is a lot slower in what we’re achieving. You know, you see a

patient in ten visits and can really make those huge remarkable changes in their moving

around. In leadership I feel like some of the things we’re working on just take a lot more

time.

Nicole noted the loss of an immediate measure of success as well, noting:

One thing that’s different, very inconsistent, is it was easy for me before to know if I was

doing a good job ... Now my interactions are less frequent and more spread out with the
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people that report to me … You do a lot of things without seeing the consequences as

quickly.

Doug always gauged success in his role as a full-time clinician by listening for the success

stories of his patients. For Doug, “The stories are a little bit more delayed. When you're working

with patients and you see progress in patients, your stories are happening constantly through the

course of your day. Now the stories have a longer timeframe to go.”

For all of the participants in this study, considering themselves successful in their new

roles meant still bringing about positive changes for patients, but redefining the manner in which

those successes were achieved. In order to establish a professional role identity informed by their

PT identity, but not restricted by it, the participants in this study redefined success to include the

outcomes of their entire department and all the patients whose lives were touched by it. Melissa

noted how her efforts as a leader allowed her “to impact so many more patients and take that

better care of them as a result, and then even, it’s really cool to be able to use some of my

expertise and skills as a therapist to help guide the program.” Using those skills as a PT, but in a

more expansive manner, allowed Melissa to recognize how many more people she was able “to

impact through some of this work. But it really took kind of my skills as a therapist to be able to

create that from a leadership perspective to impact more people.” Bryan also noted how he now

had “the opportunity, instead, of creating impact for folks I haven’t even met before.” Doing so,

however, required Bryan “to sort of reconsider how I felt like I was being, again, how I’m

successful.”

For Stacy, Katelynn, and Sarah, redefining success meant no longer linking their success

to patient care but, instead, linking success to the performance of their team. Stacy found

satisfaction in helping her individual clinic managers “feel successful in that which makes them
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be seen as a stronger leader in their own department. So, I feel like that’s something I’ve worked

really hard on.” Katelynn noted how her “satisfaction isn’t my relationship, my patient, it’s kind

of more global. How is my team … as far as getting patients home versus SNF or inpatient rehab

you know, the therapists under me, how well are they doing?” Katelynn went on to say, “It’s not

necessarily like patients or an individual person. It’s more like the floor itself or the whole staff,

it's more global I guess versus just a specific patient.” Sarah put it in a more straightforward

manner when she stated, “Instead of, you know, my own success stories, I am proud when I hear

other success stories, clinicians emailing me.”

By redefining success in terms of the success of their teams and the ability to impact a

larger number of patients, the participants in this study leverage two key components of their

prior clinical identities, a focus on relationships and alignment with their organization. As such,

the participants’ used group identity as a means of defining their professional role identity as

leader, identifying with their organization and team instead of strictly identifying with their

professional identity as members of the PT profession (Fitzgerald, 2020). By redefining how

they perceive success in their leadership position, the participants in this study demonstrated the

results of identity work. They have revised their clinical PT identity, using it as a foundation for

redefining how they perceive success. The participants do not abandon that component of their

identity, but instead revise it to better fit the role of leader within their departments and their

overall organization. This revision lends further support to their professional role identity as

leaders being a new role identity, the result of identity work, distinct but not fully divorced from

their prior professional role identity (Alvesson & Willmott, 2002).

Expanding Their Focus

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A final aspect of establishing their professional role identity as leaders involved

expanding the focus of their work, and thus their identity, beyond the confines of physical

therapy clinical practice. Because the participants were now in positions which required

interprofessional collaboration and a more global approach in order to realize success, they

needed to expand the focus of their work to include other disciplines for which they were now

responsible. Additionally, the participants in the study were also required to expand their focus

beyond the confines of rehabilitative services and to begin to consider how their actions affected

the larger organization.

For Katelynn and Amanda, working in similar hospital environments which required the

need for collaborative care in order to achieve patient outcomes, establishing a professional role

identity in their leadership role required an expansion beyond the confines of a PT-only

viewpoint. Katelynn described how she worked “very closely with the respiratory manager and

CNO, and ultimately we work together.” Amanda noted, “Not only do I need to be

knowledgeable in my area, I need to be knowledgeable in what’s going on with OT and what’s

going on with speech.” Additionally, Amanda found, in her leader role, the need to “look outside

your scope … to look at more than just the therapy piece.” By engaging with the entire

healthcare team and considering aspects of how the team functioned outside of physical therapy,

Amanda found her:

clinical identity has expanded. It has encompassed a whole lot more than being a

clinician, but that center point is always being a PT. That’s the reason I enter the room

most times as the PT, but there’s so many more aspects that I can be involved in.

Doug, also working in a hospital environment, experienced a similar need to expand his focus

beyond PT. As a therapist, Doug’s “goal was to be the best PT in the moment that I could be.”
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By transitioning into leadership, Doug noted the need “in this role to have that broader view.” He

noted how, “now my leadership is more expansive because now, not only is it my service areas

and the rehab facility, but it’s the larger organization as well. So, my role has expanded.”

The experience of expanding one’s focus in order to establish a professional role identity

in leadership was shared by participants working in different environments as well. Bryan found,

“one of the bigger challenges in my specific company working for a multidisciplinary group is

working with other departments. So, collaboration, teamwork, and trying to understand the

perspective of someone else.” To accomplish this, Bryan needed to expand not only his skill set

but also expand the focus of his professional role identity. In his new role, Bryan, “can see things

from a little higher up and I see more perspective across the landscape.” Like Bryan, Melissa

also found the need to operate with an expanded focus in order to establish a professional role

identity consistent with the needs of her new role. Comparing her new role to her role

exclusively in clinical practice, Melissa recalled, “Before, you know, I was, I had one patient in

front of me at a time and it was a little more clear,” describing how now, “When you step back

and you’re making decisions for a broader team or making decisions that are really impacting the

program going forward, it’s just a lot more things to consider.”

Interestingly, the expansion of focus was also experienced by participants working in

private organizations which were exclusively PT-owned and operated. Sarah noted how, in her

new position, “there’s a lot of interdepartmental collaboration that goes on here.” Nicole found

that taking a more expansive focus as a leader came naturally. She described how “Often PTs are

the people who have the skill set to like coordinate care and see the whole picture and direct the

patient. I mean, they’re like the one who gets all the time with them and figures out maybe what
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they really need.” For Nicole, her professional role identity as a physical therapist provided the

foundation on which she went on to build the more expansive focus required of her as a leader.

By expanding their focus beyond the bounds of their PT professional role identity, the

participants in this study demonstrated a new professional role identity, grounded in the basic

tenets of their prior identity as PTs, but no longer bound by them. One possible outcome of

identity work is the revision of an existing professional role identity (Alvesson & Willmott,

2002). None of the participants abandoned their prior identity as physical therapists. Instead, they

revised the existing identity to focus on issues outside the immediate realm of clinical PT patient

care, creating a new and distinct professional role identity. A key component of healthcare

professional role identity is the concept of exclusivity, identifying oneself as a professional based

not only by what one does, but also by what does not do or who one is not (Fitzgerald, 2020). In

contrast, the participants in this study retain their connection to the PT profession while

expanding their role identity to encompass the concerns of other professionals as well as the

overarching needs of the organization as a whole. Their concept of inclusivity and exclusivity

becomes more organizationally-focused instead of professionally-focused, revealing the presence

of a new and distinct professional role identity (Alvesson & Willmott, 2002; Fitzgerald, 2020).

Summary

This chapter discussed the themes which emerged from the data analysis of the three-part

qualitative interviews completed with the eight physical therapist who participated in this study.

Six overarching themes were discussed, each with subthemes which provided further detail on

the development of the theme using representative quotations from the study participants. Each

subtheme was also described in relation to the integrated conceptual framework for this study

based on the works of Alvesson and Willmott (2002), Giddens (1984), and Fitzgerald (2020).
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CHAPTER 6
SUMMARY, DISCUSSION, RECOMMENDATIONS, CONCLUSION

This study sought to describe how physical therapists make meaning of their professional

role identity when transitioning from clinical to leadership positions. This chapter will provide a

summary of the research study and how the developed themes and subthemes answer the

research question. The chapter will also discuss how the findings of this study relate to the

existing literature on the topic, the study’s implications and recommendations for the physical

therapy profession, and avenues for future research.

Summary of the Study

Chapter one explored the gap in the literature and the problem of practice this study

sought to address. As the landscape of healthcare has changed, so has the need for healthcare

leaders with clinical backgrounds (Brocklehurst et al., 2013; Delmatoff & Lazarus, 2014;

Desveaux, 2015; Hamilton, 2008; Masoumi, 2019; Spehar et al., 2012; Wikstrom & Dellve,

2009). While the transition from clinician to leader has been studied in healthcare fields such as

nursing, medicine, and occupational therapy (Barrow et al., 2011; Camilleri, 2020; Fleming-

Castaldy & Patro, 2012; Heard, 2014; Krishnasamy et al., 2019; Masoumi, 2019; McGowan et

al., 2020; Phillips et al. et al., 2018; Shams et al., 2019; Sofritti, 2020; Sonnino, 2016; Spehar et

al., 2012; Young et al., 2018), there remains a deficiency in the literature concerning this

transition in physical therapy. The importance of successful clinician to leader transitions in

modern healthcare (Masoumi, 2019) coupled with the importance of physical therapy in modern

healthcare (Vore, 2019) and the dearth of literature on this topic in physical therapy created a

need for this study.

Chapter one also introduced the conceptual framework for this study, representing an

integrated framework based on the work of Alvesson and Willmott (2002) and incorporating the
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components of healthcare professional role identity established through grounded theory research

by Fitzgerald (2020). This integrated conceptual framework was used to frame the literature

review in chapter two and in data analysis later in the study.

Chapter two examined the literature related to why clinician leadership matters in

healthcare generally and physical therapy specifically, the current status of the leadership

literature in physical therapy, and issues with the clinician to leadership transition. The literature

reflected a growing need for healthcare professionals to assume roles in management and

leadership in order to balance the unique demands of patient-care and business practices (Barrow

et al., 2011; Brocklehurst et al., 2013; Desveaux, 2015; Gilmartin & D’Aunno, 2007; Kreindler

et al., 2012; Masoumi, 2019; Spyridonidis & Currie, 2016). Healthcare organizations which

successfully integrate clinicians into leadership and management generally enjoy improved

patient safety, improved business performance, decreased prevalence of medical errors,

improved healthcare quality and outcomes, and improved job satisfaction and employee retention

in nursing and physiotherapy (Aggarwal & Swanwick, 2015; Georgiou et al., 2021; Niemi et al.,

2018; Niki et al., 2021; Masoumi, 2019; Specchia et al, 2021). Looking specifically at physical

therapy, clinician leadership matters due to the growing recognition of PT as an important

component of moving away from the inefficiencies of fee-for-service care and toward a model of

value-based reimbursement (Vore, 2019). The use of physical therapy as a first-line treatment for

many common musculoskeletal conditions has been shown to lower overall cost of care, reduce

overall health resource utilization, improved outcomes, and reduce disability when compared to

other forms of medical care (Burge et al., 2016; Garrity et al., 2019; Hon et al., 2021; Vore,

2019).
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Despite the importance of clinician leadership to modern healthcare, leadership in

physical therapy remains an under-researched phenomenon (McGowan & Stokes, 2015;

McGowan & Stokes, 2017; Sebelski, 2020; Vore, 2019). The majority of physical therapy

leadership research centers around the identification of traits or competencies believed to be

important to physical therapists from a leadership perspective (Chan et al., 2015; Desveaux,

2015; Desveaux & Verrier, 2014, Desveaux et al., 2016; Lopopolo et al., 2004, McGowan &

Stokes, 2015; McGowan & Stokes, 2017; McGowan et al., 2019a, 2019b; Schafer, 2007). This

historic approach to studying physical therapy leadership leaves key gaps in the literature from a

more contextual view and continues to fail in terms of accurately describing leadership and its

importance in the PT profession (Sebelski, 2020). Likewise, the research on physical therapist

leader self-perception displayed mix results, with some indication that physical therapists

perceive of themselves as leaders and value leadership in the clinical realm, but fail to perceive

of themselves as leaders outside of patient care (Desveaux & Verrier, 2014; McGowan & Stokes,

2017; Rasmussen-Barr et al., 2019).

While the clinician to leader transition has received limited attention in physical therapy

(Glendinning, 1987), it has received attention in other healthcare fields. A review of the literature

found issues of insufficient training, mentorship, and succession planning, motivation to enter

leadership, and role identity conflict as potential reasons for ineffectiveness of first-time clinician

managers (Masoumi, 2019). Role identity conflict was examined in specific detail. Role identity

conflict may occur when a clinician transitions from patient care to leadership because of

significant socialization efforts which develop a strong identity as an individual performer and

the inherent conflict between the mindset of a professional as opposed to the more team and

organizationally-focused mindset of a leader and manager. How a healthcare provider navigates

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this role identity conflict may determine their level of success in transitioning into leadership

(Harviksen, 2021; Masoumi, 2019; Sofritti, 2020; Spyridonidis & Currie, 2016). Despite the

importance of professional role identity in the transition from healthcare provider to healthcare

leader, research on this topic in physical therapy remains almost non-existent.

A qualitative research approach was used to conduct this study as outlined in chapter

three. This approach was informed by a constructionist epistemology and an interpretivist

theoretical perspective. A phenomenological methodology was chosen in order to focus on the

lived experience of a phenomenon and the process of making meaning when experiencing the

phenomenon (Creswell & Poth, 2018; Merriam & Tisdell, 2016). Data collection was conducted

through the use of a three-part, semi-structured, qualitative interview. Additional data was

collected in the form of individual artifacts including resumes or curriculum vitae, job

descriptions, descriptions/syllabi of leadership trainings taken, and detailed examination of

audiovisual materials including organizational websites and online information. Data was

analyzed via qualitative coding. Open codes were assigned to each interview transcript, then

combined into focused/analytical codes before being consolidated into themes, using the

conceptual framework as a guide.

Chapter four described the 8 study participants in detail. All study participants were

physical therapists occupying their first leadership position, defined as no more than 60% patient

care and no less than 40% leadership responsibilities. The demographic makeup of the study

participants was presented in Table 4.1. Data analysis produced 6 themes, each containing

subthemes. Each of the developed themes independently answered the research question while

also presenting an overall picture of the lived experience of physical therapists transitioning from
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clinical to leadership positions and how they made meaning of their professional role identity

during this transition.

Summary Answers to the Research Question

The research question posed by this study was: How do physical therapists make

meaning of their professional role identity when transitioning from clinical to leadership

positions? Data analysis revealed six themes, including subthemes, which answered the research

question. This section will summarize how each theme and its associated subthemes addressed

the research question.

Theme 1: Beginning With a Strong Role Identity Focused on More Than Clinical Skills

The physical therapists in this study made meaning of their professional role identity

when transitioning from clinical to leadership positions by beginning with a strong role identity

which was focused on more than just clinical skills. The professional role identity possessed by

the study participants prior to transitioning into a leadership position was focused on more than

simply the clinical skills and professional membership which comprise a physical therapist’s

scope of practice. On the contrary, the pre-transition professional role identity of these physical

therapists centered around affective and interpersonal skills, a focus on growth, flexibility, and

an ever-expanding identity, alignment between self-identity, clinical identity, and leadership

identity, and alignment with their organization.

A Focus on Affective and Interpersonal Skills

The physical therapists in this study all identified the possession of excellent affective

and interpersonal skills as requirements for successful physical therapy practice. As a result,

these affective and interpersonal skills were routinely referenced as vital components of what

made the study participants physical therapists. When discussing skills, the possession of specific
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clinical skills was not referenced by a single participant, with only one participant referencing

the general identity of physical therapists as experts in biomechanics and anatomy as it relates to

movement. The physical therapists in this study considered this knowledge and skill base a pre-

requisite for entry and participation in the profession. When asked to describe the skills required

of a physical therapist, the study participants instead referenced key affective skills such as

communication, emotional intelligence, and the ability to establish trust and rapport with a

patient in order to develop a strong interpersonal relationship. These affective and interpersonal

skills formed one of the pillars on which the participants’ pre-transition professional role identity

was constructed.

A Focus on Growth, Flexibility, and an Ever-Expanding Identity

The pre-transition professional role identity of the study participants was also described

as flexible, adaptable, and continually under construction. The focus on progressive growth and

expansion of the participants’ pre-transition professional role identity painted a picture of the

identity as malleable, rather than a rigid concept to which the participants remained committed.

All participants valued continuous education and growth to continue to hone and develop their

professional role identities. Furthermore, the participants viewed this flexible and malleable

professional role identity as an aspect which separated them from other healthcare professionals.

This flexibility and adaptability infused all aspects of their professional lives and was a

foundational concept carried by the participants as they embarked on the process of making

meaning of their professional role identity when transitioning into leadership.

Alignment Between Self-identity, Clinical Identity, and Leadership Identity

The physical therapists in this study all began their transition into leadership possessing a

pre-transition professional role identity well-aligned with their overall self-identity and in
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alignment with a view of themselves as leaders in their clinical and personal lives. For the study

participants, the desire to help others and to lead were not viewed as separate from their lives and

identities outside of work. Instead, the participants described consistency between the role of

physical therapist and leader with their self-identity. Because this consistency pre-dated the

transition into leadership positions, the study participants began the process of making meaning

of their professional role identity in possession of an identity devoid of inconsistencies or role

conflict.

Identification with Their Organization

Finally, the study participants possessed a strong identification with their organizations

prior to transitioning into leadership positions within them. For the study participants, the

alignment between their organizational identification and their professional role identity rivaled

or, for some, outpaced their identification with the larger profession of physical therapy. For the

study participants, this alignment was a natural one, given the consistency between what

participants perceived to be the values of their organization and the values they held as PTs and

as individuals. As a result, identifying with their organization did not pose a conflict with their

existing professional role identities as clinicians. Like the other aspects of the participants’ pre-

transition professional role identities, identification with the organization formed an important

part of the identities these physical therapists carried with them into the transition process.

Theme 2: Accepting the Role of Discomfort During the Transition Process

The physical therapists in this study made meaning of their professional role identity

when transitioning into leadership positions by embracing the role of discomfort during the

transition process. Not only did the physical therapists in this study accept discomfort as a part of

transitioning out of full-time clinical practice and into leadership, they also found ways to
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embrace and use that discomfort to aid in the process of developing a leader identity. The

participants embraced feeling overwhelmed, adjusted to the loss of patient care, used past

experiences with discomfort to facilitate their meaning-making process, and ultimately accepted

the separation of management from leadership to make meaning of their role identities.

Feeling Overwhelmed

All study participants felt overwhelmed at various points in their transition from full-time

clinical practice into leadership. Some participants were overwhelmed by the sheer workload

required of them in their new positions where others were overwhelmed by feelings of being lost

or lacking direction. Still others felt overwhelmed in their new positions due to a lack of critical

skills or knowledge needed to feel successful in a leadership position, or by the needs placed

upon them by team members which was not a component of their clinical roles.

While feeling overwhelmed was obviously not a pleasant experience, the participants in

this study also did not avoid the sensation. Instead, the participants acknowledged this feeling of

being overwhelmed and used it as a catalyst to make meaning of their professional role identity

during this time of transition.

Adjusting to the Loss of Patient Care

A second source of discomfort for the participants was the reduction of time spent in

patient care. While all participants expressed discomfort due to the departure from full-time

patient care, not all participants experienced the discomfort in the same way. For some, the

discomfort arose from the loss of time and connection with patients which was a hallmark of

their clinical careers. For others, the sense of loss, and thus discomfort, was the result of either a

departure or a change in the relationship with their colleagues and team members. Finally, some

of the participants experienced discomfort brought on by the fear of appearing less legitimate in
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the eyes of their fellow therapists for transitioning out of patient care and into a leadership

position. Despite variation on how the departure from patient care was experienced by the

physical therapists, all of them recognized the discomfort, accepted or embraced it, and

recognized it as a catalyst which spurred them to engage in identity work. The identity work

process which stemmed from the discomfort was a part of the process by which the PTs made

meaning of their professional role identity.

Using Past Experiences to Embrace Discomfort

Each of the study’s participants had experienced discomfort in previous transitions. For

some, the transition from classroom to clinical education during their training was a period of

time marked by discomfort and dissonance. For others, the transition from student to

independent and self-reliant clinician was a time of discomfort. For each of the participants,

these transitions served as formative learning experiences and equipped them with the capacity

to recognize and overcome feelings of discomfort when transitioning from one role identity to

another. Having had these experiences, and successfully navigated them, the PTs in this study

possessed the ability to not only recognize the discomfort of transitioning into a leadership role,

but also possessed the ability to accept the role of the discomfort and use it to make meaning of

their professional role identity.

Separating Management From Leadership in Identity Construction

When making meaning of their professional role identity during the transition from

clinical to leadership positions, the physical therapists in this study made a point of separating

management from leadership. The participants recognized the differences between management

and leadership as separate constructs, both of which represented components of their new job

role. In doing so, the physical therapists were able to acknowledge the management components
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of their new positions as a source of discomfort and inconsistency with their prior identities as

full-time clinicians. Furthermore, by recognizing the management components as the source of

the discomfort, and separating them out from leadership, the physical therapists were able to

accept and embrace the discomfort brought on by their management duties as a necessary and

more tolerable part of their new professional role, while being able to recognize the consistency

between their leadership responsibilities and their existing professional role identity as a

transitioning clinician. Doing so allowed the participants to embrace and accept the discomfort

while not rejecting the entirety of their new roles outright.

Theme 3: Focusing on Relationships

The physical therapists in this study made meaning of their professional role identity

when transitioning from clinical to leadership positions by focusing on relationships.

Interpersonal skills and the ability to develop relationships were key components of their existing

professional role identities as clinicians. The participants in this study leveraged their abilities to

develop relationships, and focused on the importance of doing so, when making meaning of their

professional role identity during the transition. The participants focused both on past

relationships as well as current relationships when transitioning into leadership. Whether past or

present, the participants focused on work relationships and mentoring relationships when making

meaning of their professional role identity.

Work Relationships

The participants in this study focused on work relationships when making meaning of

their professional role identity. Focusing on the formation and maintenance of interpersonal

relationships with patients and coworkers was a key component of the participants’ existing

professional role identity while working exclusively in patient care. By focusing on work
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relationships during the transition to leadership, the physical therapists in this study were able to

use a valued component of their existing identity as a reference point from which to make

meaning of their developing identity in a leadership role. Whereas the participants focused on

patient-therapist relationships while working in clinical care, the relationship focus of the

physical therapists in this study shifted to work relationships with their team members. The

physical therapists in this study prioritized their focus on the development, maintenance, and

improvement of work relationships when making meaning of their professional role identity in

leadership.

Mentoring Relationships

The physical therapists in this study focused on both positive and negative experiences

with mentors and former leaders when making meaning of their own professional role identity.

For several participants, prior leaders served as examples of what to avoid as they made meaning

of their own professional role identity in leadership. Predominantly however, the participants

referenced positive relationships with past and current mentors as influential in how they made

meaning of their professional role identities when transitioning out of clinical care positions.

Sometimes these mentors were the individuals who prompted the transition to begin with. Other

times, it was the presence of a strong mentor during the transition process which proved to be an

influential input into the meaning-making process of the participants. Focusing on mentorship

relationships both past and present served as a reference point and a standard by which the

participants in this study measured their developing leadership identities.

Theme 4: Exercising Agency Over Construction of Their Leader Identity

The participants in this study made meaning of their professional role identity by

exercising autonomy over the processes by which they constructed their leader identities. A lack
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of rigid or highly structured efforts on the part of their organizations created a common need

amongst the study participants to exercise this autonomy. The participants in the study exercised

autonomy in response to a lack of organizational identity regulation efforts by charting their own

paths toward a leader identity and simply putting the work in and getting things done.

Responding to a Lack of Formalized Organizational Identity Regulation Efforts

Most of the participants in this study received some type of orientation to their new

leader/manager roles and support in terms of training on the operational demands of the job. In

contrast, the participants were not subjected to significant efforts by their organizations to

regulate their identities as leaders. The physical therapists in this study all described some degree

of on-the-job learning. This on-the-job learning, or “learning on the fly”, created cognitive

dissonance in their new roles. For the participants, this cognitive dissonance served as the

stimulus to make meaning of their professional role identities in these new positions.

Charting Their Own Path

The lack of a rigid organizational definition of a preferred physical therapist leader

identity left the physical therapists in this study to chart their own paths forward as they made

meaning of their professional role identity. For some of the participants, an overall lack of

guidance in defining even some of the basic duties of their job roles created a need to define their

leader roles and identities for themselves. For those participants, this was generally viewed as an

opportunity as opposed to an obstacle, one which the participants seized upon to make meaning

of their role identity. Other physical therapists in this study chose to chart their own path as a

way to differentiate themselves from other leaders in the organization and to mold the manner in

which they conducted their leadership work to be more consistent with their natural or preferred
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style. The participants welcomed the opportunity to chart their own paths as a means of

exercising agency over the process of making meaning of their professional role identities.

Getting Things Done

When making meaning of their professional role identities during the transition to

leadership, the participants exercised agency over the construction of their leadership identities

by simply getting things done. Putting in the necessary work and getting things done was an

approach which the physical therapists drew from their time in direct patient care. Finding ways

to accomplish the work necessary to develop into leaders required initiative, persistence, and a

sense of autonomy. The study participants all noted how hard work, taking initiative, and

remaining persistent in the pursuit of a goal were strong characteristics of physical therapists

generally. As a result, when the participants felt the need to reduce the cognitive dissonance

resulting from a lack of regimented organizational identity regulation, the participants leaned on

these strengths when exercising autonomy over the meaning-making process.

Theme 5: Recognizing Consistency Between Physical Therapist and Leader Roles

Recognizing the consistency between their role as a physical therapist in patient care and

their role as a physical therapist in leadership was a key recognition as the participants made

meaning of their professional role identities. Participants recognized a direct connection between

the skills they used as physical therapists in patient care to the skills required of them as they

transitioned into leadership. The participants also recognized the consistency between their

clinician and leader roles on a conceptual level, focusing on service to others and the consistency

in values.

Recognizing a Clinical Skill Set is Applicable to Organizational Leadership

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The physical therapists in this study made meaning of their professional role identity by

recognizing the applicability of clinical physical therapy skills to their roles as leaders in their

respective organizations. The need for strong affective and interpersonal skills in PT practice was

found to be directly applicable to their new roles in leadership. Likewise, the functional,

inclusive, global, and patient-centered approach of the physical therapist was also directly

applicable to the participants’ leadership roles. This approach to solving problems made the

physical therapists in this study unique to their leadership teams and helped them view leadership

issues from a unique perspective which was relevant to the leadership required of them by the

organization but also relevant to the care of the physical therapist they now supervised.

Recognizing Clinical Work and Leadership Work Focus on Service to Others

The physical therapists also recognized how a focus on serving others was consistent

between their roles as physical therapists in patient care and their new roles as leaders. Serving

others was a core aspect of their identity as physical therapists and meeting the needs of others

was a primary focus of their work. The participants were able to make meaning of their

professional role identities during the transition into leadership roles by recognizing that service

to others was also a key component of their developing leadership identities. More specifically,

participants recognized the consistency between serving as a patient advocate in their clinical

work to serving as an advocate for both patients and team members as a leader. Recognizing this

consistent focus on service during the transition allowed the physical therapists to retain a core

aspect of their PT professional role identity, while expanding the service focus to a larger

audience as they made meaning of their professional role identity in leadership.

Recognizing the Alignment of Organizational Values with Clinical and Personal Values
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Participants made meaning of their professional role identities in leadership by

recognizing the consistency between the values of their organization and the values they held as

clinicians and as individuals. Clearly stated organizational values made recognizing this

alignment easier for the participants and made the application of organizational values to their

leadership decisions clearer. Furthermore, the participants recognized a patient-first orientation

to their organizations’ values which was consistent with the patient-first ethos of the physical

therapy profession. In addition, it was the espoused values of the physical therapy profession

which drew many of the participants to the field in the first place because those values were

consistent with their personal values even before entering the PT profession. Recognizing the

consistency between their personal values, their values as practicing clinicians, and the values of

their organizations guided the participants as they worked to construct their leadership identities

and make meaning of their professional role identities.

Theme 6: Establishing a Professional Identity Informed By, But Not Bound By, Their

Physical Therapist Identity

The study participants made meaning of their professional role identity when

transitioning from clinical to leadership roles by establishing a professional role identity which

was informed by their physical therapist identity, but no longer bound by it. The participants’

identities as physical therapists became the foundation upon which they built a leader identity.

More specifically, the leader identity constructed by the participants included becoming the “go

to” person for their team members, having a foot in both worlds of PT and leadership, redefining

what it meant to be successful, and expanding their focus beyond the scope of physical therapy

clinical practice.

Becoming the “Go To” Person

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The participants in this study made meaning of their professional role identity in

leadership by cultivating and accepting their role as the “go to” person for the department.

Becoming the “go to” person meant an expanded degree of accountability and the need to lead

by example. For the participants, the role of leader in their respective departments meant they

were looked to for guidance on therapy-related issues by both their own team members as well as

individuals from other departments or teams. Becoming the “go to” person meant taking

responsibility for a larger scope of work than when they served as PTs in direct patient care.

Having a Foot in Both Worlds

Inhabiting both clinical physical therapy and leadership worlds simultaneously was a

component of how the participants made meaning of their professional role identity. By moving

back and forth between both worlds, or inhabiting both worlds simultaneously, the participants

were able to retain their foundation as physical therapists while bridging the gap between the

clinical world they were transitioning from to the leadership world they were transitioning into.

By having a foot in both worlds, the participants were able to make meaning of their professional

role identity because they could see, sense, respond to, and accept a gradual evolution from their

foundational identity as a PT to their broader professional identity as a leader.

Redefining Success in Their New Role

In order to make meaning of their professional role identity when transitioning from

clinical to leadership positions, the participants needed to find ways to redefine how they

measured success in their new roles. As physical therapists, success was measured in terms of

direct patient outcomes. In their clinical roles, the participants could see the direct correlation

between their work with a patient and the patient’s outcome with physical therapy. This direct

and visible correlation between daily work and a measure of success was lost as the participants
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transitioned from full-time clinical work into a leadership role. Given the goal-oriented and

motivated nature of the study participants, making meaning of their professional role identity

necessitated redefining success using measures which were still consistent with their self-view

but also applicable to detecting success in their new role. The participants redefined success by

expanding the timeline on which their expectations were set, focusing on the successful

outcomes of care provided by their team members instead of themselves as individuals, and

taking pride and a sense of accomplishment in their ability to provide for and facilitate the

success and growth of their team members and departments.

Expanding Their Focus

Finally, the participants made meaning of their professional role identity during the

transition from clinician to leadership by expanding their focus beyond the limited confines of a

physical therapist’s scope of clinical practice. While the participants’ physical therapist identity

continued to serve as a foundation, the participants developed the ability to view issues,

problems, and solutions from a more global and interprofessional perspective. The expanded

focus of the participants’ professional role identity was born out of necessity as they were now

responsible for the supervision of professionals from other disciplines. The participants were also

expected to view their day-to-day work from the standpoint of the organization, not only the

perspective of a physical therapist providing clinical care.

Discussion of Themes with Prior Literature

This section discusses the six themes identified in this study and their relation to existing

literature on the research topic. Given the overall lack of research on this topic in physical

therapy, existing research from related professions is also discussed. Areas in which this study’s
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findings support the existing literature are examined, as are areas in which this study’s findings

were unique.

Theme 1: Beginning with a Strong Role Identity Focused on More Than Clinical Skills

Plack (2006) noted how the acquisition of expert clinical knowledge alone was not

sufficient for providing competent physical therapy services to patients. The Professional

Behaviors for the 21st Century (Duke Doctor of Physical Therapy, n.d.), the Clinical

Performance Instrument (American Physical Therapy Association, 2019a), and the Physical

Therapist’s Manual for the Assessment of Clinical Skill (Texas Consortium for Physical Therapy

Clinical Education, n.d.) support this notion when assessing students on skills such as

communication, time management, and interpersonal relationships. Overall, the physical

therapists in this study began their transition into leadership in possession of a strong but

malleable professional role identity which included more than just clinical skills. This finding

was consistent with the limited body of literature on leadership in physical therapy, with a few

exceptions. In contrast, this finding conflicted with literature from the broader realm of

healthcare, indicating the unique nature of the physical therapist professional role identity

compared to more widely studied fields of nursing and medicine.

The pre-transition professional role identity of the physical therapists in this study

included strong communication skills and the ability to develop interpersonal relationships. This

finding is consistent with prior research which has emphasized the importance of communication

as a key leadership skill for leaders in physical therapy (Chan et al., 2015; Desveaux et al., 2012;

Lopopolo et al., 2004; McGowan & Stokes, 2017; McGowan et al., 2016). The ability to develop

and maintain interpersonal relationships as a component of the PT professional role identity is

also supported by research on the professional socialization of physical therapists during

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training. Prior research has demonstrated the strong influence of faculty and clinical instructors

on the development of physical therapists’ professional role identity as opposed to the

acquisition of specific knowledge or skills (Greenfield et al., 2012; 2015; Teschendorf &

Nemshick, 2000). Additionally, the physical therapists in this study described a pre-transition

professional role identity as flexible, malleable, and focused on growth and expansion of their

identities. This is also consistent with prior research on the PT professional role identity

(Echternach, 2003; Hammond, 2013; Nesbit & Fitzsimmons, 2021; Stiller, 2000). Hammond

(2013, 2016) specifically noted how physical therapists will adopt a process of on-going revision

and updating of their professional selves. Chan et al. (2015) found the “achiever” strength to be a

component of physical therapists’ self-identity, although more common in PTs inhabiting

leadership positions than those inhabiting non-leadership positions. According to Gallup (n.d.),

the “achiever” strength is characterized by a relentless drive for achievement and growth, a need

which provides the stimulus to take on new tasks or challenges. The participants in this study

demonstrated a focus on growth, flexibility, and an ever-expanding identity consistent with this

drive as part of their professional role identity before they assumed formal leadership positions.

The possession of leadership characteristics prior to the transition into leadership by the

PTs in this study speaks to the alignment between self-identity, clinical identity, and a leadership

identity. Whether or not physical therapists perceive of themselves as leaders has received

attention in the prior literature, with variable findings. Multiple studies have demonstrated a high

level of leadership self-perception amongst physical therapists (Desveaux et al., 2012; LoVasco

et al., 2016; McGowan, 2017; McGowan & Stokes, 2017; McGowan et al., 2015; McGowan et

al., 2019b). Desveaux and Verrier (2014) as well as McGowan (2017) also found leadership self-

perception amongst physical therapists to be high, at least within the realm of clinical leadership.
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The fact that the PTs in this study possessed a professional role identity which demonstrated

alignment between a clinical identity and a leadership identity is consistent with the findings of

this prior research.

There are inconsistencies in the existing literature concerning the leadership self-

perceptions of physical therapists, however. Mallini (2019) found inconsistencies between the

contemporary definitions of leadership and management and the understanding of these

constructs by physical therapists. Rasmussen-Barr et al. (2019), Pascal et al. (2017), and Pereira

(2020) all found leadership self-perception amongst PTs to be low, albeit in physical therapists

outside of the United States. A similar inconsistency has been noted in the literature surrounding

leadership self-perception in the related field of occupational therapy (Fleming-Castaldy & Patro,

2012; Heard, 2014; Pitts, 2020; Shams et al., 2019). Adding to this, multiple studies have

suggested a lack of leadership and management content, and a lack of perceived need for said

content, in the academic preparation of physical therapists (Clark, 2016; Green-Wilson, 2011;

Lopopolo et al., 2004; Sebelski et al., 2020; Shafer, 2007), leading Tschoepe et al. (2021) to

advocate for all physical therapists to develop leadership competence. Given these

inconsistencies, it begets the question as to whether physical therapists do indeed perceive of

themselves as leaders, and if so, does this perception pre-date not only their transition into

leadership positions but also their training and socialization into the PT profession in the first

place.

The findings of this study seem to suggest so. The participants possessed a strong

professional role identity consisting of key leadership competencies and mindset before

transitioning into leadership. This identity included alignment between clinical and leadership

identities, but also alignment with their self-identity. The alignment with self-identity is
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suggestive of leadership self-perception as a component of self which may pre-date their entry

into the profession. This finding is supported in the general literature as well as the physical

therapy literature. Students arrive in professional training programs with multiple social

identities and are often drawn to a profession because of the consistency between the espoused

beliefs of the profession and their existing self-image and belief system (Cowin et al., 2013;

Kornives et al., 2005; Perez, 2016). Eventually, as students progress through training and into

practice, their existing self-image and key aspects of the professional role identity become

intertwined (Fitzgerald, 2020; Hamilton, 2008; Kreindler et al., 2012; Vivekananda-Schmidt et

al., 2015; Volpe et al., 2019). Chan et al. (2015) found the leadership strength of strategic vision

to be stable over years of experience, while LoVasco et al. (2016) found high leadership self-

perception amongst first year doctor of physical therapy students. Both of these studies support

the notion of leadership as a component of the physical therapist’s self-identity which pre-dates

their training. The alignment between self-identity, clinical identity, and leadership identity as

part of the overall pre-transition professional role identities of this study’s participants adds

further support to this concept from the prior literature.

The presence of a strong, pre-transition professional role identity by this study’s

participants, one which focused on more than just clinical skills, may be supported by prior

literature in physical therapy, but it stands in contrast to the larger body of research on the topic

amongst healthcare professionals in general. Most healthcare professionals do not perceive of

themselves as leaders. The centrality of the clinician role to their professional role identity and

their lack of leadership and management training promotes a uni-professional view antithetical to

leadership or to alignment with the views of an organization or a team (Brocklehurst et al., 2013;

Crane 2021; Greathouse et al., 2018; Heard, 2014; Masoumi, 2019; Maurer & London, 2018;
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Mitchell, 2019; Phillips et al., 2018; Pitts, 2020; Sonnino, 2016; Young et al., 2011). As a result,

new clinician managers often fail to re-align their values or goals to those of the organization.

This may lead to ineffectiveness in their new position (Masoumi, 2019). In contrast, the physical

therapists in this study already possessed a focus on others and a focus on their team. This focus

was consistent amongst their multiple social identities. Possessing a flexible and growth-oriented

professional role identity not focused strictly on clinical skills allowed for alignment between the

participants’ self, clinical, and leader identities as well as alignment with their organizations. The

findings under theme one are generally supported by the prior literature in physical therapy

leadership but also stand in contrast to findings from many other health professions. These

findings indicate a potential uniquity amongst physical therapists in the leadership realm which

may separate them from other healthcare professional colleagues.

Theme 2: Accepting the Role of Discomfort During the Transition Process

Recent research supports identity work as nuanced, individualized, and contextual, with

leaders practicing self-awareness, self-regulation, and metacognition (Andersson & Liff, 2018;

Lega & Sartirana, 2016; Magill, 2020; McGivern et al., 2015; Perez, 2016; Reay et al., 2017; Yip

et al., 2020). Theme two is consistent with the idea of identity work as a process of self-

awareness, self-regulation, and metacognition amongst the physical therapists in this study. Each

of the physical therapists experienced discomfort in multiple forms during the transition from

full-time clinical work to a leadership position. The physical therapists were able to recognize

this discomfort, acknowledge it, reflect upon it, and take steps to accept the discomfort and use it

as a stimulus to develop a leader identity consistent with their prior identity. This process is

consistent with prior literature from other fields (Magill, 2020; Yip et al., 2020). It is also
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consistent with clinicians who are successful in their transition from clinical to leadership and

management roles (Masoumi, 2019).

The participants in this study experienced discomfort in several ways. First, most

participants described being overwhelmed. While the transition from clinical to leadership roles

remained unstudied in physical therapy, being overwhelmed has been noted amongst physical

therapists transitioning from clinical care to academic positions (Barrett et al., 2019a). Feeling

overwhelmed and facing a steep learning curve is a common experience amongst new leaders in

other healthcare fields including nursing, medicine, radiography, and occupational therapy (Daly

et al., 2014; Shams et al., 2019; Sonnino, 2016; Thompson & Henwood, 2016).

The previous literature on leadership in physical therapy demonstrates a consistent need

to legitimize leadership and management skills and concepts by framing them in or linking them

to a clinical perspective (Bennie & Rodriguez, 2019; Lopopolo et al., 2004; Luedtke-Hoffman et

al., 2010; McGowan et al., 2016; Silberman et al., 2020). Green-Wilson (2011) suggested

leadership and management constructs were only deemed important in academic programs if

related directly to clinical care, while physical therapists who transition into junior faculty

positions felt their clinical experience is what gave them credibility with students (Barrett et al.,

2020). In one of the only studies on the transition from a physical therapy patient care role to a

leadership/management role, Glendinning (1987) found Australian physiotherapy managers felt

the need to maintain a clinical caseload in order to retain the appearance of competence in the

eyes of the clinicians they supervised. The fear of appearing less legitimate in the eyes of fellow

clinicians has been found amongst new leaders in other healthcare professions as well. This fear

may lead new healthcare leaders/managers to disengage or diminish the attention paid to their

new roles in favor of the continued centrality of the clinical identity (Camilleri, 2020; Cantillon
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et al., 2019; Spehar et al., 2012; Mitchell, 2019; Thompson & Henwood, 2016). For the

participants in this study, the transition process meant adjusting to the loss of patient care time.

Each of the physical therapists expressed some concern over feelings of loss, guilt, or separation

from their clinical roles. Absent was the need to disengage from their leadership and

management duties, however. Instead, the physical therapists in this study were aware of the

discomfort brought on by their departure from full-time patient care. They used this discomfort

to frame their identity work instead of allowing the discomfort to hamper it. This finding appears

unique compared to the limited prior literature on this topic and suggests a degree of self-

awareness and self-regulation amongst the study participants. Self-awareness and self-regulation

were needed to make meaning of their professional role identity during the transition into

leadership (Magill, 2020; Masoumi, 2019; Yip et al., 2020).

Accepting and ultimately embracing discomfort as part of the process of making meaning

of their professional role identity required the physical therapists in this study to reference past

experiences in which they had done so successfully. More specifically, the physical therapists in

this study reference their discomfort during the transitions from classroom to clinical education

and from student to new graduate. This finding adds to the existing research base on this topic.

Physical therapy clinical education experiences have been found to play a significant role in the

formation of a physical therapy student’s professional role identity (Greenfield et al., 2012, 2015;

Plack, 2006). Additionally, clinical experience as a practicing clinician also helps form a PT’s

professional role identity and is referenced to help the PT make meaning of their new role during

a transition (Barrett et al., 2020). Perez (2016) noted how professional students may experience

cognitive dissonance when they enter the workplace and find differences between their idealized

professional role identity and the actual demands of the job. The students then engage in identity
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work to resolve the discomfort brought on by this dissonance. One resource these professional

students drew upon was past experience (Perez, 2016). Thus, the use of past experience by the

PTs in this study to embrace discomfort and ultimately make meaning of their professional role

is consistent with prior research and adds to the limited body of evidence on the topic in PT.

Finally, the physical therapists in this study experienced discomfort in the transition

because of a lack of familiarity or experience with specific components of their new role. More

specifically, the participants felt discomfort with the management and operational components of

their positions, in part due to the absence of this content in their prior training. The work of

Lopopolo et al. (2004), Shafer (2007), and Green-Wilson (2011) support this finding. Of the 10

Professional Behaviors for the 21st Century only one, “effective use of time and resources,” may

be construed as speaking to management skills. Even this skill is described purely in terms of

patient care. A failure to relate to the new role may cause the leader/manager to reject the role. A

rejection of the leader/manager identity has been linked to new manager ineffectiveness and

attrition from the leadership and management ranks in other healthcare professions (Machin et

al., 2011; Masoumi, 2019; Mitchell, 2019; Sofritti, 2020).

Instead of rejecting their new role entirely, the physical therapists in this study took a

unique approach to making meaning of their professional role identity. Leadership and

management skills have been lumped together in the previous literature (Lopopolo et al., 2004;

Shafer, 2007). The physical therapists in this study did not do this. Instead, they embraced their

discomfort with the management portions of their new positions and recognized them as separate

from the components requiring leadership. In doing so, the participants were able to accept and

embrace their discomfort with the management components of their position while accepting the

leadership components as more consistent with their existing self-image. Doing so reduced the
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dissonance caused by their role transition and helped them avoid rejection of the role entirely.

This separation of management from leadership is consistent with contemporary views of

leadership and management as separate but linked constructs (Antonakis & Day, 2018).

Theme 3: Focusing on Relationships

The physical therapists in this study focused on relationships to make meaning of

professional role identity during the transition from clinical to leadership positions. This finding

is consistent with prior research on this topic. Perez (2016) noted how professional students

experience dissonance when transitioning from school to a work environment. Students and new

professionals will rely on different resources when attempting to reduce feelings of cognitive

dissonance. Some students and new professionals will rely on social contacts and salient cues

from other professionals and people in authority positions as they attempt to rectify the

difference between their idealized professional role identity and the role identity required in

actual practice (Perez, 2016). Student who drew upon social contacts and salient cues from

others were found to be more accepting of the required adaptations to their professional role

identity than students who relied more on internal cues (Perez, 2016). When constructing a

professional role identity, healthcare professionals have been found, in part, to rely on a group

identity and a sense of exclusivity from other disciplines formed by working alongside and being

a part of that group (Fitzgerald, 2020).

The reliance of this study’s participants on relationships to make meaning of their

professional role identity supports and builds upon prior research on the topic in the physical

therapy field more specifically. Physical therapy faculty and clinical instructors have been found

to play influential roles in the development of a physical therapy student’s professional role

identity (Greenfield et al., 2012, 2015; Teschendorf & Nemshick, 2000). Physiotherapists have
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also been found to engage in an ongoing process of identity work triggered by episodes of non-

coherence between their perceived self-narrative and the perceived experience in the workplace

(Hammond, 2013). Physiotherapists were found by Hammond (2013) to continually co-construct

their professional role identity through discussions with other physiotherapists, family, and

friends. The findings of this study strengthen this prior research by providing an example of the

use of relationships during identity construction in a leadership position, something not

considered in the prior research (Greenfield et al., 2012, 2015; Hammond, 2013; Teschendorf &

Nemshick, 2000). Furthermore, the results of this study also add to the prior work on this topic

by providing detail on the types of relationships used and the value derived from those relational

experiences. This detail includes which types of work and mentoring relationships were accessed

as well as the use of negative relationship examples in identity construction in addition to

positive examples.

Theme 4: Exercising Agency Over Construction of Their Leader Identity

In order to make meaning of their professional role identity during the transition from

clinical to leadership roles, the physical therapists in this study exercised agency over the

construction of their developing leader identities. The act of exercising agency during the

identity work process has support in the literature. Perez (2016) described how healthcare

students exercise agency over professional role identity construction when faced with differences

between an idealized version of their professional identity and the realities of the workplace.

While older conceptualizations of the physical therapist’s professional role identity were focused

on differentiation and exclusion (O’Hearn, 2002), more contemporary conceptualizations have

recognized the physical therapist’s professional role identity as malleable and in a continual state
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of reflection and revision, a state in which the physical therapist plays an active part (Echternach,

2003; Hammond, 2013; Nesbit & Fitzsimmons, 2021; Stiller, 2000).

The findings of this study add to the prior literature by extending the concept of agency

over the construction of professional role identity into the realm of physical therapy leadership.

Research on how a physical therapist makes meaning of their professional role identity when

transitioning from a clinical to a leadership position is almost non-existent. Thus, any insight into

how a physical therapist may exercise agency over the construction of a leader identity during

this transition may be considered novel. As noted previously, the prior literature on leadership in

physical therapy lacks a unifying definition of what leadership in physical therapy is (Desveaux,

2015; Sebelski et al., 2020; Tschoepe et al., 2021). Furthermore, the academic physical therapy

community has struggled to keep pace with the changing professional role identity of physical

therapists in clinical practice as it pertains to topics of leadership and management (Green-

Wilson, 2011; Tschoepe et al., 2021). It is interesting that the stimulus for the participants in this

study to exercise agency over the construction of their leader identities was a lack of formalized

and regimented efforts by the organization to regulate their leader identity. This stands in

contrast to the business world where identity regulation efforts by an organization may produce a

role conflict and thus stimulate identity work (Alvesson & Willmott, 2002). Furthermore, this

finding stands in contrast to studies on new clinician leaders in other healthcare fields. Previous

research in other healthcare fields has found clinicians to be subjected to significant identity

regulation pressures to shift from individualized technical excellence as a professional to a leader

and manager of a work group, with strict organizational boundaries and constraints placed on

them by organizational bureaucracy (Langendyk et al., 2015; Masoumi, 2019; Sofritti, 2020).

When other healthcare professionals have not been provided time and options to re-align their
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values and goals as professionals to those of a leader within an organization, they have proven

ineffective as managers and leaders (Kreindler et al., 2012; Masoumi, 2019; Spehar et al., 2012;

Thompson & Henwood, 2016; Young et al., 2011).

In contrast, the participants in this study, while provided orientation to the tasks of their

job, all described some aspect of on-the-job learning, or “learning on the fly.” For the physical

therapists in this study, however, this did not result in ineffectiveness or disillusionment but

instead stimulated them to work harder. The physical therapists in this study exercised agency by

charting their own path and simply getting to work and getting things done. This response may

have been due to several factors which do have support in the limited literature on this topic.

First, as noted in theme one, the physical therapists’ original professional role identity included

alignment with their organization. This original alignment of professional role identity as a

clinician with the goals/values of the organization may have reduced the need for increased time

and options to re-align their values and goals to the organization’s, because they were in

alignment already (Kreindler et al., 2012; Masoumi, 2019; Spehar et al., 2012; Thompson &

Henwood, 2016; Young et al., 2011). Likewise, the original professional role identity of the

study participants also demonstrated consistency between self, clinical, and leader identities even

prior to the transition. The possession of a professional role identity which included aspects of

leadership may have negated the need for highly regimented efforts at organizational identity

regulation after transitioning into leadership, in contrast with other health professions such as

medicine, nursing, and dentistry (Aggarwal & Swanwick, 2015; Brocklehurst et al., 2013;

Kippist & Fitzgerald, 2009; Phillips et al., 2018; Schyns et al., 2020; Spehar et al. 2012; Young

et al., 2011). The physical therapists in this study also exercised agency over the construction of

their leader identities by charting their own path and getting things done. The participants
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frequently referred to the autonomy of physical therapist practice and identified themselves and

other physical therapists as unique on the healthcare teams in their willingness and ability to get

things done and follow through. The combination of the physical therapists’ willingness to

exercise autonomy by charting their own path and getting things done and the lack of a highly

regimented and formal attempt by their organizations to regulate their leader identity

development may have played to the inherent strengths of the physical therapist turned leader.

This concept is supported in the literature, as organizations which allow for greater autonomy in

organizational decision-making and those which actively work to recognize individual

professional contributions to overall team performance enjoy more successful clinician to leader

transitions (Antony, 2021; Kreindler et al. 2012; Reay et al., 2017; Salvatore et al., 2018).

Theme 5: Recognizing Consistency Between Physical Therapist and Leader Roles

According to Hammond (2013), physical therapists co-construct their professional role

identity, in part, by referencing other identities which comprise their self-concept. When making

meaning of their professional role identity during the transition from clinical to leadership roles,

the physical therapists in this study did exactly that. Through the process of identity work, the

participants recognized the consistency between their roles and identities as physical therapists

and their roles and developing identities as leaders. Healthcare professionals who find

consistency between their existing professional role identity and an organizational identity, in

this case the developing leader identity, are more likely to integrate or hybridize the two roles

(McGivern et al., 2015; Sartirana, 2019; Sofritti, 2020).

The physical therapists in this study recognized the applicability of their clinical skills to

their roles in organizational leadership. This finding conflicts with the majority of the general

literature on clinicians turned managers/leaders while exposing some interesting paradoxes in the
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limited research on leadership in the rehabilitation professions. First of all, the applicability of

clinical skills to the leadership realm stands in opposition to one of the key findings of the

literature review and the conceptual framework of this study, role conflict. Fitzgerald (2020)

included clinical knowledge and skills as one of the six components of the healthcare

professional’s professional role identity. Furthermore, the possession of exclusive knowledge

and skills was one of the means by which a healthcare professional was found to differentiate

themselves, and thus their identity, from other professionals (Fitzgerald, 2020). In contrast, the

participants in this study referenced their clinical skills as useful in a completely different realm

and as part of the process of developing their professional role identity as leaders. Recognizing

this consistency allowed them to retain a key component of their clinical identities while still

embracing their transition into leadership, effectively limiting the experience of role conflict. The

retention of key components of a clinical identity and using those components to make meaning

of their developing leader identities stands in contrast to previous literature from other healthcare

fields which suggests the failure to let go of the clinician identity and embrace the leader identity

leads to ineffectiveness in both roles (Cantilon et al., 2019; Masoumi, 2019; Shams et al., 2019;

Spehar et al., 2012).

Recognizing the applicability of a clinical skillset to leadership exposes a paradox in the

existing PT leadership literature. As noted previously, the existing body of research in physical

therapy leadership may attempt to legitimize leadership and management skills by framing these

skills in clinical terms (Bennie & Rodriguez, 2019; Green-Wilson, 2011; Luedtke-Hoffman et

al., 2010; McGowan et al., 2016; Silberman et al., 2020). The larger body of physical therapy

research, often times inadvertently, considers leadership and management as a separate set of

skills or competencies to be acquired outside of the clinical skill set of a PT (Green-Wilson,

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2011; Lopopolo et al., 2004; Tschoepe et al., 2021; Shafer, 2007). In contrast, the study

participants did not separate the two. Instead, they recognized the applicability of their clinical

skills directly to the practice of leadership. In doing so, however, the participants’ meaning

making process supported the practice of framing leadership skills in terms of clinical skills and

the commonly accepted patient-management model (Lopopolo et al., 2004; Shafer, 2007). This

finding also supports current efforts underway to develop a unified conceptualization of

leadership competency in physical therapy and to advance the cause of leadership as a key

component of the physical therapist professional role identity regardless of whether or not the PT

inhabits a formal organizational leadership position (Desveaux & Verrier, 2014; Green-Wilson et

al, 2022; McGowan, 2017; McGowan & Stokes, 2015, 2017; Rasmussen-Barr et al., 2019;

Sebelski et al, 2020; Tschoepe et al., 2021).

The physical therapists in this study also recognized the consistent focus on other people

between their roles as clinicians and their roles as leaders. The research on clinician to

leader/manager transitions from other fields, including other healthcare fields, regularly

references the shift from an autonomous, uni-professional, and self-focused mindset on

individual performance to a more outward, team-oriented focus as a key source of role conflict,

and thus ineffectiveness, for new leaders and managers (Crane, 2021; Cavaness et al., 2020;

Delmatoff & Lazarus, 2014; Masoumi, 2019; Maurer & London, 2018; Sonnino, 2016). The

findings of this study generally conflict with this prior research. Instead, the physical therapists

in this study came from an original professional role identity which included a focus on service

to other, not only patients, but fellow team members and their organizations. Furthermore, the

participants recognized alignment in the values of their organization with the values they held as

clinicians and individuals. A lack of alignment in values between two roles inhabited by an
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individual has been found to lead to role conflict and subsequent ineffectiveness in new leaders

(Harviksen, 2021; Masoumi, 2019; Soffriti, 2020; Spyridonidis & Currie, 2016; Wikstrom &

Dellve, 2019). The participants in this study did not appear to experience the role conflict noted

in the prior literature from other professions due to their recognition of consistency in skill set,

focus on others, and alignment of values. More specific to PT, the participants in this study did

not appear to experience the role stress described by Glendinning (1987) in one of the only

examinations of this topic in the field. Another potential reason for the lack of role conflict and

overall satisfaction noted by the participants may be linked to motivation. Masoumi (2019) noted

those clinicians who entered management with a drive to make others better were more

successful as first-time clinician managers.

Theme 6: Establishing a Professional Identity Informed By, But not Bound By, Their

Physical Therapist Identity

Ultimately, the physical therapists in this study made meaning of their professional role

identity while transitioning from a clinical role to a leadership role by establishing a professional

identity which was informed by their physical therapist identity, but no longer bound by it. Their

original physical therapist professional role identity informed their newly established leader

identity as they became the “go to” person for their teams. Being the “go to” person meant an

increased sense of accountability, leading by example, serving as a stabilizing force, and being

the delegate or representative of the department to the larger organization. These findings

generally conflict with one of the few studies on this topic in physical therapy (Glendinning,

1987). In a study of Australian physiotherapy managers, Glendinning (1987) found only 5% of

their time was spent as the spokesperson for their department, 4% as the liaison, and 7% in the

figurehead role, conflicting with the delegate/representative identity formed by this study’s
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participants. Furthermore, Glendinning (1987) found only 1% of physiotherapy managers’ time

was spent as a disturbance handler and 2% as negotiator whereas this study’s participants

recognized their role as a stabilizing force. In further contrast, Glendinning (1987) found the

majority of time spent by physiotherapy managers was in resource allocation, whereas the

participants in this study specifically separated that type of business operations focus from their

developing leader identity. In a more contemporary study, Hoekstra et al. (2021) noted how

hybrid physical therapy clinician-managers felt a sense of personal responsibility and

commitment to ensuring their departments provided exceptional experiences to both patients and

staff. The findings of increased accountability and being the “go to” person are consistent with

Hoekstra et al.’s (2021) findings. This consistency is likely due to the more contemporary nature

of the study by Hoekstra et al. (2021) and is reflective of the significant development, growth,

and expansion of the physical therapy profession since the time of Glendinning’s (1987) earlier

study.

Establishing a professional identity informed, but not bound by, a physical therapist

identity left the physical therapists in this study inhabiting two worlds. Prior research from other

health professions has noted this phenomenon as a source of role conflict, and thus, new clinician

manager/leader ineffectiveness (Masoumi, 2019; Sofritti, 2019; Wikstrom & Dellve, 2009).

Rather than a source of role conflict, the findings of this study seem to indicate the physical

therapists embraced the fluidity in their role identity which allowed them to occupy two different

worlds. While Masoumi (2019) found this state of liminality as a source of ineffectiveness,

several studies have found this to be an effective response to identity work (Gordon et al., 2020;

Ibarra, 1999; Sofritti, 2020; Wikstrom and Dellve; 2009). The findings of this study support the

idea of inhabiting two different worlds as an effective result of identity work. This response may
 227

also blunt the feelings of loss over the departure from patient care. Having a foot in both worlds

may also represent an act of integration or hybridization of roles, another response to identity

work which has been reported as effective in the prior literature (Noordegraaf, 2015; Yip et al.,

2020). This finding has also been noted in PT and OT clinical instructors. Clinical instructors

who learn to integrate their teacher and clinician roles experienced reduced dissonance and were

able to perform each role effectively (Greenfield et al., 2014; Ong et al., 2019).

The physical therapists in this study also demonstrated the integration and hybridization

of their PT and leader identities by redefining success in their new roles. As clinicians, the

participants measured success in terms of patient outcomes. As leaders, the participants were

required to define success in terms of their team’s performance. The hybrid PT clinician-

managers studied by Hoekstra et al. (2021) were also required to redefine their measures of

success, but struggled to do so. Those PT clinician-managers inferred quality based on

operational metrics such as cancellation/no show rates and profit margins. The PTs in this study

were able to better define success at the team level through team-focused yet objective measures

of patient satisfaction, outcomes, successful discharge processing, and community reintegration

and wellness practice adoption.

Finally, the physical therapists in this study expanded their focus beyond individual

interests as a physical therapist to include the interests of multiple other professions under their

supervision while also expanding to consider the needs of the broader organization. Lopopolo et

al. (2004) described organizational analysis as a skill not needed for the entry-level physical

therapist but one that would need to be learned after taking on new roles later in a physical

therapist’s career. The experiences of the PTs in this study are consistent with Lopopolo et al.

(2004), given that establishing a new professional role identity as a leader involved this
 228

expansion of focus to the organizational level. Likewise, Masoumi (2019) noted how effective

clinician-managers were the ones capable of learning the cultures of multiple stakeholder groups,

a capacity demonstrated by this study’s participants. In a specific example, Reay et al. (2017)

highlighted how Canadian general practice physicians engaged in identity work and ultimately

were able to shift from a highly autonomous and individually-focused professional role identity

to an identity consistent with the leader of a team. In order to make meaning of their professional

role identity when transitioning from clinical care to leadership positions, the physical therapists

in this study were required to make a very similar transition.

Implications and Significance of the Study

This study represents a valuable addition to the already limited body of research on the

topic of clinician to leadership transitions in the physical therapy profession. More specifically,

this study provides insight into professional role identity and how role identity is affected by

living through such a transition. While the concept of role stress or role change has been noted in

prior PT literature (Glendinning, 1987; Hoekstra et al., 2021), this study examined the concept in

much greater detail, providing a description of how PTs make meaning of their professional role

identity when transitioning from a clinical to a leadership role. The ability to successfully

transition is necessary for the physical therapy profession to meet the needs of modern healthcare

which requires successful clinician-leaders to help transform care in a demanding and ever-

changing healthcare environment. This study provides insight into how the PT professional role

identity is formed, repaired, retained, or modified in response to the demands of this transition.

This study also highlights the uniqueness of the physical therapist’s professional role

identity when compared to other healthcare professions, including the closely-related profession

of occupational therapy. The process by which the physical therapists in this study defined their
 229

clinical role identity and the manner in which they made meaning of their professional role

identity during the transition differed from other healthcare professionals in part because the

original clinical identity was less exclusive and more global and expansive than the professional

role identities of other healthcare professions as described in the extant literature. This finding is

significant as it highlights the need for further research on this topic, given that research findings

from even closely-related professions may not be fully applicable when looking to understand,

and thus better facilitate, successful clinician to leader transitions in the field of physical therapy.

While the findings of this study found unique aspects of the PT professional role identity

during the transition from clinical to leadership roles, it also provided additional support for

existing research on such transitions. The existing literature supports the need for mentorship for

new leaders, a need supported by the findings of this study. Likewise, the study provides further

evidence for the benefit of consistency and alignment between organizational and professional

missions, visions, values, and goals when facilitating successful clinician to leader transitions.

The findings of this study also lend support to the research on greater autonomy and less rigidity

in the leadership onboarding process for professional physical therapists and the need to foster a

leadership identity which represents a hybridization or integration of identities in order to be

successful.

Finally, the findings of this study are significant as they further refute the perception of

leadership in physical therapy as simply a set of skills or competencies which, once acquired,

will define a leader in the profession. Instead, the findings of this study present a picture of

physical therapist professional role identity which is more expansive than simply the

accumulation of clinical skills, one which is malleable and also includes a focus on key affective

and interpersonal relational skills which may be key antecedents to leadership even when not
 230

being used in a formal leadership position. Furthermore, the study also sheds light on the

consistencies between physical therapy clinical practice and leadership practice. This finding

adds support to the growing trend in the PT leadership literature calling for the inclusion of

leadership in the professional role identity of all physical therapists, regardless of level of

practice or placement in an organizational hierarchy.

Recommendations for Practice

The findings of this study shed light on the unique manner in which physical therapists

make meaning of their professional role identity when transitioning from clinical to leadership

roles. This section will discuss recommendations for physical therapists engaged in practice,

those involved in the educational preparation of physical therapists, and the organizations which

employ physical therapists.

Recommendations for Practicing Physical Therapists

Achieving, maintaining, improving, and adding to the unique clinical knowledge and

skills required of a physical therapist is a necessity and an on-going requirement for remaining a

competent and contemporary physical therapist. That being said, each of the physical therapists

in this study possessed a professional role identity which included key antecedents of leadership

even before entering formal leadership roles. Furthermore, these skills were found to be

applicable in all settings of physical therapy practice, including direct patient care as well as

leadership and settings requiring interprofessional collaboration. Practicing physical therapists

should regularly self-assess not only the specific cognitive knowledge and psychomotor skills

required in their practice setting, but should also engage in regular self-assessment of the

affective and interpersonal relationship skills needed. Practicing physical therapists should also

consider their professional role identity as flexible, malleable, and open to change, even if that
 231

change never involves a formal transition into leadership. Leading at the clinical level should be

considered equally important and physical therapists can advance their clinical practice and

influence in the healthcare setting by embracing the concept of personal and authentic leadership

at whatever level of the organizational hierarchy they currently occupy.

Recommendations for Physical Therapy Educators

Physical therapy educators should embrace and support the development of a broader

conceptualization of professional role identity beyond just the acquisition and demonstration of

competence in scientific and clinical knowledge and psychomotor skills. Advancing the interests

and broadening the scope of the physical therapy profession in a modern healthcare environment

requires professionals who are flexible, adaptable, growth-oriented, and able to view complex

issues from multiple perspectives. Participating in this type of environment requires training

which equips students with not only the clinical knowledge and skills to competently perform the

day-to-day essential functions of a physical therapist, but also the affective skills to navigate

complexity and meet the needs of a variety of stakeholders. Physical therapy educators should

work to foster grit, resiliency, and a growth mindset and assist students in embracing discomfort

and failure as learning experiences that will make them better physical therapists and leaders in

their future careers. Furthermore, physical therapy educators should move away from the historic

tendency to separate skills into “clinical” and “non-clinical” skills altogether. Instead, educators

should reflect upon their educational programs and curricula and work to instill concepts such as

leadership and management not as a set of skills to be acquired once a title is achieved, but as

essential skills required of the contemporary physical therapist at all levels of practice.

Recommendations for Employers

 232

First of all, organizations which employ physical therapists should consider physical

therapists when seeking to fill leadership positions. The physical therapists in this study all began

with a professional role identity which included a strong focus on affective skills including

communication and relationship building. The participants’ professional role identity also was

expansive, flexible, and growth-oriented indicating a willingness and ability to address problems

and issues of practice in a more global manner and with consideration for a variety of

perspectives. These skills were applicable as they transitioned into leadership positions,

lessening the role conflict and easing the transition when compared to the descriptions of other

healthcare professionals and their leadership transitions as described in the extant literature.

Recognizing, respecting, and embracing the unique perspective and skillset of physical therapists

and seeking them out for leadership opportunities may help organizations develop a more diverse

leadership team, one which is better equipped to tackle the complexities of modern healthcare.

Once organizations hire/promote physical therapists for leadership positions, the findings

of this study may help inform practices to aid in the transition from a clinical to a leadership role.

Leadership development is often a significant expense for organizations (Antonakis & Day,

2018). However, the results of this study suggest that organizations should consider focusing less

on highly rigid and structured onboarding processes and instead leverage personal relationships

to facilitate the work role transition. This study’s findings suggest physical therapists may

possess a capacity for autonomy and flexibility and place a high value on interpersonal

relationships both past and present. Organizations can play to these strengths by providing

structured training for the operational and technical aspects of the PT’s new role while providing

mentoring and peer to peer relationship building opportunities from which they can build a

support system.
 233

Organizations should also incorporate opportunities for the new physical therapist leader

to engage in reflective and metacognitive practice, individually and as part of a cohort of peers,

as well as with more senior leaders or mentors. New physical therapist leaders should also be

given the bandwidth to struggle and learn while also having the safety net provided by these

personal relationships. Finally, the boundaries of clinical care, leadership, and management

responsibilities should be clearly defined, adhered to, and if needed, enforced. The physical

therapists in this study occupied both worlds, clinician and leader, and did so successfully. This

stands in contrast to the literature on other healthcare professionals turned leaders which suggests

retaining a strong clinical identity may hamper other healthcare professionals in their role

transition. The physical therapists in this study used their clinical identity to inform their

leadership practice, making them stronger leaders. Organizations which promote physical

therapists to leadership positions should recognize and respect this uniquity in their PT leaders

and support it, while also ensuring through clear boundaries that it does not serve as a restriction

to their growth and development.

Recommendations for Future Research

Given the overall paucity of research on this topic, the avenues for future research

stemming from the findings of this study are many. This study was unique in that it addressed the

process by which physical therapists make meaning of their professional role identity while

transitioning from a clinical care role into a leadership role, and did so using a qualitative

methodology. Recommendations for future research include:

1. Further research into the process by which physical therapists define their

professional role identity is warranted. This study supported prior research (Hammond,

2013, 2016) which described the PT professional role identity as a malleable construct
 234

subject to modification and change. This study also identified the central importance of

affective and interpersonal skills as well as a flexible and growth-oriented focus. These

findings were unique and different from the conceptual analysis used to frame the study

(Fitzgerald, 2020). Future research should consider whether this definition is common

amongst a broader sample of physical therapists, or is unique to physical therapists who

ultimately pursue leadership positions.

2. Each of the participants in this study experienced a successful transition into leadership.

None of the participants reported any intention to leave their leadership positions or were

contemplating a return to clinical care exclusively. Future research should focus on how

physical therapists who chose not to remain in leadership positions made meaning of

their professional role identity during the transition. Furthermore, such a study could also

shed light on the pre-transition professional role identity of clinicians who attempted a

transition and were unsuccessful or chose to return to an exclusively patient care position.

3. Future research should consider the role of professional role identity when studying the

concept of leadership in physical therapy. Prior research has included a strong focus on

the identification of traits, competencies, and skills in order to define leadership in the

profession. This research is often performed using quantitative methods. Future research

should consider approaching leadership as a component of an overall professional role

identity, which in turn is a psychological and social construct developed by the individual

physical therapist through identity work within the confines of their lived experience.

Complimenting the quantitative quest to identify traits, competencies, and skills with a

qualitative focus on describing the phenomenon of leadership in physical therapy will

 235

provide a broader and more expansive view consistent with more contemporary

leadership research.

4. The participants in this study used discomfort as a reference point and a stimulus in

which to make meaning of their professional role identity. Future research should

consider the role of discomfort and the ability to use discomfort positively as a catalyst

for professional role development during significant professional transitions.

5. The consistency between self, clinical, and leader identities warrants further research

attention. Inconsistencies exist in the prior literature on this topic, with some research

suggesting this consistency may pre-date entry into professional training, some research

recommends the consideration of certain traits in the admissions process, and other

research suggests varying degrees of leadership self-recognition and self-efficacy

amongst PTs in different locations and settings. Future research should examine whether

physical therapists are drawn to the profession because of its consistency with their

existing self-image, or these consistencies are products of education, training, or work

experience.

6. The physical therapy leaders in this study all reported having a foot in both worlds, one in

the clinical realm and one in the leadership realm. This was not a hinderance to them, but

rather a component of their new role identity as leaders which they leveraged in order to

be successful and retain a valued component of their professional role identity. However,

each of the participants in this study were in their first leadership position which required

a significant departure from patient care responsibilities. Even the participants who

occupied full-time leadership positions retained some type of contact with clinical care
 236

responsibilities. Future research should examine the effectiveness of this component of a

leader identity over the long-term or when the demands of a leadership position increase.

7. This study shed light on the under-researched concept of professional role identity during

the transition from a clinical care role to a leader role. While the presence of physical

therapists in first-line or middle management positions is relatively common

(Glendinning, 1987; Hoekstra et al., 2021), physical therapists rarely occupy higher level

leadership positions in healthcare and academia (Sebelski, 2017). Future research should

examine how physical therapists make meaning of their professional role identity when

transitioning from first-line or middle management positions into higher level, executive,

or academic leadership positions.

Conclusion

To make meaning of their professional role identity when transitioning from a clinical

position to a leadership position, the eight physical therapists in this study began with a

professional role identity which was focused on more than just clinical skills. As the physical

therapists began their transition into leadership, they embraced discomfort and remained focused

on relationships. By doing so, they began to recognize the consistencies between their

professional role identity as a physical therapist and their developing professional role identity as

a leader. Ultimately, the physical therapists in this study made meaning of their professional role

identity when transitioning to a leadership position by establishing a professional role identity

which was informed by, but no longer bound by, their physical therapist identity. This study

represents one of only a few studies to examine the transition from a clinical physical therapist

role to a leadership role and the only study located to date which addresses the process of

professional role identity work during such a transition. The findings of this study hold
 237

implications for physical therapists, the physical therapy educational community, and the

organizations which employ physical therapists in their ranks. This study also highlights the need

for additional research in the field of physical therapy research to develop an improved

understanding of leadership in the physical therapist’s professional role identity so physical

therapists may be better prepared for the complex challenges of the modern healthcare

environment.
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APPENDIX A

SAMPLE E-MAIL FOR SOLICITING PARTICIPANTS VIA THIRD PARTIES

Dear __________,
I am conducting a dissertation study on how physical therapists make meaning of their
professional role identity when transitioning from full-time clinical practice to leadership and
management roles. At this time, I am working to identify potential participants for this study
with whom I have no professional or personal relationship. I am emailing you because you may
know of individuals who could serve as potential study participants.
I would like to request your assistance in recruiting participants for this study. If you have
contacts who meet the following criteria, I would greatly appreciate you sharing the topic of my
study with them and asking if they would be an interested participant.
Criterion for inclusion in this study include:

1. Physical therapist licensed in the United States

2. Currently serving in their first leadership/management position,
3. For the purposes of this study, “leadership/management” positions are defined as the
following:
a. Formal leadership position with title in a healthcare organization (ie: manager,
director, coordinator, etc.)
b. Excludes positions in academics
c. Excludes clinical teaching positions (ie: Clinical instructors, Site/Center
Coordinator of Clinical Education)
d. Excludes positions where primary workload remains patient care (ie: Lead
therapist, Team Lead, Senior Therapist, etc.)
e. Excludes leadership positions in professional organizations (ie: APTA, ACAPT,
CAPTE, etc.)
4. Hybrid clinician/managers will be considered if no more than 50% of their workload
consists of direct patient care.
5. Minimum 1 year and maximum 3 years in their leadership position
If you identify individuals who may be appropriate participants for this study, please send me
their names and contact information, including an email and/or phone number.
Thank you in advance for your assistance, it is truly appreciated. Please contact me with any
questions you may have.

Sincerely,
Christopher Wiedman
Doctoral Student
Drake University
[email protected]
319-464-2545 (cell)
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APPENDIX AA

SAMPLE E-MAIL WITH CLARIFICATIONS FOR SOLICITING PARTICIPANTS VIA

THIRD PARTIES

Dear Colleague,
I am conducting a dissertation study on how physical therapists make meaning of their
professional role identity when transitioning from full-time clinical practice to leadership and
management roles. At this time, I am working to identify potential participants for this study
with whom I have no professional or personal relationship. I am emailing you because you may
know of individuals who could serve as potential study participants.

I would like to request your assistance in recruiting participants for this study. If you have
contacts who meet the following criteria, I would greatly appreciate you sharing the topic of my
study with them and asking if they would be an interested participant.
Criterion for inclusion in this study include:

6. Physical therapist licensed in the United States

7. Currently serving in their first leadership/management position.
a. If the PT served as a “Lead Therapist”, “Team Lead”, “Senior Therapist”, or any
similarly-titled role which remained primarily clinical, I would not consider that
role as their “first leadership/management position.
b. In other words, if a participant was a lead PT and is now a Manager, Director, etc.
as defined below, for the purposes of this study we will consider the
manager/director, etc. role as the “first leadership/management” position.
8. For the purposes of this study, “leadership/management” positions are defined as the
following:
a. Formal leadership position with title in a healthcare organization (ie: manager,
director, coordinator, etc.)
b. “First leadership/management position” is considered the first position with
substantial leader/manager responsibilities. If the PT previously served in a lead
PT, Team Lead, Senior Therapist, etc. role which was still primarily clinical, and
is now serving in a leader/manager role as defined below, they would be
appropriate for this study.
c. Excludes positions in academics
d. Excludes clinical teaching positions (ie: Clinical instructors, Site/Center
Coordinator of Clinical Education)
e. Excludes positions where primary workload remains patient care (ie: Lead
therapist, Team Lead, Senior Therapist, etc.)
f. Excludes leadership positions in professional organizations (ie: APTA, ACAPT,
CAPTE, etc.)
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9. Hybrid clinician/managers will be considered if no more than 60% of their average

workload consists of direct patient care.
10. Minimum 1 year and maximum 3 years in their leadership position
If you identify individuals who may be appropriate participants for this study, please send me
their names and contact information, including an email and/or phone number.
Thank you in advance for your assistance, it is truly appreciated. Please contact me with any
questions you may have.

Sincerely,
Christopher Wiedman
Doctoral Student
Drake University
[email protected]
319-464-2545 (cell)
 265

APPENDIX B

RECRUITMENT EMAIL

Dear _______,

My name is Christopher Wiedman. I am a physical therapist and a student in the Doctor of

Philosophy in Education program at Drake University. I am seeking participants for my
dissertation study on how physical therapist make meaning of their professional role identity
when they transition from full-time clinical work to a leadership or management position.
You were referred to me by ________ as a potential participant in this study. This study seeks to
expand our understanding of professional role identity and how physical therapists adapt, revise,
maintain, or construct a professional identity when transitioning out of patient care and into
leadership/management roles. To collect data for this study, I am seeking licensed physical
therapists in the United States who have transitioned within their organization from full-time
patient care duties to formal leadership/management roles such as coordinators, managers, or
directors. Participants in this study should have served in this role for at least 1 year and no
longer than 3 years. If you meet these criteria and would be interested in participating, please
contact me using the information below.
Your participation will last approximately three to six weeks and will consist primarily of three
interviews which we will conduct over Zoom at times convenient for your schedule. Each
interview will last approximately 60 minutes. You will also be asked to provide basic
demographic details regarding yourself and your training. As the study progresses, I may send
additional emails asking for your feedback on emerging themes in the data analysis. Responding
to these emails should require a minimal time commitment at best.
Please know that your participation in this study is voluntary, you may decline to answer any
interview questions you wish, and you reserve the right to withdraw or pause your participation
in the study at any time. Likewise, strict confidentiality of your information will be practiced
throughout the completion of this study and the dissemination of its results.
If you are interested in participating, please contact me via email at [email protected]
or by cell phone at 319-464-2545.
Thank you for your time and consideration,
Christopher Wiedman
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APPENDIX C

SEMI-STRUCTURED INTERVIEW GUIDE

Interview One: Semi-Structured Life History/Clinical Professional Role

Identity/Professional Socialization Process as Identity Regulation

1. Tell me about your clinical career prior to taking a leadership position.

a. Positions held/Organizations worked for?
2. What was a typical day like for you as a clinician?
a. What were your day-to-day tasks?
b. What did “being a PT” or “acting like a PT” mean to you? What did it look or feel
like to you?
3. What knowledge and skills does a PT need to possess?
a. Which of these skills did you use regularly on the job as a PT?
b. What attributes make a good physical therapist in your view?
4. What ethical values should a PT possess?
5. How did you see yourself as a physical therapist?
6. How did you view the PT profession as a whole?
7. How did you view yourself as a member of the larger PT profession?
8. What differentiates physical therapy from other professions?
9. How would you describe your identity as a physical therapist when you worked in a
clinical role?
a. How did you come to see yourself this way as a physical therapist?
10. Looking back on your PT education, what experiences stand out as meaningful to you?
a. Describe your clinical experiences in physical therapy school.
b. Describe the experiences you had with your physical therapy instructors?
c. Can you describe how your professors influenced your view of a physical
therapist’s role or identity?
d. Describe what role, if any, the APTA has had in the development of your
professional role identity.
e. Why do you think these experiences stand out to you? What made them
meaningful?
11. How did you respond to these experiences in your training?
a. How did these experiences affect the view you held of yourself at the time?
b. How did these experiences shape the overall view of yourself?

12. When working in full-time patient care, how would you describe your role/place in the
healthcare system and team?
a. What exemplified your role in your healthcare organization?
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b. How was your role identity as a PT affected by the organization(s) you have
worked for?
c. When working for these healthcare organizations, did you identify more strongly
with the PT profession or the organization? Or Both? How?
13. What else would you like to tell me about your clinical experience and your professional
role as a clinical PT?

Interview 2: Lived Experience/Organizational Identity Regulation/Leadership Identity

Work

1. Tell me about your leadership position?

a. Describe a typical day in your leadership position.
b. Describe what the transition to this position looked like/felt like.
c. What tasks does your leadership position involve?
d. What knowledge or skills do you use regularly in your leadership role?
2. What has it been like for you as a new leader?
3. How does one act the part of a leader in your organization?
4. How did you decide to transition from a clinical position to a leadership position?
5. How would you describe the transition from clinician to leader?
a. How has the transition from clinician to leader made you feel?
6. Tell me about the leadership training, development, or mentorship you received when
transitioning?
7. Tell me what you feel your organization’s expectations are of you as a leader?
a. How do you feel about these expectations?
b. How have you responded/reacted to these expectations?
8. What do you feel your organization’s core values are?
a. What do you feel is important to this organization?
b. How do you think these values impact your day-to-day work?
c. How do these values compare with your personal values?
d. How do these value compare with the values important to you as a physical
therapist?
9. How do you see yourself as a leader?
10. What role do you see yourself playing as a physical therapist in a leadership position?
11. How would you describe other leaders in the organization you work for?
12. What differentiates you in your leader role from others in your team, organization,
and profession?
13. Describe how you see yourself in your leadership role.
14. What else would you like to share with me regarding your leadership position or the
transition from a clinical position to the leadership position?
 268

Interview 3: Reflection/Making Meaning of Role Identity – Outcome of Identity

Work/Reaction to Identity Regulation

1. How would you compare your typical day as a clinician to your typical day in a
leadership position?
2. How would you define the transition from clinician to leader?
3. What has transitioning from clinician to leadership meant to you?
4. What specific experiences during this transition have been most meaningful to you?
a. Why?
b. High points/Low points/Challenges/Rewards
5. Looking back, what did leadership mean to you when serving as a clinician?
6. What does leadership mean to you now?
7. Looking back, how do you feel the process of training and being socialized into the PT
profession affected you?
a. Did living through that process affect your self-identity in any way?
b. If yes, how?
8. How has taking this leadership position affected you?
a. Has living through this transition affected your self-identity in any way?
9. Have you been given the opportunity to provide any feedback on the transition, or any
training you may have received?
a. Are you willing to share what that feedback was?
10. How do you feel about your role and your work now compared to when you were a full-
time clinician?
a. Similarities?
b. Differences?
c. Consistencies? Inconsistencies?
11. How has transitioning to a leadership position affected your role in the physical therapy
profession?
a. How has it affected your role in your organization?
12. How does your view of yourself in this leadership position compare to your self-view
when working full-time as a clinician?
13. Is there any aspect of yourself that you have needed to change or adjust to adapt to your
new role in leadership?
14. Is there any aspect of the leadership role that you have adjusted to fit it with the view you
hold of yourself?
15. Overall, how would you describe your professional role now, as a physical therapist
serving in a leadership position?
16. What other insights or reflections would you like to share about the effects of this
transition on your professional identity?
 269

APPENDIX D

INFORMED CONSENT DOCUMENT

Title of Study:
Physical Therapists’ Professional Role Identity and the Transition to Leadership: A
Phenomenology
Investigator: Christopher Wiedman
This is a research study. Please take your time deciding if you are willing/able to participate.
Please contact me with any questions you may have.

Introduction
The purpose of this study is to understand how physical therapists make meaning of their
professional role identity when transitioning from clinical to leadership positions.

Procedures
Upon agreement to participate, your participation will consist primarily of three interviews over
the videoconferencing application Zoom. Each interview will be recorded on the Zoom platform
with a secondary audio recording being done for redundancy. The three interview format will
proceed as follows:
1. A semi-structured life history interview designed to allow me to get to know you and
learn about your clinical work as a physical therapist, your training and education, and
your professional role identity prior to moving into a leadership/management position.
2. A semi-structured second interview concerning your transition to leadership/management
and your experiences during this transition.
3. A semi-structured final interview reflecting upon the meaning of the clinician to
leadership/manager transition and your professional role identity.
In addition to interviews, you may be asked to share demographic information about yourself as
well as share any documents relative to your physical therapy and leadership/management
training.
Your participation will last approximately three to six weeks and will include at least six points
of contact:
1. Initial contact/introduction of the project and completion of informed consent
documentation;
2. The first 60-minute semi-structured interview (via Zoom);
3. The second 60-minute semi-structured interview (via Zoom);
 270

4. The third 60-minute semi-structured interview (via Zoom);

5. An emailed copy of the interview transcripts for you to review for accuracy;
6. An email summary of emerging themes from the data analysis with an opportunity to
provide feedback.

Risks
There are few foreseeable risks from participating in this study. Participants will give up their
time when participating in this study. If you are negatively impacted by this study in any way,
please contact the Drake Institutional Review Board at [email protected] or 515-571-3472.

Benefits
If you decide to participate in this study, there may be no direct benefit to you. However,
participants may derive benefit from the opportunity to reflect on their professional journey and
their role identity as physical therapists and leaders. The results of this study may help inform
physical therapists and healthcare organizations in the transition of physical therapists into
leadership positions.

Compensation
You will not be compensated for participation in this study.
Participant Rights
Your participation in this study is voluntary, and you may decline to participate or leave the
study at any time. If you decide to not participate in the study or leave the study early, it will not
result in any penalization or loss of benefits to which you are otherwise entitled. You can skip
any questions that you do not wish to answer in the interviews, decline requests for documents,
and choose not to reply to any requests for review of transcripts or data analysis findings.

Confidentiality
Any written reports, publications, or disseminations of this study will not include any personal,
identifiable data about any participant. However, federal government regulatory agencies,
auditing departments of Drake University, and the Institutional Review Board (a committee that
reviews and approves human subject research studies) may inspect and copy your records for
quality assurance and data analysis. These records may contain private information. To ensure
confidentiality to the extent permitted by law, your identity will be kept confidential. Any
personal information by which participants can be identified (such as your name, employer,
place of business, or other key demographic data) will be replaced with pseudonyms or non-
specific identifiers. All documentation of the interviews, including digital recordings and their
transcripts, will be stored on a password-protected computer and backed up on a second
password-protected computer. All documents, demographic information, and data analysis
documents will also be housed on a password-protected computer and backed up on a password
 271

protected computer. The Drake University Institutional Review Board committee, my

dissertation advisor, and my dissertation committee may view the data. The data collected will be
retained for a minimum of three years and destroyed when it is deemed no longer useful for
research purposes. If the results are published, your identity and all identifying information will
remain confidential.

Contacts and Questions

You are encouraged to ask questions at any time during this study.
For further information about the study, please contact:
Christopher Wiedman (researcher) Dr. Robyn Cooper (Advisor)
[email protected] [email protected]
319-464-2545 515-271-4535

If you have any questions about the rights of research participants or research-related injury,
please contact the IRB Administrator at 515-271-3472 or [email protected].
You may keep a copy of this form for your records.

Statement of Consent
Your signature indicates that you voluntarily agree to participate in this study, that the study has
been explained to you, that you have been given the time to read the document, and that your
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