BACKGROUND AND PURPOSE
Truthiness is defined as “the quality of seeming to be true according to one's intuition, opinion, or perception without regard to logic, factual evidence, or the like: the growing trend of truthiness as opposed to truth.”1 Television host, Stephen Colbert, coined the word “truthiness” on Comedy Central as a playful way to think about an important issue.2 When a person says something is a fact or true because it feels true, as opposed to having evidence, it is considered “truthy.” A gut feeling of being true rather than reality. By comparison, the American Physical Therapy Association (APTA), deemed integrity a core value of the profession, and defines integrity as “steadfast adherence to high ethical principles or professional standards; truthfulness, fairness, doing what you say you will do, and ‘speaking forth’ about why you do what you do.”3 Truthiness implies situation-based deviation from the APTA definition of integrity when an individual feels there is a good reason to do so. In clinical practice, truthiness may manifest as a therapist who does not check the start and end time of a treatment session, yet documents the time he or she feels was spent with the patient, even though this may not be accurate. In the academic setting, this may appear if classmates share information about an assignment or an assessment. Students later justify this as helping one another, which they feel is desirable, rather than a deviation from the core value of integrity.
Emma Stokes, BSc, MSc, PhD, President of the World Confederation of Physical Therapy, delivered the keynote address at the 2016 Education Leadership Conference. In her address, Dr. Stokes challenged physical therapy educators to create leaders by teaching doctoring professionals how to be, in addition to what to know.4 There are many aspects to consider when trying to develop future leaders. One must train students not just within the cognitive and psychomotor domain but also within the affective domain. Teaching and evaluating within the affective domain, while difficult, is necessary to assist students along their path toward professional formation. Many of the APTA Core Values, including altruism, integrity, and social responsibility, have components within the affective domain. In general, behaviors within the affective domain are measured by the approach-avoidance tendency of a student toward a topic.5 For example, if a student positively receives, approaches, and examines a topic, then learning within the affective domain has occurred. Conversely, if a student avoids a topic altogether after introduction, no growth in the affective domain can be assumed. Finding ways to engage students within the affective domain can help educators to ensure they are facilitating students' professional formation.
One of the most important characteristics for a leader to possess is integrity. Not only is integrity associated with effective leadership and higher status within organizations, but is also a quality expected of health care professionals by society.6,7 Integrity is applicable to a variety of scenarios. Academic integrity, for example, is defined as “adherence to moral and ethical principles; soundness of moral character; honesty,” as it relates to behaviors in the education setting.8 In regards to personal and professional success after educational training, integrity is a key factor.8 Physical therapy faculty identified integrity, along with clinical reasoning and honesty, as the top 3 most important professional skills for physical therapists9; however, integrity remains difficult to teach and monitor.
Integrity in the academic setting is nothing new to medical professions. Literature from medicine, nursing, and other health professions programs identifies academic integrity as a key component of professional development.10,11 Students in health professions programs appear to have varied understanding of what constitutes integrity or cheating and may see cheating as a way to help themselves or peers in the face of a high-pressure environment.12 Unfortunately, this type of unprofessional behavior in medical education often transfers to practice, impacting patient outcomes.10 Medical literature has reported that those medical students disciplined by state medical boards were twice as likely to have had problematic behavior during their professional education.13
Two psychological frameworks described in the literature reinforce integrity in the academic setting. Students are typically either principled or pragmatic when it comes to decisions about cheating.14 Those who are principled are more likely to resist temptation to cheat because they believe cheating is wrong. If they do cheat, they feel guilty for violating the value of integrity. Students who take a pragmatic approach justify cheating with a rationale.15 For example, cheating is not wrong if there is a good reason to do so, such as to avoid failure or academic dismissal.
In addition to the known relationship between integrity and individual professionalism, the impact of professional deviance can extend beyond the student and into a class cohort.16 This act is referred to as social cheating. Social cheating occurs when students share knowledge prior to turning in work and is seen as mutually beneficial.12 Cooperation among cheaters changes student perception of cheating behavior from negative to positive.12 Those principled students who would not normally cheat wish to have the same advantage as their classmates and they engage in cheating behaviors.15,17 Peer cheating behavior can have either a positive or negative influence on a cohort. In fact, peer cheating behavior, peer disapproval of cheating, and perceived severity of penalties for cheating are significantly more influential in one's decision to cheat than are individual factors, such as age, gender, or grade point average.16
There are both extrinsic and intrinsic factors related to integrity. Extrinsic factors influencing student integrity are tied to environmental and/or organizational controls, which influence one's willingness to try to cheat. Academic institutions may attempt to limit cheating by securing examinations via organizational controls, such as having multiple exam versions, assigning student seating, or proctoring exams.18 Some develop honor codes and display those on examinations.19 These measures may help promote a culture where integrity is viewed as important, but ultimately, they are all focusing on controls extrinsic to the student.
Intrinsic factors related to cheating involve the moral barrier an individual or cohort may have against cheating. To teach a student not to cheat because cheating is wrong is to increase the student's intrinsic resistance to doing wrong when the opportunity arises, that is, integrity development. Some examples of this strategy include education on the psychology of cheating, relating cheating as a student to fraud or malpractice as a professional, and providing students with strategies to help them better understand unethical behavior through examining case studies posing ethical challenges.20
Physical therapy educators are tasked with training the next generation of professional leaders, yet how to best assess and understand integrity as a component of professional development remains unclear. This case report describes a novel classroom activity that tests students' current moral character and provides an opportunity for them to examine their beliefs and perceptions about integrity using a Jar of Truthiness (JoT). The purpose of this case report was to discuss the serious issue of academic dishonesty in the context of developing integrity as a core value of the physical therapy profession and a key factor in creating effective leaders.
The JoT activity was an original creation by faculty meant to engage students within the affective domain as related to their thoughts, feelings, and beliefs about integrity, with the hopes of facilitating professional formation. Three iterations of the JoT (activities A, B, and C) were implemented across physical therapist education programs at 2 institutions (I and II). Institution I is a private university that uses a problem-based learning curriculum in a 3-year physical therapist education program. Institution II is a public university that delivers a traditional physical therapist education curriculum across a 3-year program. Faculty delivering the JoT activities used a common framework that was applied to different student cohorts under the discretion of the faculty member. In each JoT activity, students were provided an opportunity to cheat or to report observation of cheating by placing a piece of paper in the JoT. The first JoT activity (A) was applied to a cohort of first-year physical therapy students in the first week of their didactic training. The second application of the JoT activity (B) was administered to second-year students, and the third application of the activity (C) occurred in the second semester of the study for a cohort of first-year students. Activities A and B occurred at institution I and activity C at institution II. Both activities B and C were developed in conjunction with and based on activity A. Regardless of the activity (A, B, or C), students were asked to reflect on their decision either to cheat or to refrain from cheating, then results from the JoT were shared with each class. During these reflections, a physical therapy faculty member facilitated discussion on integrity as a core value, identifying connections to professionalism, legality of practice, and patient outcomes.
Activity A (Figure 1) was completed at institution I in a course on professionalism in physical therapy. This activity spanned a full semester, integrating take-home quizzes, case examples, and class discussions to enhance content delivery.
Students read the APTA Core Values and rated themselves using the Core Values Self-Assessment3 during the first week of the program. These self-ratings were paired with clinical scenarios, whereby students determined which core value is deficient based on a given clinical behavior.
During week 3, students were assigned a take-home quiz and provided with verbal and written instructions, which indicated using sources or peers on the quiz was prohibited.
During the next class session, students were given 2 slips of paper printed with only the words “yes” and “no.” Students were instructed to circle “yes” if they used sources or peers during the recent take-home quiz and “no” if they did not. Assurance of anonymity in reporting and no class consequences was provided by the facilitating faculty member. Students then placed their slips of paper into the JoT.
Likely, some percentage of the class did access sources or peers during the quiz but chose to indicate “no” on the slip of paper due to denial or fear of repercussion. As a result, students were again assured of reporting anonymity and reminded no consequences to a “yes” response existed. They were then asked to answer the question, “Did you lie when you answered the previous question?” and report either “yes” or “no” on the remaining slip of paper, then place the paper into the JoT.
The facilitating faculty member then left the room to count responses and four second-year physical therapy students entered. These students reflected on their growth and experiences, especially as related to the core value of integrity, over the past year. On return, the facilitating faculty member led a discussion linking academic integrity to professional integrity. Students were asked to compare their actions when given an opportunity to cheat against their answers to the Core Values Self-Assessment. Resultant emotions were varied and included anger, guilt, and shame if they did cheat and pride if they did not. The faculty member intentionally stated, “This is what lack of integrity feels like,” and students were encouraged to remember the feeling as a way of recognizing and preventing cheating in the future.
During the next week, the students read and reflected on articles connecting a lack of professionalism and integrity in medical students to license suspensions during their medical careers.13,21
The JoT process was completed twice more during the same semester and the integrity of the class was tracked. After surveying the class each time, the facilitating faculty member discussed what may have changed about student professionalism from quiz to quiz and offered praise for the class on their professional growth.
Students were asked to fill out an anonymous questionnaire at the end of the semester asking them several reflective questions about their professional growth related to integrity.
Activity B (Figure 2) took place at institution I, also in a course on professionalism; however, there were significant differences in how activity B was implemented. Students in this cohort were in the second year of their physical therapist education program, and faculty suspected breaches in academic integrity were occurring among the class. Fifty-three students began the program, and after first-year attrition, the number of students in this cohort was 51. In comparison to activity A, this activity was not centered around a specific quiz and took place during one class period rather than over multiple class sessions.
Students were provided with blank pieces of paper. They were asked to write “yes” or “no” in response to the following question, “Have you ever shared information or received shared information on an assessment in the physical therapy program?” Students placed their responses in the JoT.
Responses, “yes” or “no,” were counted and shared with the class. In a large group discussion regarding the results led by the faculty member, students were asked to discuss how the results made them feel about themselves and their classmates. The faculty member asked follow-up facilitation questions about how academic integrity relates to professional integrity, and students were prompted to reflect on their assumption cheating was the best choice at the time.
Activity C (Figure 3) took place at institution II among a cohort of 52 students in their first year of professional physical therapist education. Students were enrolled in a class containing material related to professionalism and the APTA Core Values. Two quizzes related to rehabilitation and medical abbreviations were scheduled as a component of this course.
Students participated in didactic instruction related to professionalism and the APTA Core Values. Lectures occurred in the 2 weeks prior to the JoT activity.
The first quiz on rehabilitation abbreviations was scheduled for the end of lecture in week 7 of the course. Instead of issuing the quiz in-class, students were given the quiz as a take-home item. They were instructed to complete the quiz independently, without using sources or consulting peers. Quizzes were to be returned to the main Program Office within 24 hours.
During week 8, students were issued blank pieces of paper and asked to write “yes” or “no” on the paper related to their work on quiz number 1. A response of “yes” indicated they used sources or consulted peers. A “no” response indicated students completed the work independently. Pieces of paper were collected by the course coordinator in the JoT. No related discussion occurred.
During week 9 of the course, the second medical abbreviations quiz was scheduled. Similarly to the first quiz, this quiz was issued to students as a take-home quiz. All students were instructed to work independently without consultation with sources or peers. Quizzes were collected within 24 hours in the main Program Office.
During the next class session, the JoT was again used to collect “yes” or “no” responses, indicating whether students consulted with sources or peers for quiz 2.
Results from both quizzes were reviewed with the class. A discussion related to integrity and the APTA Core Values was facilitated by the course coordinator. Students were given examples of how integrity relates to clinical practice, as well as opportunity to engage in the class discussion.
On the first quiz, 35 of 57 students indicated that they cheated and an additional 5 selected “yes” when asked if they had lied on the first question. During the second quiz, 2 of 57 students indicated they cheated and an additional 5 selected “yes” when asked if they lied on the first question. And finally, on the third quiz, 6 of 57 students indicated they cheated and an additional 3 selected “yes” when asked if they lied on the first question.
At the end of the semester, students were assigned an anonymous assignment. They were asked to answer 1) “What was it about the situation that made you cheat?” and 2) “How will this activity affect you as a student and future physical therapist?” Themes identified in student responses included: cheating due to feeling underprepared, feeling mentally wrapped up in getting good grades, and being anxious about failing. Common student responses to question 2 (asking how they will be affected by the activity) included having a better appreciation of integrity in the practical sense and identifying a connection between integrity in school and becoming a health care professional with sound moral values (Table 1). Overall, the students responded positively to activity A.
Forty-seven of 51 students responded “yes,” 2 students answered “no,” and 2 students provided an ambiguous response (neither yes nor no) for activity B. During the large group discussion, students reported feeling angry with the faculty member and feeling accused of cheating. Students blamed faculty for not providing enough administrative controls to prevent cheating, such as creating multiple versions of quizzes and limiting student interactions between assessments. Students also reported the wording of the question was unfair or unclear, stating they believed they were being asked about collaboration and group work rather than dishonesty. Some students denied a correlation between academic dishonesty and fraudulent practices in a clinical setting, and others felt their actions demonstrated grit, as they had used any means necessary to be successful.
Strategies were used by the facilitating faculty member to attempt to mitigate student emotions during the JoT discussion. These included active listening (as in Ref. 22, chap 7) strategies of restating the students' comments and acknowledging the emotions associated with them, helping students feel heard, and their feelings validated. Notes about student concerns were taken, and the faculty member followed up with students during a subsequent class session, openly acknowledging things that could be improved for the future, such as the way the question was phrased for the activity, the lack of clarification about on which assignments collaboration is acceptable, and the need for administrative efforts to reduce opportunities for academic dishonesty during assessments.
Two of the 52 total students who completed the JoT activity at institution II responded “yes” to using sources or consulting peers on the rehabilitation abbreviations quiz. Similarly, 2 students in the same cohort responded “yes” to using sources or consulting peers on the medical abbreviations quiz. Related to the activity, formal student comments were not collected. Given the time gap between the first JoT activity and the second, one student wrote on their JoT paper, in addition to “no” for using sources, “I can't wait to hear what this is all about.” Discussion revealed students were interested in the results of the JoT activity and able to connect the activity to integrity in practice.
There are educators who hesitate to teach within the affective domain. Some may view it as coercive indoctrination, manipulation of student emotions, may downplay its usefulness, or simply not have a clear idea about how the domain can be approached.5 Although risky from the viewpoint that student emotions and beliefs may be challenged, teaching within the affective domain can result in important student growth. Balancing the feel of negative emotions by students to engage in affective learning may be one of the best ways to facilitate professional formation.5 Without this, educators may be less certain student values will align with those of a professional health care provider. In the described JoT activities, the authors observed primarily positive effects within the affective domain through the deployment of each variation of the JoT; negative effects were present, but few. Between the 3 classes and 2 different institutions, each variant of the JoT activity elucidated different outcomes, student attitudes, and lessons learned.
Activity A provided true anonymity of the process by using slips of paper preprinted with “yes” and “no” instead of handwritten responses. The identification of growth and ending each discussion on a positive note reassured students of the ongoing development of integrity over time. For this reason, faculty highlighted the take-home quizzes as an opportunity to test and track integrity rather than cognitive learning alone. Keeping the JoT results and perceived consequences isolated to within the classroom was also found to be an important aspect of the activity. If students hear about their lack of integrity from multiple sources, such as faculty members, advisors, or the school's dean, the activity may feel more punitive than developmental. Students responded well to the discussion in class, not when they felt scolded by authority figures outside the classroom. Open discussion on academic and professional integrity with upperclassmen added credibility to the activity while leveraging positive peer influence to establish a culture of academic integrity within the cohort.
Key opportunities for improvement were identified from activity B (Figure 4): timing, focus, and explicit instructions. Given the timing of JoT implementation in the second year of the curriculum, the cohort had already established a practical approach to academic dishonesty, and their responses match previous reports on student cheating behaviors.12,15 While a few students determined dishonesty gave them the advantage they needed to be successful, many believed their practices were justified in the name of efficiency and teamwork. Because of the established culture of dishonesty in the cohort, principled students in the class feared retaliation or isolation from the group if they informed faculty of cheating. Therefore, the JoT activity may only be effective when used early in the curriculum to intentionally weave academic integrity into the culture of a cohort.
Activity B was also unsuccessful as it lacked a focus on specific behaviors surrounding one ethical situation. By asking the broad question, “Have you ever shared information or received shared information on an assessment in the physical therapy program?,” students were unable to reflect on specific choices, remember times when they shared information, or distinguish group work from individual work. As a result, the “yes” and “no” responses in activity B may not be a valid reflection of student behavior. The confusion created by this question likely contributed to students' negative emotions about the JoT activity.
Unfortunately, there was only partial resolution of students' emotions, as evidenced by multiple negative comments about the JoT on the course evaluation and exit survey at graduation. Efforts to mitigate students' emotions during activity B may have been unsuccessful due to the students' association of the behavior with their individual character traits. Individuals are more likely to be honest when there is implication of the person rather than the behavior, and when the behavior is not associated with personal identity, individuals are more likely to be dishonest.23 In other words, an individual wants the benefits of cheating but does not want to be called a “cheater.” When students felt accused of cheating, they desired to defend their character, creating distance between the behavior and how they want to be perceived as individuals.
Important changes to academic policies were implemented at institution I after activity B. The program's academic honor code was revised, and students were reminded of the honor code before each exam. Faculty began clearly explaining what kind of collaboration, if any, is allowed on each assignment. And finally, practices to eliminate the opportunity to share information were implemented, such as monitoring hallways and restrooms during exams, creating multiple versions of quizzes and exams, and scheduling a combined testing period for classes that were split into multiple sections.
Unlike activity A, the pieces of paper used for activity C did not have preprinted “yes” and “no” answer for the students to circle. The absence of assurance their handwriting could not be traced to them may have impacted student honesty in reporting and may explain the large difference in number of students who admitted to cheating across the 3 activities. The implementation timeline was also different. In activities A and B, results of the JoT were discussed with students immediately, whereas the discussion was deferred in activity C. While the students expressed interest in the results as well as the reason for JoT activity, the time gap between steps in activity C may have had a negative impact on the richness of the discussion.
The authors created 3 unique activities with the intention of facilitating students' professional integrity through the use of a novel class activity that teaches within the affective domain. By using the JoT at each of the participating institutions, students felt comfortable enough to confess to cheating on quizzes when given the opportunity. Student reports, although anonymous, allowed faculty to engage students in active reflection of their professional growth. Faculty and students had a positive experience when the JoT activity was used early in the curriculum; however, when used later in the curriculum and when cheating was suspected, the students experienced negative emotions. Additionally, the activity worked best when focused on a recent assessment and when accompanied by assigned readings on professional behaviors (Figure 4). Readers desiring to implement the JoT will likely need to augment the timing, type of discussion, and student reflection component to best meet the needs of their educational programs.
Further research is recommended to determine validity of student responses using the JoT, as well as the long-term effects on professional integrity. Longitudinal assessment of JoT participants during clinical practice would present an interesting opportunity to review the impact of the JoT activity. Is, for example, a clinician who participated in a JoT activity as a student more likely to identify lapses in integrity once in clinical practice than a clinician who did not? Of particular interest would be a comparison of the frequency of ethical violations, employment termination, or State Board disciplinary action. With the different approaches and reported outcomes of the JoT activity described, one question remains. Are physical therapy students learning how to be, rather than just what to know?