Professionalism – Difficult to Teach and Hard to Evaluate!
Professionalism is an area of increasing focus and concern in many health professional programs, PT among them. Despite “Professional” being one of the seven core roles in the Essential Competency profile for physiotherapists in Canada, the number and variety of “unprofessional behaviour” incidents seen in academia and in the clinical setting seem to be escalating at a rapid rate, causing those of us involved in education to pause and take stock of how we are developing professionalism in our students, and why it appears so hard to do.
In many ways, professionalism preparation begins before admission, as programs attempt to select students who already have personal values and traits that mesh well with the PT profession. Admission to Canadian PT programs is competitive, and many programs use methods such as the “MMI” (multiple mini-interview) to select applicants who not only have academic excellence but who can also demonstrate traits such as leadership and professionalism. Once admitted, “Professionalism” is part of every entry-level PT program curricula across Canada, and is assessed using a variety of methods including practical demonstration of skills in OSCE (objective structured clinical examination) type assessments. In the clinical setting, entry-level physical therapy students are assessed on the competencies for the “professional” role during their using the ACP (Canadian Physiotherapy Assessment of Clinical Performance) tool. Why then do there seem to be an increasing number of “professionalism” issues being cited, both in students and in practitioners?
Perhaps the first issue is definition. While most of us have a “gut feel” as to what professionalism is (or is not – it is often easier to recognise unprofessional behavior than professional), there is no universally agreed definition as to what professionalism is. Although there are some core elements such as professional communication and cultural sensitivity, professionalism varies significantly between different contexts – what is acceptable in one setting may be labelled completely unprofessional in another. (For example, sports wear may be very appropriate and considered professional in a sports clinic; the same attire would likely be considered highly unprofessional in acute care.) This makes defining professionalism and professional behavior complex, with resulting difficulty in designing the professional curriculum and teaching professional norms.
Even when the professionalism curricula have been developed, how and when professionalism elements should be taught and assessed is remarkably unclear. Most would agree that a large portion of professionalism education occurs in the ‘real world’ of the clinical setting during clinical placements. However, this places the burden of assessment of professionalism on clinical preceptors, who are often unprepared for this task. Adherence to “rules” such as a dress code policy or showing up on time are easily assessed but are only a small part of the whole picture of professionalism. Many aspects of professionalism are hard to pinpoint and quantify. It is relatively easy to point a student to the steps they missed carrying out a particular physical assessment; it is much harder to provide feedback on an inappropriate tone of voice or choice of words, which can feel much more subjective and more like a personal attack on the student. Preceptors are (understandably) loathe to take on this task and frequently focus clinical feedback and assessment on the more technical clinical skills that are easier to address, have clear guidelines on which to base assessment, and are often easier to remediate. This can lead to a student with solid clinical skills but with unprofessional behavior being “passed through” their clinical training with little challenge to inappropriate behavior.
Preceptors may also feel that teaching and assessing professionalism is not part of their role, and students should come to the clinical setting with already developed professional competencies, however professionalism needs to be learned and developed as with other skills. A student may initially exhibit weak professional skills but these skills and competencies should and must develop alongside their clinical skills to new graduate level. Targeting learning objectives to developing professional competence is a helpful strategy that ensures these skills are addressed during the evaluation.
The “hidden curriculum” (which can be defined as “what students inadvertently learn in a setting”) is also a strong influence on learning professional behavior. Role modelling by preceptors is a key part of the hidden curriculum, and breaches of professionalism by preceptors are often emulated by students in the desire to “fit in” and succeed in a specific context. Learners are also less likely to understand the nuances of the clinical setting which can lead to mistaken assumptions and understandings about what is appropriate. For example, in acute care, students may not overtly see informed consent being obtained (for example with a confused or psychotic patient) and then assume that it is “okay” to proceed with treatment whether or not the patient consents. Explanation by, and discussion with, the preceptor is key to making sure the clinical context and treatment rationale are fully understood.
From the academic perspective, courses designed to teach professionalism competencies are not always successful in teaching skills which translate to “real life”. Success in a “professionalism” course does not necessarily translate into professional behavior in the clinical setting, or accurately predict students who will struggle in this area. There is little literature to provide faculty with guidance on the best methods of teaching professionalism to PT students, and even in medical education, where there is a significant body of literature related to teaching professionalism, there is little agreement about a “magic bullet” for learning to be a professional. As with clinical preceptors, academic faculty also struggle with providing feedback and remediation to students with lapses in professionalism, and must work within their University policies in providing appropriate supports and sanctions.
One area that is receiving increasing attention is the development of an individual’s “professional identity” rather than focusing solely on competence in professional behaviors. Development of professional identity or “who one is” as a professional is a complex process and involves integrating the person’s various social roles, statuses and diverse experiences into a coherent image of their professional self. For example, if a female student comes from a background that is hierarchical and male-dominated, it may be hard for the student to take on an advocacy role when discussing client care with an older, male physician. Alternatively, a student may be able to demonstrate excellent conflict resolution in an Objective Structured Clinical Examination (OSCE), yet appear unable to positively resolve disputes in a clinical setting. This may be because the learner’s identity in that setting is as a student whose conflict resolution skills are inferior to those of their preceptor, or that students should avoid conflict at all costs to pass the placement, in which case they will be unlikely to demonstrate this professional behavior. Professional socialization, clinical placements and experiences during their training all contribute to the development of professional identity, however the short time frame of most Canadian PT programs can limit time available for some of these activities.
So where does all this leave us? Certainly, educational programs need to take a long and hard look at where, when and how professionalism is taught and learned. New complexities of practice, such as the realities of Interprofessional and team based care, emerging roles for PTs in areas such as primary care, and changing consumer expectations raise new questions as to what professionalism means; educators in both academic and clinical settings need to be thoughtful as to how to shape curricula to meet the professional expectations of these new paradigms. Teaching and learning methods need to incorporate strategies to facilitate the development of professional identity as well as professional competence, and ensure that appropriate assessment and feedback (both positive and constructive) is provided across the learning continuum. It may also be time for a national “think tank” on professionalism in the PT profession, brining together educators, researchers, regulators, clinicians and consumers, to determine not only what todays professional milieu demands of PTs, but also to look at how we adequately prepare the practitioners of tomorrow.
Sue Murphy, PT, Grad Dip PT, B.H.Sc (PT), M.Ed, CPA Member since 1980
Sue Murphy is Head of the Department of Physical Therapy, and an Associate Director at the Centre for Health Education Scholarship at the university of British Columbia. Sue has taught in the professionalism curriculum of the Master of Physical Therapy program at UBC for the last 10 years, and has a keen interest in the teaching and learning of professionalism, as well as in teaching and learning in the clinical setting.