Paul Finch, PhD, MSc, DPodM
Chair, Health Sciences and Wellness Programs, Conestoga College Institute of Technology and Advanced Learning
Purpose:In previous research, the motivation of massage therapy students was observed to change between commencement of their professional studies and entry into practice. The change involved a decrease in intrinsic motivation (associated with altruism) and an increase in extrinsic motivation (associated with the prospect of external rewards). This paper reports on the influences underlying those changes.
Methods: The research used a qualitative design in which data were collected during a series of individual in-depth semi-structured interviews with massage therapy graduates, just after completion of a 2-year (2200-hour) full-time program. After informed consent was obtained, interviews were taped, transcribed, and analyzed, resulting in identification of a number of themes and subthemes.
Results: Previously noted changes in student motivation involved an increase in the influence of extrinsic rewards and a decrease in motivation related to helping and working with people. The findings of the present study suggest that these changes are explained by two main themes, each with a number of subthemes. The first theme, The Reality of Life in Practice, is associated with two subthemes: Debt Load, and Effectiveness in Achieving Positive Health Outcomes. The second theme, An Evolving Self-Image As a Health Care Professional, is associated with three sub-themes: Rigor/Intensity of the Educational Program, Developing Perspective of Massage Therapy As a Career, and Interaction with Faculty.
Conclusions: The data suggest that the change in motivation noted in previous work (increased extrinsic motivation and decreased intrinsic motivation) is influenced in different ways by each identified theme. Although schools must be vigilant in ensuring that their programs support the humanistic mission of health care, the present study indicates that the change in motivation noted in earlier work is not sinister. Rather, it appears to be related to the development of a realistic perspective of life as a health care practitioner, which departs from the more naïve expectations of students when they commence their professional studies.
KEYWORDS: Massage therapy, motivation, education, professional socialization
The use of massage therapy and other complementary health care practices has been increasing globally(1,2). It is important that appropriately motivated individuals be admitted to professional schools, and previous work revealed that students entering professional education at a massage therapy school were more strongly motivated by intrinsic values related to helping and working with people than by the prospect of extrinsic rewards(3). Those results are similar to findings relating to medical students(4–7) and dental students(8), the importance of which is highlighted by Guze(9), who suggested that one way of meeting society's needs is through medical—and by extrapolation—health care programs.
In more recent work(10), the motivation of massage therapy students was found to change during the course of their professional studies. Those findings indicate that students entering a massage therapy school were motivated more strongly by intrinsic values related to the desire to help and work with people than by extrinsic rewards. This was the case when students first entered the program and also shortly before graduation and entry to practice. However, the level of intrinsic motivation decreased and the level of extrinsic motivation increased significantly over the course of studies. That is to say, the gap between intrinsic and extrinsic motivation narrowed. The qualitative research reported in this paper explored the reasons for the observed change.
The intrinsic and extrinsic motivation of a class of massage therapy students was assessed at the commencement of their professional education and again just before graduation from Sutherland–Chan School and Teaching Clinic. Shortly after graduation, 10% (9 individuals) from the class were randomly selected, and their participation in the present research study was requested. A larger sample would have been desirable, but the decision to use a sample size of 10% was pragmatic in that this was the number accommodated by available resources. Additionally, because the participants had already graduated, their availability proved to be limited.
The 9 participants [2 men (22.2%), 7 women (77.8%)] reflected the gender mix of the class (21.7% male, 78.3% female). The mean age of the subjects was 31 years, which approximated that of the entire class (29 years, 3 months).
In this qualitative study, in-depth semi-structured interviews were used to explore the explanations of the participants for observed changes in motivation. It is important to recognize that this research was exploratory in nature and did not seek to support or refute specific hypotheses. Thus, although insight into reasons underlying motivational change was gained, no cause-and-effect relationships were tested.
Interviews were scheduled, and after informed consent was obtained, the change in the motivation of the class was presented to each participant. An opportunity to ask questions was provided, and to ensure the participant's understanding of what had been presented, the participant was asked to describe the change in motivation.
The interview then proceeded, and after basic demographic information was obtained, the participant's initial reaction to the findings presented was ascertained. Thereafter, a series of consistently asked questions focused on the participant's perspective of why the observed changes in motivation might have occurred. The questions were oriented so as to ask the participants to reflect on the formal content of the program, formal and informal interactions with faculty and staff, institutional influences (including values, priorities, policies, and ethics espoused by the organization), factors outside the school environment (such as family, friends, and social networks), and lastly, any other influences not already covered.
Recordings of the interviews were transcribed and subjected to thematic analysis. This iterative process involves identification of themes and subthemes within the data. Two themes were identified, each one being associated with a number of subthemes. The first theme, The Reality of Life in Practice, was associated with two subthemes: Debt Load, and Effectiveness in Achieving Positive Health Outcomes. The second theme, An Evolving Self-Image As a Health Care Professional, was associated with three subthemes: Rigor/Intensity of the Educational Program, Developing Perspective of Massage Therapy As a Career, and Interaction with Faculty. Fig. 1 presents the findings schematically, and the subsections that follow present the findings in text, in relation to each of the subthemes identified.
| Fig. 1. Schematic of motivation in massage therapy students. | ||
The theme The Reality of Life in Practice comprised two subthemes and spoke to the reasons for change in motivation related to extrinsic and intrinsic complexes alike.
Debt Load
The Debt Load subtheme related to the debt load accumulated during the participant's time as a student and the need to earn a living. Participants commonly reported that the prospect of entering practice brought with it heightened awareness of the need to address these issues, and they suggested that this was a reason that the level of motivation related to extrinsic rewards had increased. This heightened awareness is evident in a representative quote:
At the end of the program, reality kicks in, and you remember that you need to get a job and earn a living. You graduate with all this debt and, wow, that's pretty scary.
In that context, students commented that the effect of debt load might be, at least to an extent, offset by forward (financial) planning, thus reducing the stress experienced in this regard toward the end of the program.
Effectiveness in Achieving Positive Health Outcomes
The Effectiveness in Achieving Positive Health Outcomes subtheme related to a changing perspective of the contribution that massage therapy can make to the health of individuals. Participants noted that, although their appreciation of the therapeutic benefits of massage therapy had increased, they had naturally become more realistic during the course of their studies. This change occurred at the expense of a somewhat naïve perspective regarding the extent to which massage could benefit the population, as evidenced in a representative quote:
You start to realize that massage can help a lot of people with a lot of conditions, more than you thought in Term 1, but you also realize that you are not going to save the world. Perhaps this is why the level of intrinsic motivation dropped. Because you realize you are not going to help everyone with everything so you are less motivated....
The second theme, An Evolving Self Image As a Health Care Professional encompassed three subthemes.
Rigor/Intensity of the Educational Program
The Rigor/Intensity of the Educational Program subtheme speaks to the students' understanding of the rigor and intensity of the educational program before they entered their professional studies. It became apparent that students commencing their studies were largely unaware of the commitment it would take to successfully complete the program, and as the level of this commitment became evident, the expectation of extrinsic rewards increased. This sentiment is captured in the following representative quote:
I didn't realize it was going to be so tough. All the time, effort, and expense.... after a while, you begin to hope that all this hard will work result in some payback....
And similarly:
I've sacrificed a lot. More than I originally intended to, and now I'm looking for a return on all that investment....
The rigor/intensity of the program also appeared to influence intrinsic motivation, if indirectly. This influence is best explained by the following quote:
Pretty quickly I began to feel completely overwhelmed, and I guess I became totally focused on doing what I had to. I guess that's like, survival, and I was so busy surviving I didn't have so much time for idealism, altruism, or whatever....
Developing Perspective of Massage Therapy As a Career
The data suggest that as students proceeded through the program, their perspective of massage therapy as a health care career became increasingly well established:
When you're in clinic with a client who has a lot of problems and maybe has ... MS or diabetes as well, and your instructor expects you to know about it all, and the client hopes you're going to help them ... you think ... I guess this is health care. You probably knew it for a while, but at some point it hits you....
This focus is further elaborated and associated with the prospect of a future career as a health care professional and an increased expectation of extrinsic reward:
There are things people have when they have a career ... a car, maybe a nice car, a house ... and other stuff. You think ... maybe I should have that, even though it's not the most important thing. You think about it more.
Interaction with Faculty
Formal and informal interaction with faculty both reinforced the altruistic aspect of practice and also the need to see massage therapy as a health care career. The dual effect of this interaction with regard to motivation was complicated, in that it supported change in extrinsic motivation related to the developing perspective of massage therapy as a career, but despite explicitly reinforcing the altruistic nature of practice, the net effect was what could be described as "realistic altruism," related to the ability to effect positive health outcomes. This altruism is different from the naïve perspective with which students entered the program, the net influence therefore being to reduce intrinsic motivation from its original (naïvely inflated) level.
In previous work(4), massage therapy students were found to be influenced more strongly by intrinsic than by extrinsic motivations at the commencement of their studies. Subsequent work(10) supported this finding and also indicated that, as the students approached the end of the educational program, altruistic motivation was still greater than motivation related to the prospect of extrinsic rewards. However, the same research also indicated that motivation had shifted toward the extrinsic value complex.
The results of the present research suggest that increasing extrinsic motivation is attributable to accumulated debt, the rigor/intensity of the educational program, a developing perspective of massage therapy as a career, and interaction with faculty. Reduced intrinsic motivation appears to be related to the development of what the author has termed "realistic altruism," and is related to effectiveness in achieving positive health outcomes and interaction with faculty. How unique or consistent these findings are in the context of the health care milieu is not known because the literature is largely silent on this matter.
Schools must be vigilant in ensuring that programs support the humanistic mission of the profession, but the present study suggests that the change in motivation noted in earlier work does not represent a threat to that mission. Rather, it appears to be related to the development of realistic expectations regarding life in practice as a health care professional, which departs from the more naïve expectations of students entering the program.
It is important to recognize that the qualitative research findings presented above relate to students enrolled at one massage therapy school in Ontario. Although the results may be relevant to massage therapy schools (and other professional schools) in general, care must be taken in extrapolating the findings. Individual schools should consider the issue of face generalizability(11) when deciding how relevant the results are to their own situation. In particular, the length and scope of the educational program and the positioning of massage therapy as a health care profession within a specific jurisdiction may alter the applicability of the results.
Additionally, the researcher was known to participants because he was also the Director of Education of the school at the time. Although the researcher's position could have affected what the participants might have said during their interviews, this potential was mitigated by the fact that the interviews took place after the students had completed the program, and the influence, real or imagined, that the researcher had over their professional futures was limited. That being said, the dual role is nevertheless a weakness in the study.
A further limitation is that results were not triangulated because of resource issues. Future studies with a similar focus should include this design feature if feasible.
Research is being planned that will assess the motivation of therapists to engage in practice at 1 year and subsequently at 5 years after graduation. Additionally, the notion of realistic altruism will be explored further, initially in qualitative research involving massage therapy faculty and practitioners.
The author declares that there are no conflicts of interest.
Published under the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License .
1. Goldbeck-Wood S, Dorozynski A, Lie LG, Yamauchi M, Zinn C, Josefson D, et al. Complementary medicine is booming worldwide. BMJ. 1996;313(7050):131–133.
2. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998;280(18):1569–1575.
3. Finch P. The motivation of massage therapy students to enter professional education. Med Teach. 2004;26(8):729–731.
4. Kutner NG, Brogan DR. The decision to enter medicine: motivations, social support, and discouragements for women. Psychol Women Q. 1980;5(2):341–357.
5. Siverston SE. Why medical students become medical students. Wis Med J. 1988;87(6):23,25.
6. Kahler JA, Soule DJ. A survey of students' attitudes toward medical school and factors motivating them to become physicians. S D J Med. 1991;44(9):269–272.
7. Hojat M, Brigham TP, Gottheil E, Xu G, Glaser K, Veloski JJ. Medical student's personal values and their career choices a quarter century later. Psychol Rep. 1998;83(1):243–248.
8. Vigild M, Schwarz E. Characteristics and study motivation of Danish dental students in a longitudinal perspective. Eur J Dent Educ. 2001;5(3):127–133.
9. Guze PA. Cultivating curricular reform. Acad Med. 1995;70(11):971–973.
10. Finch P. The changing motivation of massage therapy students. Educ Health (Abingdon). 2007;20(1):1–5. http://www.educationforhealth.net/articles/subviewnew.asp?ArticleID=26. Published April 17, 2007. Accessed February 27, 2009.
11. Maxwell JA. Qualitative Research Design: An Interactive Approach. Thousand Oaks, CA: Sage Publications; 1996.
Corresponding author: Dr. Paul
Finch, Chair, Health Sciences and Wellness Programs,
Conestoga College Institute of Technology and Advanced
Learning, 299 Doon Valley Drive, Kitchener, ON N2G
4M4 Canada.
E-mail: paul.finch2@yahoo.ca
International Journal of Therapeutic Massage and Bodywork—Volume 2, Number 1, March 2009