Perspectives on gender and professional issues among female physical therapists.

P Raz, MS, PT, is Physical Therapist, Physical Therapy Department, Lewis Gale Hospital, 1900 Electric Rd, Salem, VA 24153. She was a student in the Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham, Birmingham, AL 35294, when the study was completed in partial fulfillment of her master's degree requirements. GM Jensen, PhD, PT, is Associate Professor, Division of Physical Therapy, School of Health Related Professions, The University of Alabama at Birmingham.

J Walter, EdD, PT, is Associate Professor and Director, Program in Physical Therapy, School of Health Sciences, Oakland University, Rochester, MI 48309.

LM Drake, PhD, ATR, OTR, is Associate Professor, Division of Occupational Therapy, School of Health Related Professions, The University of Alabama at Birmingham.

Address all correspondence to Ms Raz at 2603 Derwent Dr SW, Roanoke, VA 24015 (USA).

This article was submitted January 28, 1991, and was accepted March 20, 1991.

The purposes of this study were to identify gender-related values, perceptions, and experiences of female physical therapists as these factors relate to female Physical therapists' professional development and to offer an initial critique of the identified elements in comparison with a traditional model of professionalism. In-depth interviews were conducted with 10 physical therapists in two different states by the primary investigator The interviews were analyzed utilizing qualitative data-analysis techniques, and a conceptual framework was developed from the literature and the interviews. Three major thematic categories were identified.- 1) values, comprising the subcomponents of caring, relationship, empowerment, and context, (2) family role, comprising the subcomponents of enhancements, limitations, and coping strategies, and (3) sexism, comprising the subcomponents of leadership, money, and respect. These findings provide an initial basis for understanding more about factors that may both limit and enhance female physical therapists'professional development. [Raz P, Jensen GM, Walter J Drake LM. Perspectives on gender and professional issues among female physical therapists. Phys Ther 1991;71:530-540.]

Key Words: Gender identity,. Physical therapy profession, professional issues; Professional competence.

Physical therapy in the United States was originally an occupation composed almost entirely of women., The field currently remains about 75% female.2 Since the 1970s, there has been an organized effort among physical therapists, especially among the leadership as represented by the

American Physical Therapy Association (APTA), to achieve greater autonomy and professional status.(3) Several attributes or characteristics have traditionally been associated with an occupation gaining professional status.(7,11) The core attributes that differentiate professions from occupations have been drawn from the practice and ideology of established, predominantly male professions (eg, medicine, law, the clergy).(7,8) These attributes include possession of an established body of theoretically based knowledge; extensive, specialized training., a code of ethics; control over standards and training; a service orientation; autonomy of judgment; and a professional culture.(7,8) Although sociologists continue to argue that the process of professionalization involves a dynamic, interorganizational, political process,(7,9) there still is general agreement about possession of certain core attributes.(7-9) These attributes provide an ideology to which an occupation often aspires in trying to remove apparent deficits. Critics and other scholars of the professions suggest that the true attributes of professionalism are more vague and inconsistent and may be used to mask more objectionable qualities, including sexism, racism, classism, ambition, and greed. They describe the process of professionalization as being dynamic and both politically and economically motivated.(9,10) The "semiprofessions" are identified by Etzioni(11) as a middle ground between profession and nonprofession.

They are characterized as being predominantly female, being involved in direct client contact, having a strong emphasis on caregiving, and requiring supervision and outside control. In addition, semiprofessionalism implies a technical rather than a theoretical knowledge base, a limited sense of competency, and less intrinsic commitment to professional norms. At present, the occupation of physical therapy could be categorized as a semiprofession,(12) similar to those identified by Etzioni(11) for social workers, school teachers, librarians, and nurses.

The struggles of a predominantly female semiprofession to achieve greater professional status, as defined by an ideology based on male-dominated fields, present some important questions for women in the field. What are women's experiences in relation to their work and their professional development? What values are central to women's work as physical therapists? What questions arise when the predominant model of professionalism is viewed in light of women's experiences?

A review of the physical therapy literature in the United States reveals a lack of critical examination of questions such as these, although investigators in other countries have raised more general questions about physical therapy in relation to gender, social class, and medical dominance.(12-14) Researchers in the fields of nursing and education have been much more active than researchers in other fields in performing a feminist critique of the professions.(10,15,16) Melosh(16) argued that the second-class status afforded to women by our society precludes a true women's profession from existing, although individual women may attain professional status. Rosenow(15) stated that an incompatibility exists between the ideal feminine role and the professional role. Noddings(10) posed the challenge to nurses to achieve professional status among the otherwise male-dominated professions and yet maintain their own internal standards, which include an emphasis on relatedness, caring, and social context. This claim to separate internal standards is supported by current moral and psychological theorists such as Gilligan,(17) who proposed that there may be inherent differences in the way women and men prioritize, conceptualize, and behave.

In developing an understanding of the relationship between women and work, an investigation of the caregiving role is needed. Graham states, "Caring, it appears, describes more than the universal feelings women have: it describes the specific kind of labor they perform in our society."(18(p25)) Dual roles within the home and the work place are viewed by some as creating tensions for working women. A concurrent commitment to family often requires discontinuous, part-time work schedules. In many instances, professional socialization norms have required continuous, full-time work commitments.

According to Finch and Groves,

Because paid work is mostly organized around the lives of men, few allowances are made for employees who may also have responsibility for the care of a highly dependent relative. Women who by choice or necessity attempt to combine work with caring often ... reduce their hours of work or restrict their employment opportunities to accommodate their "caring" responsibilities. 19(p7)

A 1986 special report to the APTA House of Delegates entitled "Women in Physical Therapy" was presented to "provide more detailed information on the [economic and professional] disparities between women and men in physical therapy and on the factors that may contribute to the disparities."(20(P156)) The report revealed that female active members of the APTA significantly lag behind male active members in self-employment, responsibility for administration and management, holding the master's degree as the highest earned degree, and gross annual income, although they lead male active members in holding part-time salaried positions.

One of the future objectives in this report called for the study of the societal and negative influences that limit the aspirations of women in physical therapy.

Morrow(21) reported that the professional attitudes of the APFA membership and leadership indicated significant potentially gender-related differences in values and experience between these two groups. He reported that delegates to the APTA House of Delegates had a greater tendency to be male (44%) than did representatives of the general membership (27%). Delegates tended to work in more responsible or creative settings, to be strongly in favor of increased professionalization, and to hold value priorities of self-reliance and achievement, which included traits of independence, ambition, and logic. In contrast, active nondelegate members of the APTA tended to work in environments that limited the exercise of professional judgment, responsibility, and decision making. Active nondelegate members reported less favorable attitudes toward continued professionalization and showed virtuous or humane values, which included traits such as love, cheerfulness, helpfulness, and forgiveness.

Morrow's(21) data and the APTA report on women in physical therapy(20) suggest the necessity of an active investigation into the thoughts, values, and experiences of the physical therapy community in order for meaningful and authentic changes related to professionalization to occur. Additionally, many scholars of the professions have called for a new career model that takes into account the lifestyles and values of women.(10,16,22-25) The purposes of this study were (1) to investigate the values and experiences of a small sample of female physical therapists in the course of their professional development, as they relate to key elements of the gender and professional issues identified in the literature, and (2) to develop an initial conceptual framework, based on the literature and the data obtained in this study, that can be used for posing questions about the traditional view of professionalism and for guiding future investigations.

Method

Sample

A purposive sample was used. The subjects (interviewees) were 10 female physical therapists from two geographic locations (northern California and Alabama). The criteria for participation in the study were that each subject (1) be female, (2) spend at least 50% of her work time in patient care, and (3) be willing to give thoughtful consideration to a discussion of gender issues. Eighteen possible interviewees were nominated by five clinically or academically active physical therapists in both geographic areas. Ten available subjects were then selected to represent a spectrum of physical therapy specialties, with the aim of describing the personal experiences of a diverse group of physical therapists (Table). The use of only female subjects disallowed any inference as to the values and experiences of male physical therapists, except as they were perceived by the female subjects of this study.

Instrumentation

The interview was chosen as the primary method of data collection in order to examine the values, perceptions, and experiences that influenced these female physical therapists' professional development. The interviews were conducted by the primary investigator (PR), utilizing an interview guide and following a nonstandardized format; that is, the order of interview questions varied. Interview questions were developed from a review of the literature, discussions with experienced physical therapists, and pilot interviews. The interview questions addressed the issue of personal background, work experience, opinions, and analysis of gender and professionalism as related to professional development. The interview guide was reviewed for content validity by the research committee, consisting of two physical therapists (GMJ and JW) and an occupational therapist (LMD), all trained as social scientists. These individuals reviewed the interview guide questions that pertained to gender and professional issues, and minor revisions were made.

Two pilot interviews were conducted to better assess the effectiveness of the interview guide and to refine the primary investigator's use of the interview format and equipment. Both interviews were audiotaped, reviewed, and transcribed. Additional revisions were made in the interview guide on the basis of the pilot interviews.

Procedure

Initial contact with each subject was made by telephone, and an interview appointment was scheduled.

Interviews were conducted either by telephone or in person. Prior to the interview, demographic data were requested from the subjects in order to provide a description of the sample population. Interviews were conducted using the interview guide and open-ended questions to clarify the responses of the subjects.

All interviews were audiotaped and later transcribed.

Data Reduction and Analysis

The analytic procedure followed the five modes outlined by Marshall and Rossman.(26) These modes consisted of organizing the data, generating coding categories and identifying major concepts or themes in the data, testing emergent hypotheses against the data, searching for alternative explanations of the data, and writing the results. The initial organization of the data was accomplished as the primary investigator transcribed each audiotape.

Transcriptions of each interview ranged from 6 to 16 single-spaced pages in length. A preliminary conceptual framework was formulated, based on the literature review and initial data from the transcribed interviews, that grossly identified potential major concepts (ie, the values and experiences of female physical therapists that may alter the traditional view of professionalism). The values and experiences identified at this time were sexism in society, whole-person experience, family responsibilities, caring, and empowerment. The data were then coded according to the coding categories generated by the interviews, the review of the literature, and the initial conceptual framework. More than 15 coding categories were utilized Appendix).

The coded data were analyzed, including consideration of frequency and negative examples, and then consolidated into three major concepts of values and experiences: values, family role, and sexism.

These concepts were incorporated into the revised and finalized conceptual framework (Figure). Reliability was addressed through the use of low- inference descriptors (eg, verbatim accounts of interviews, direct quotes as supporting data), a conceptual framework grounded in theory, the data, and the defined categories.(26,27) The results and discussion section of the project was sent to each subject for feedback and correction of any researcher misinterpretation. The subjects' responses served as a check on internal validity.(26,27)

Results and Discussion Conceptual Framework

The original representation of the conceptual framework was expanded and clarified following an analysis of the data. These modifications resulted in the final form presented in the Figure. The top part of the framework represents attributes associated by scholars and critics with the traditional professions, such as law and medicine.(7,8) The middle level contains the primary data collected from the 10 interviewees, categorized according to the three primary concepts (ie, values, family role, and sexism).

These concepts and the respective subcomponents were perceived by the interviewees as the values and experiences that have influenced and guided their professional development. The data collected from the subjects, along with the investigators' interpretive comments, will be discussed first. The bottom part of the Figure represents a secondary purpose of this study (ie, to explore what questions arise when the role of a traditional professional ideology is compared with women's experiences in the profession). This part of the conceptual framework will be addressed in the Implications" section.

Values

Relationship and caring. The interviews revealed the high degree to which the physical therapists valued their interpersonal relationships with both patients and colleagues, supporting the theories of Gilligan(17) and Noddings(10,23) that women tend to orient themselves around issues of care, social context, cooperation, relationship, and responsibility. Many subjects viewed interpersonal sensitivity and skill as their greatest attributes as professionals.

My strengths? ... I would say communication abilities, working with difficult patients ... I think that's probably my strongest point ... I can get along with almost any kind of patient. (Subject 6, p 11)

I had a patient today who said, You all are always so cheerful, and you're always so interested in your patients." .

She was talking about PTs [physical therapists] in general ...... You're so nice, you just make everyone feel so special." I feel like that's a lot of it. It's making people feel a personal touch, a motivation kind of thing. And really, I know the therapy is a big part of it, but

I almost feel like that's the biggest part. (Subject 9, p 6)

The qualities of receptiveness and responsiveness were considered important components of the physical therapy intervention itself and also important, and sometimes critical, to the other general health needs of the patient. The importance of these qualities is demonstrated by these two examples:

Oftentimes, a number of us have had a physical therapy session . . the person comes in and all we do is sit and talk, because that's what they need. it's not that we were counseling them; it's just that we were listening to them and letting them talk. And oftentimes as they talk, they come up with the answers and with the next decision that they need to [make]. Subject 1, p 7)

This week I saw a patient ..., and, after talking to him, I realized that this man was probably somewhat suicidal and had a lot of things going on with him, and so I left him [the physician] a big note and said we have to deal with this gentleman not on a PT or medical level but let's get this guy to a psychiatrist or something... So, you know, it's not always PT-related, when I alert the physician. (Subject 4, p 3)

Context. The subjects also viewed their patients not as isolated individuals, but within the context of their homes, families, and communities.

This attention to social context allows the patient to be viewed as a person within a complex network of relationships and responsibilities.10,23

At the time you're treating them. you have to care about that person and their family and how they're going to fit back into the family and their own personal lives. (Subject 3, p 7-)

Home health I really enjoy, because it has the flexibility of the situation. Each home is different; you have to adapt things differently for each patient. . . .

You do see them to an end point and see them functioning in a community, so I think I enjoy that the most. (Subject 4, p 3)

.. to me, it's more rewarding to see the person as part of a family or part of a unit and to see the impact I might be making on not only the patient, but their family as well. (Subject 7, p 3)

Empowerment. Another value espoused by the subjects was empowerment of the patient. Perhaps linked to their gender roles as nurturers and mothers, the women spoke frequently of their clinical roles as enablers and assisters, fostering independence and individual growth.

I don't see my patients for a real long time. As soon as I feel like they can do it on their own, I let them go on and do it on their own, 'cause the cost is so much. ... A lot of it's one-on-one motivation and hands-on manual therapy of some sort, as well as trying to give them a home program and take responsibility of their injury on themselves and handle it themselves. (Subject 9, p 2)

I've changed my own philosophy from being a physical therapist to being a teacher. What that means is that I approach people from a point of view of not being responsible for making changes in their bodies, but rather teaching them to take control of them and giving their bodies back to them. (Subject 10, p 4)

These values are not exclusive to women, and a similar study of male physical therapists might also reveal a strong orientation toward caring, relationship, context, and empowerment.

Conversely, we cannot assume that all female physical therapists experience or exhibit these types of behaviors all or even some of the time. Failure to care or to empathize clearly does occur among women, although, perhaps not surprisingly, the research did not reveal many examples of the absence of these values.

Family Role

Family responsibilities and the care-giving role assumed by the women within the family structure emerged as a significant factor influencing the shape of the interviewees' work lives. Six of the 10 women interviewed were mothers. Two of the 4 women who were not mothers and who were in their early 30s foresaw motherhood as a definite option for themselves in the future. When asked where they saw themselves in 5 years, they responded:

In 5 years, possibly having a family... and working, definitely working, but having a family, not necessarily working full-time. (Subject 1, p 4)

It depends on if I have a family or not.

If I don't have a family, I'll probably be a partner in a practice, my own practice.

If I do have a family, in 5 years I may not have that practice. (Subject 2, p 3)

These women anticipate the impact family responsibilities may have on how they coordinate their time and their careers. When asked what impact having children has had on their careers, the six therapists who are mothers spoke of both enhancements and limitations. They also outlined some of the coping strategies used by themselves and other women to balance their personal and professional lives.

Enhancements. Although not explored in-depth in this research, the personal and professional enhancements of child rearing mentioned by the subjects included personal development and growth; increased incentive to earn income, especially in single-parent households; and expanded professional interests.

Having a family has affected my career in terms of aiding my own emotional development. (Subject 10, p 7)

It probably has enhanced it [my career], because ... since my husband died, I've had to support my family.

I've had to achieve a certain amount of income from my work. (Subject 3, p 3) It's really enhanced [my knowledge in] an area that I never knew anything about, which is the prepartum and postpartum aspects ..... I've been lecturing at some seminars for nurses on postpartum exercise, and I put on a course for physical therapists ... on basic physical therapy and obstetrics 

..... Having a kid has actually really made a difference in an area that I probably wouldn't have gotten involved with. (Subject 6, p 5)

Certainly, the emotional, developmental, and intellectual rewards of motherhood cannot be neglected as important factors in many physical therapists' family- and career-planning decisions. In addition, the financial responsibilities assumed by women heading single-parent households would certainly be a strong motivating factor for those physical therapists in maintaining and developing their professional identity. Finally, the appeal of pediatric, obstetric, and geriatric physical therapy practice may be increased for some women in light of their reproductive, nurturing, and care- giving roles,

Limitations. in terms of limitations in their career development, a major recurrent theme was the time and energy constraints family responsibilities placed on these women and the subsequent impact these constraints had on their ability to participate in continuing education courses and professional organizations and to assume administrative and supervisory positions within their work place.

My ability to take continuing education courses has changed dramatically in having children.... Some of the more

.. advanced courses are done 5, 6, 7, 8 days at a time ..., which makes it almost impossible to participate ... and to commit to a course 6 months in advance when I don't really know if my husband will be around to take care of the kids if I'm not there. (Subject p 5)

If I didn't have a family, I'm pretty sure I would have been in a supervisory role, administrative. Subject 5, p 3) I think if I didn't have a family, I would be full-time in a position where I could be an administrator. ... [Regarding professional organizations,] I'd love to ... run for delegate or something, but ... it takes a lot of time and energy, and I'm not sure that I can do that. . .. If you're going to chapter meetings and all that stuff, you're going to miss a lot of time with your kids. ...

I've thought about serving on committees and things, and I think, well, that means my husband will have to babysit more. You know, I'm putting a lot off on him, and I don't think that's fair. (Subject 9, p 5)

The interviews demonstrated that the impact of family responsibilities on the professional development of these women was considerable. Despite the high level of commitment many of the subjects expressed toward their work, they tended to view their commitment to family as being somewhat in conflict with their commitment to their career.

During the time when my children were younger, they were more of a priority, rather than therapy. . . . I didn't ever want to not work, but if something would have come up where it would have been very difficult for me to choose. ... But I still worked almost the whole time. (Subject 5, p 3) Since I have children now, that's become even much more important than what I do at work. And what I'm really trying to do now is move away from that concept of my work being the most important thing and treating it more as just a job. (Subject 10, p 6).

The degree of conflict between family and career varied considerably among subjects. Evetts,(25) based on her study of British headteachers, attributes this variation in level of conflict to variations in individual career ambitions, spouse relationships, and attitudes toward motherhood. Generational and geographic factors also may be influential.

I would say definitely that family comes first. I'm a mother; that goes along with that. But at the same time, my family has never made me compromise anything. My kids have always been healthy. ... I think I've probably lost 4 days of work in the 17 years I've had kids due to child illness. (Subject 8, p 3)

My work is equal to my kids. 1 mean my work is very important to me, and I love my work, and I wouldn't give it up for anything. . . . But now I've got these two children, and I feel like it's also a big responsibility. ... This is why women don't progress in our profession. Cause once you have kids, you're split. . . . Men apparently are not. . . . I don't know many men [who] are torn between their profession and their kids. (Subject 2, p 4)

Although some subjects did mention shared responsibilities and supportive husbands, the subjects appeared to consider women the primary caregivers in child rearing.

I know women out there [who] are directors of departments and have families, and they're doing an absolutely stupendous job. ... I don't know if they have a husband at home who is being exceptionally and unusually supportive, if he's a househusband, or if he also has his own career, but it is flexible in the hours [so] that the two of them feel very good about the care that their kids are getting and the attention their kids are getting. I think that's rare though. I think that's the exception. (Subject 1, p 12)

I do see women having to maybe put their careers second, or they choose to put their careers second, because, for whatever reason, their husband's profession is ... still seen as more important.

. . . I still hear from female friends who talk about having to take care of so much at home that it makes it difficult for them to have the energy or the time to pursue some professional aspirations. (Subject 7, p 11)

The subjects interviewed confirmed an observation found in much of the literature that women who assume the dual roles of primary caregiver and career woman often must make compromises among income, career development and advancement, and time at home attending to their domestic lives, Many cite the demands of childbearing, child rearing, and other family responsibilities as major impediments for women in achieving the model of traditional professional behavior. Coping strategies. To cope with the dual responsibilities of career and family, female therapists use a variety of strategies. None of the women interviewed chose the option of discontinuing their work completely while rearing children. Most commonly, they chose to work part-time or to put stricter limitations on the hours they do work. Job sharing, convenient location, and private practice also allowed the subjects more freedom to attend to family responsibilities.

I've just recently started working halftime.

... For the first time, I'm ... able to do things that I ... need to do to keep my sanity and spend more time with my kids and [participate in] functions in their lives. ... Working three-quarters-time was essentially what I did from the time of the birth of my second child, who is 2 1/2 And that was extremely frustrating, 'cause I was scheduled to work 32-hour weeks, but

I usually worked 36 to 40. ... Especially in a management role, I think you find yourself working longer hours. ... Now that I've stepped down from that, I'm working essentially between 20 and 24 hours a week, to be primarily a patient care person. (Subject 6, p 4)

I leave on time. That's my biggest thing. . . . I work part-time, and I work 9-hour days so that I can get full-time benefits so that I can be home 1 day a week with the kids. And it just takes a lot of energy, and I just try to have it. (Subject 9, p 4)

There's always a little bit of the edge of guilt. ... [H]ow is that affecting my child, having to go to day care at the end of the day and all that stuff? And so what I have done to balance that is that when I leave work, I leave work. I do not take work home. And on weekends, it's totally for the family. (Subject 10, p 7)

Private practice, although perceived by some women as being more time and energy intensive, may actually afford some women greater flexibility to attend to their family's needs.

Being in private practice helps to balance (my personal and professional lives) a little bit, because I can arrange my schedule any way I want to; whereas, if I worked in a 9-to-5 job, at a certain point that ... would start to interfere with other people, and then that becomes a problem (Subject 10, p 7)

An informally cooperative work situation allowed one subject the flexibility to care for her children to a satisfying degree.

I enjoyed the part-time job I had at the clinic. . . . I shared it with another gal,

We just had a great time, because she'd cover for me if I needed to have time off if my kids were sick, and vice versa, cause we started doing it when our kids were ... 6 or 7 or so, During those times of your children's lives, you have unexpected illnesses or commitments. You want to go with your kids on a field trip ... or vacation times. ... That was a wonderful experience. (Subject 3, p 5)

Another physical therapist expressed the importance of job site in helping her maintain the balance between her private and public work lives.

.. so I worked part-time and have tried to find jobs locally, so I don't have a big commute. ... It's worked out great. I've always tended to work fairly locally, so that I'm sort of close around. Subject 5, p 3)

As noted by Evetts,(25) the career patterns of professional women often do not progress in the traditional linear manner, but rather in accommodation with the needs of young children. Once the children are older, women may feel freer to devote more of their time to their careers.

Well, I think I may be expanding my career again once both children are in elementary school. ... In my forecasting, I would imagine I would be more involved in my career at that point, (Subject 6, p 6)

[I was] a full-time physical therapist when I was first working and [became] a part-time physical therapist when I was raising my family, and now I've gone back to full-time, because I'm single, I lost my husband, my girls are raised, and 1 don't see why there's any reason why I shouldn't work full- time right now. (Subject 3, p 2)

Sexism

Prejudice or discrimination against women has been implicated in the exclusion or limitation of women within the professions.16,2 A number of the study participants clearly stated, however, that they did not feel that sexist attitudes affected their professional development.

I don't think I'm excluded from enjoying things of the professionals just because I'm a woman. (Subject 2, p 8) I have never felt that being a female limited me in anything I wanted to do. (Subject 3, p 8)

Nonetheless, these women, along with the other interviewees, revealed interesting insights concerning the impact of gender issues and sexism on leadership, money, and respect within the field of physical therapy.

Leadership. A commonly expressed opinion was that there is a tendency within physical therapy and within the medical world in general for men to disproportionately assume leadership positions, a fact confirmed by previously noted data.20,21 Some of the physical therapists interviewed acknowledged that women's dual roles are responsible for the limited time and energy available to them to pursue leadership positions, and they expressed dissatisfaction with the powerlessness and diminished status and opportunity associated with the lack of leadership.

Most of the time, the upper echelon are males. . . . [I]f you're in a hospital, usually the director of services is a male, or, in the case of working for the county ... the entire administration and who everyone answers to are all males. So as it filters down . . ., the women have a lot of push and pull, but the bottom line is still who's running the show up top. (Subject 5, p 8) I think the men are being picked for management positions, and ... I don't think that's a positive from the female point of view, especially from the mother point of view. There's no question, I felt that I was a fairly effective manager when I was a mother, but the issue of wanting to work part-time and be a manager never worked. So what happened ... with my department is that it went from female run, almost exclusively female, to now all the men are seeking the management positions

. . ., and I think that's unfortunate, because a lot of the men coming, you know they're buying private practice, they're managing, and getting more money ... (Subject 6, p 13)

Unlike the therapists who denied the influence of sexual discrimination on their professional development, some subjects believed that they had experienced or witnessed overt incidences of sexism, in which disrespect and discrimination against women served to limit the influence and advancement of female physical therapists

In my setting, more of the managerial-type people have been men, and I do feel like ... there has been somewhat of an "old-boy network" among some of the administrators where I work. ... [S]ometimes I wonder if what I say is going to be valued or considered as much as the comments of the crony of the administrator. (Subject 7, p 9) Within the profession itself, as more males aggressively moved to the top within departments, it was perpetuated that the female stayed down and the male went up. . .. Men would come in and take over the department, and all of a sudden the guys were getting these assignments, and they were being given extra things outside the hospital, and they were being sent to continuing ed in a different way, and the whole perspective was different than if the female came in and said, "This is what I want to do." And if a man came in and said, "I want to develop this program," fine, go ahead and do whatever you want. The female came in, they'd say, "Well no, you have to work through this, and this, and this, and this." (Subject 10, p 11)

Money. The low salaries of physical therapists historically were viewed by some of the interviewees as resulting from the lesser financial need of women. The entrance of men into the profession is credited with the current rise in salary that physical therapists come to expect, with the male role as "breadwinner" being an important factor.

We were primarily or exclusively a female profession at first. . . . Probably

.. that hindered us from going on and being viewed as professional, because

.. women weren't looked at as being equal. . . . I think that shaped us a lot, I think that ... kept salaries very low for a long time, because it was seen as not that important for a woman to make a decent salary, because she was just supplementing her husband's income. or maybe she didn't have children, so

.. people thought they didn't need much money. Subject 7, p 11)

.. and the other side of the coin is that they [men] helped to change the profession, so that all of a sudden we weren't being paid $7,200 a year; we were getting paid more. And so there was something from the male point of view that was going to push some change on the profession. Subject 10, p 11)

The subjects also noted that male therapists tended to earn more money than female therapists. The subjects often attributed this difference to the more well-paying fields within physical therapy that they perceived men entering. Several subjects associated men's roles with increased greed and ethical misconduct within physical therapy.

I think maybe the male gender of the physical therapist end of it is more into moneymaking, sometimes not too ethically. (Subject 3, p 8)

What has developed out of this [men entering the profession] is a stronger private practice, a lot more independence, a lot more push into the business aspect of it. . . . But there's also ... a lot more greed involved in the profession [now]. [There have] been a lot more scandals, a lot more being sued. (Subject 10, p 11)

Although the interviewees seemed to find financial ambitiousness within physical therapy as distrustful and alien, several of the subjects expressed the opinion that physical therapists continue to be underpaid for the worth of their work. This lack of remuneration may be linked to the failure of society to monetarily reward caregiving and women's work in general, to many women remaining financially dependent on their spouses, and to women being less socialized than men to strive for financial success within the work world.

Respect. in terms of respect, the interviews revealed an imbalance of status between the sexes, with significant consequences regarding how a woman is viewed professionally.

There is still a tremendous amount of sexism out there on the part of physicians, and they will listen to a male therapist much more seriously than they will listen to the female therapist.

Even though we are saying the same thing, we come from the same educational background. Subject 1, p 9)

If you take ... supervisors of programs I still don't think that the supervisors who would be female would be considered the most professional physical therapists. Now if those same departments are run by males, whether they were competent or not, they would be given more respect and more adulation simply because they happen to be male. (Subject 5, p 10)

The following story was told almost identically by 4 of the 10 women interviewed, indicating that female physical therapists are associated with lower-status, semiprofessional nurses, whereas male physical therapists are associated with high-status, traditionally professional physicians.

We're always trying to be ... recognized as what we are and who we are and what we know. I feel like sometimes I'm constantly explaining myself Like to patients, too, it's, "Oh, did you just go to college for 2 years?" And I don't know if they would do that with a lot of male therapists, because oftentimes they'll say, "Oh, Dr so-and-so was here," and I'll say, What do you mean Dr so-and-so?" And then I say, "No, he's just a physical therapist; he's not a doctor." Subject 4, p 6)

Even the aides in the hospital setting, the physical therapy [six] assistants or aides, if they wore a white coat and they were males, more often than not the patients would call them "doctor" and ask them lots of questions. It was really funny. . .. That probably hasn't changed either. (Subject 5, p 12)

The lack of recognition and respect female physical therapists encounter from patients, physicians, and health administrators has an impact on the professional status of a female-dominated field and on the status of individual women within the field.

Implications-Questions for Consideration

This research has focused on the gender-related values and experiences of 10 female physical therapists.

The topics explored cannot be assumed to be gender-specific, because many men in the field may identify strongly with some of the issues raised, Additionally, although a review of the literature(10,16,17,24) supports our assertion that these issues are gender-related, this factor does not preclude other societal influences that cross-cultural or comparative studies might reveal.

The intent of the research was not to generalize findings to the larger population of physical therapists, but rather to gain insights from individual women in order to expand and further define the conceptual framework, identify underappreciated issues and problems female therapists may face, and explore and expose new territory for further discussion and investigation.

Formal reliability testing of our coding scheme, that is, determination of interrater reliability measures, was not done. in our research, the initial coding scheme was part of the data-reduction strategy that helped move us to identification of fewer categories and a higher level of conceptualization.

Our intent was researcher agreement on the description and composition of themes, not the frequency of occurrence of those themes. At the heart of the qualitative approach is an assumption that the research is influenced by researchers' individual perspectives.

The goal is not to produce a standardized set of results that another researcher could replicate, but to produce an illuminating description and perspective that is based on and consistent with a detailed study of the phenomenon.(26,27) Other female-dominated fields, such as nursing and teaching, are struggling to define and control their growth and development. Leaders of these professions have given considerable attention to the analysis of inherent values within their fields, such as caring, that are not included within the traditional professional model, but nonetheless are considered a vital component of the helping and healing role.(10,16,22) Continued research into the values of physical therapists may help us to develop a more balanced professional model. For example, if members of the profession embrace values such as those espoused by the subjects in this study (eg, the centrality of empowering patients and working with them in a way that demonstrates caring and compassion) as critical elements of physical therapy practice, then how might these values shape our ongoing development of theory and knowledge in the profession?

The subjects of this research project also spoke of the significant impact the dual roles of mother and physical therapist had on the shape and progression of their professional lives. Here a concurrent commitment to family that results in part-time work schedules is inconsistent with a professional ideology that subscribes to continuous full-time career commitment to the profession.(11,10) Yet women, such as the interviewees in this study and others like them, may well be a vital human resource for the field, in all areas-administration and education as well as part-time clinical work. Concerns about dual commitments to family, work, and the profession, such as those expressed by the interviewees, raise several questions worthy of future exploration, for example, what are the benefits of high-quality on-site child care?

What are the availability and effectiveness of flexible work schedules or part-time administrative and supervisory positions, as related to the career development of women? Can our professional association develop strategies that may help female physical therapists actively engage in continuing education, organizational activities, and leadership roles, while taking into account the family responsibilities of these women?

Sexist attitudes, both societal and within the health care system, may threaten the professional achievement of women and the growth of the profession of physical therapy itself Although some of our interviewees did not believe that sexist attitudes directly affected their professional development, others did recount several personal experiences from their professional lives that one could relate to sexism. The potential for conflict between the female sex role and professional achievement and recognition is real and well established in other professions.(10,16,22,24,25,28) Subscription to a traditional view of professionalism would suggest that women may face both internal barriers (eg, personal skills) and external barriers (eg, societal norms) that potentially inhibit professional achievement and respect within a patriarchal society.(29,30) For example, along with developing internal standards that emphasize relatedness, caring, and social context, women must learn to be competitive and assertive and to interact successfully within organizations.(10,2-30) External barriers or societal forces are viewed as a much larger problem, amenable only over the long term to educational, political, and legal methods.30 Although the APTA has under-taken initial steps toward exploration of factors that contribute to inequality for women in physical therapy, through the 1986 House of Delegates report "Women in Physical Therapy,"20 several of the outlined objectives remain to be implemented.

Conclusion

As the cry for increased professionalization is raised by physical therapy leadership,3-6 critical examination of the role of a traditional professional ideology for physical therapy, in light of the values and experiences of both female and male physical therapists, is needed in order to accomplish informed, responsible, and effective decision making regarding policy, education, research, and legislation.

Appendix. operational Definitions of Coding Categories Relationship: Examples or description of valuing interactive or interpersonal physical therapist/patient relationships. Caring: Examples of caring, emotional investment.

Empowerment: Subject's facilitation of the independent growth or achievement of the patient. Whole-Person Experience (patient): Examples of perceiving the patient as a whole person, within the context of family, emotional, and social needs. Recognition of needs outside of physical therapy.

Whole-Person Experience (physical therapist): Examples of therapist viewing herself and her roles holistically. Money: Discussion of financial concerns and salary.

Flexibility: Discussion of flexibility in terms of scheduling, work conditions, and treatments. Time: issues of time management, time for personal needs and family.

Collegiality and Community: Discussion of support systems and professional networks. Family Responsibilities: Examples of how work affects family life and vice versa.

Autonomy: Examples or discussion of independent professional practice and decision making.

Respect: issues and examples of professional acknowledgment and appreciation, or lack of these values.

Sexism: Examples of sexist experiences and attitudes.

Physicians: Examples of significant interactions with physicians and therapists' attitudes toward physicians. Role of Men in Physical Therapy: Opinions of historical and current roles of men within physical therapy.

Hierarchy: Discussion and examples of structural hierarchies and hierarchical relationships within the field.

Career Advancement: Discussion of plans and limiting factors regarding professional development and future.

Alternatives: Discussion of changes needed within society, work place, and profession. Examples of creative solutions to gender-related restrictions.

Although aspiring to several professional attributes has allowed physical therapy to progress along the professionalization continuum, the question remains, What attributes may be ignored by generalization of a theoretical model derived from male experiences) to a female-dominated profession? The results of this study describe the values and experiences of 10 female physical therapists that they perceived as part of their professional development. A conceptual framework developed from the literature and the data served to elucidate the importance of values, family role, and sexism as primary concepts for our subjects. Continued research in this area is critical for enhancing our understanding of a professional identity that is perhaps more gender inclusive and reality based.

Acknowledgments

We are indebted to the physical therapists who freely shared their insights and experiences. We also thank Anna Richert, PhD, for her comments on initial design of the study.

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