Motivations, sources of influence and barriers to being a podiatrist: a national questionnaire of student views

As a result of the relatively high levels of podiatry students over the age of 25 [6], respondents were categorised as individuals who had either engaged in the profession ‘before’ or ‘after’ their first career in employment (Pre-FC and Post-FC, respectively). Pre-FC respondents included individuals who made their decision to join the podiatry profession during their secondary school, college or during their initial University degree. Post-FC respondents included individuals who were previously employed in an alternative career before joining the podiatry profession. Prior to statistical analysis, N/A responses on Likert scales were removed from the analysis. NVivo was used for managing the open-ended question data. The data was initially filtered for Pre-FC and Post-FC. Thematic analysis using Braun and Clarke’s approach [14] was utilised to analyse the open-ended questions. This involved becoming familiar with the data through reading and re-reading the open-ended question responses. The next step was generating initial codes. This took place through Inductive coding and themes were then identified from groups of codes. The final step in the process was defining and naming the emergent themes. The main themes were an interpretation of the open-ended question data obtained, which had allowed for participants to share their perspectives using their own words.

Demographic and outcome data was checked for normality using tests for skewness and kurtosis, as well as a graphical assessment for normal distribution. Thereafter, Mann-Whitney U non-parametric difference tests were used to compare participants’ age, gender, ethnicity, year of study and disability between Pre-FC and Post-FC groups. A series of Mann-Whitney U tests were also used to compare outcome questions relating to personal, professional interests and day-to-day job context motivations; personal and educational, media and marketing sources of influence; and personal, professional and understanding the role barriers between groups. Data is presented as median and interquartile range (IQR; 25th–75th percentiles), mean ranks for Pre-FC and Post FC, U statistic, z score and p value. Effect sizes are also reported as r based on the following formula:

Participants identified someone in the profession I saw/met who was a really good role model for me and my own research into the podiatry profession as two important personal sources of influence (Table 2). In terms of motivations for choosing podiatry, particularly with regards to the day-to-day context of the profession, participants typically agreed/strongly agreed with all of the items reported (see Additional file 2). Where I can use my skills to improve the quality of life for a patient/service user was the most important motivation for both groups (see Additional file 2). Academic interests, interest in area of profession, intellectually stimulating and that suits my personal qualities and values were all perceived to be important motivations for engaging in the profession (Table 3). With regards to professional motivations, excluding the student bursary item, participants agreed/strongly agreed with all items (e.g., the potential for job security, the opportunity for working in the private or public sector, good job availability and employment opportunities; Table 4). With regards to barriers to the profession, lower scores were generally reported when compared to the aforementioned areas of interest, with the median score for all items being ≤4 (see Additional file 2).

Post-FC participants reported intellectually stimulating, challenging role and student bursaries as three motivations that were of greater importance to them compared to Pre-FC. The two former motivations are likely related to Post-FC participants wanting to commit to a career change that may ultimately lead to job satisfaction [15]. In promoting podiatry, the importance of these motivations suggests that there needs to be a greater focus on the seriousness and medical emphasis of podiatry work and the level of skills and knowledge required [16].

Our study complements research exploring occupational therapy career choice motivation for mature students where financial pressure was identified as the key factor deterring students choosing this career [17]. The loss of the NHS bursary was seen as the likely reason that accelerated the decline in undergraduate applications to podiatry courses [10, 16]. Podiatry was greatly affected because of the high proportion of mature students [4, 16, 18] who are more ‘debt-adverse’ than younger students and are more likely to have responsibilities which require funding [19]. Therefore, our finding relating to the importance of student bursaries among the Post-FC group is unsurprising. Minority ethnic students particularly from lower income groups are more averse to taking out loans [18] and therefore the bursary removal was likely to affect these students more. The Saks report confirmed that there had been an increase in student recruitment to podiatry courses in the current academic year and highlighted the ‘welcome reinstatement of the bursaries’ [4]. From September 2020, students starting or continuing an undergraduate or postgraduate podiatry course could apply for the NHS Learning Support Fund allowance. Our research took place in early 2021, and as such, public awareness of the fund may still be growing. That there has been an increase in student recruitment [4] suggests that awareness of the fund has improved since we undertook data collection, in addition to the vast HEE and Office for Students funded careers activity in recent years. Nevertheless, it is critical that public awareness of this fund is widespread so that different population groups (e.g., mature students; minority ethnic groups) do not see financial challenges as a barrier to choosing podiatry as their career.

There is a synonymous link between mature students and Post-FC participants, as in our study, 94% of our Post-FC group were older than 25 years of age. Interestingly, although the Office for Students stated that older podiatry students have a greater interest in private practice and potentially earning a large salary [16], such findings were not evident in our study (Table 4). For example, 86.1% of our Post-FC respondents agreed/strongly agreed that working in the NHS was a key reason for choosing podiatry. With there being a minimum of a 19% NHS vacancy rate predicted in England for podiatry by 2025 [20] and with 60% of members of the Royal College of Podiatry working in the private sector [4], it may be prudent for NHS recruitment campaigns to either: i) increase recruitment of Post-FC podiatrists as they may want to work in the NHS, or ii) develop strategies to encourage Pre-FC podiatrists to be motivated to work in the public sector.

Post-FC participants recognised own patient experiences (their own experience or that of a relative receiving care from the profession) as a more important personal influence than the Pre-FC group. In the study by Byrne [21], mature students reported a proportionally higher amount of exposure to occupational therapy through personal life experiences than the rest of the cohort. More generally, in accordance with recent research [10, 22], a high proportion of our study sample (46 and 50.1% for Pre-FC and Post-FC, respectively) were influenced by their own personal (or relatives) podiatry treatment. These findings highlight the opportunity for qualified podiatrists; they can take on the role of career ambassador when meeting patients. This message needs to be conveyed to all podiatrists through the NHS, private practice, HEE and the Royal College of Podiatry. Activating this extensive workforce to be the ambassadors for the profession so that they see every patient and relative as a future podiatrist and to overtly prioritise work experience and university clinics opening doors for work experience.

Unsurprisingly, and similar to Craik et al. [22], we found school or college sources of influence to be approaching statistical differences: these sources were more important for the Pre-FC group. However, career advisors' lack of awareness of the profession was reported to be a substantial barrier for the Pre-FC group. In accordance with past research, careers advisors, and to a lesser extent, teachers, were reported to not have a strong influence on Pre-FC’s choice to engage in podiatry [23, 24, 25]. However, previous employment in healthcare was perceived to be an important influence for the Post-FC group to engage with the profession. This was a similar finding to Craik et al. [22], who suggested that the higher number of mature students in occupational therapy may be partly owing to students only hearing about the profession through their work in health care settings and not when they first make their career choice at school or college. Career advisors are a vital conduit to the successful recruitment of students to AHPs [21], and therefore, they need to have a good level of knowledge and understanding about the podiatry profession. With medicine and nursing still primarily promoted as the key healthcare careers in schools [9], career advisors can use the familiarity of these careers to introduce students to AHPs, including podiatry.

For Pre-FC participants, someone in the profession I saw/met who was a really good role model for me and my own research were considered more important than school or college sources. The importance of seeing AHP role models and the impact on career choice, has been explored in the literature, especially the lack of role models for minority ethnic individuals in particular professions, such as physiotherapy [26, 27]. Despite increases in the ethnic diversity of podiatry students in recent years [6], the Saks report [4] recommended improving efforts to recruit a more diverse (including ethnicity and gender) podiatry student population. In our study, the majority of the sample were white (85 and 62% for Post-FC and Pre-FC participants, respectively) and the importance of seeing role models in the profession suggests that more ethnic minority role models in podiatry are needed to support student recruitment.

Job availability was perceived to be an important barrier for the Post-FC group and careers advisors' lack of awareness of the profession and misconception of profession were reported to be more important barriers for the Pre-FC group. Previous research has shown that podiatry is an attractive career path to mature students as it leads to ‘almost certain employment’ following completion of undergraduate podiatry courses [4, 9, 10]. The importance of employment for Post-FC participants was shown in our study as the more mature students reported this to be of greater importance than Pre-FC participants. Job availability is not considered a pertinent reason for selecting different AHP careers [28, 29]. However, although it may not be a key motivation, ensuring that job availability is viewed positively especially owing to the current podiatry recruitment challenges, is important especially for the Post-FC group.

Misconceptions around the profession, highlighted also in answers to the open questions, suggests that marketing needs to emphasise the ‘extensive, diverse and interesting’ scope of practice [4]. The Saks report [4] also suggested that podiatry is not portrayed sufficiently as an appealing or important career. Our study was unable to determine why individuals working as an AHP overlooked the opportunity to engage in podiatry. Despite noting that there is an opportunity to maximise on the territory of the foot [30] once invested in the profession [31], the perceived status of the profession may lead to this never being actualised. Through addressing the perceived status of the podiatry profession by contemporary research, it may be possible to target marketing to attract applicants. The Saks report [4] highlighted the image of podiatry as a profession being perceived negatively by the public. Tollafield [32] suggested overcoming the ‘ugh factor’ associated with working with feet with an emphasis on function not condition; podiatrists help return people to activity and occupation as a slogan, not podiatrists’ work with ingrowing toenails and ulcers. Current research is being undertaken to understand perceptions of the human foot among social media users and this may help understand the ‘ugh factor’. But more broadly, research is needed to understand the relationship of profession status, ‘ugh factor’ and podiatry as a career choice. It is clear that other AHPs whilst larger in numbers, also have greater visibility and a better known profile, for example physiotherapists and paramedics. Media marketing strategies for podiatry should be implemented that not only increases the public awareness of the profession, but also enhances the government and other health professionals’ understanding of podiatry [4]. In addition, that there has been an increased interest in health and care professions during the Covid-19 pandemic and changing employment circumstances and priorities [33] suggests now is the right time to market podiatry to individuals looking for a career change.