Professionalism in nursing, midwifery and the allied health professions: report

2. Understanding and demonstrating professionalism

A Dignified Revolution (ADR), a voluntary movement set up to promote and improve care for older people in hospitals in the UK, urges healthcare professionals to reflect on the following Mumbai hospital motto adapted from a quotation from Mahatma Gandhi:

"A patient is the most important person in our hospital. He is not an interruption to our work; he is the purpose of it. He is not an outsider in our hospital; he is a part of it. We are not doing a favour by serving him; he is doing us a favour by giving us an opportunity to do so."^[6]

To ADR and many other groups promoting patients' and service users' interests, this presents the benchmark - and the challenge - that health services must aspire to meet.

All healthcare staff, including NMAHPs, who are highly committed to the ethos of professionalism strive to reflect this within the delivery of person-centred, safe and effective care and make a significant contribution to the three quality ambitions for NHSScotland. Underpinning the quality ambitions are the "7Cs" that articulate what people have said are important to them:

• caring and compassionate health services
• collaborating with patients and everyone working for and with NHSScotland
• providing a clean and safe care environment
• improved access and continuity of care
• confidence and trust in healthcare services
• delivering clinical excellence

The issue

"Public confidence in a profession is sustained when its expectations are - or are perceived to be - in harmony with professional culture and actual performance. On the other hand, public confidence is undermined when a significant gap appears between general expectation and performance."^[7]

Most people who use health services will say that they have had positive experiences,^[8] and most staff are seen to demonstrate caring and professional behaviours. The fact that a noticeable proportion are reported not to demonstrate caring and professional behaviours cannot, however, be ignored. It is clear that in some instances, there is a gap between the behaviours expected of staff and those displayed to patients and service users. Attempts to address this include a renewed interest in self-regulation against recognised statutory codes of conduct, performance and ethics and the implementation of mandatory standards and codes for healthcare support workers issued as a Direction from Scottish Ministers in 2010.^[9]

Reports from bodies such as the Scottish Public Services Ombudsman (SPSO) and the Mental Welfare Commission for Scotland (MWCS) and findings from professional regulators' fitness to practise hearings reflect the trends in dissatisfaction among the public regarding professional behaviours and attitudes. SPSO investigations^[10] reveal:

"... an attitude - both personal and institutional - which fails to recognise the humanity and individuality of the people concerned and to respond to them with sensitivity, compassion and professionalism".

A common subject of complaint in these investigations, reflected also in evidence from the UK professional regulators,^[11] involves patients, service users, families and carers describing an NHS that is process-driven and bureaucratic rather than efficient and person-centred. Issues highlighted in complaints include lack of information and failure to promote autonomy and involvement, leading to people feeling helpless and powerless rather than empowered and in control. Cultures are also highlighted, with a lack of clear values leading to local cultures that can be hierarchical, or even bullying. Poor communication, poor attitudes and poor behaviours underpin many of the complaints.

Some health and social care staff may believe these failings relate to other people's practice rather than their own. When they reflect on their practice in an insightful and meaningful way, however, they are often able to identify instances in which their verbal communication and non-verbal behaviours have been inadequate and where the quality of their care has not been of the required standard. They may also be able to recognise the impact of small gestures or relatively insignificant interactions on patients', service users' and colleagues' perceptions and experiences, and may be able to recall occasions when their actions have been less than satisfactory.

Articulating professionalism

Although healthcare professionals and support staff perceive behaving in a professional way as a central facet of their role, they may find it difficult to articulate exactly what professionalism means and what it looks like in everyday practice.

Professionalism within the context of healthcare delivery should therefore be accepted as a fluid construct. It is dynamic, socially constructed and multi-faceted and is applicable to all staff who work as part of the healthcare team regardless of their role, status, title or designation. As was noted by a study of paramedic, occupational therapy and podiatry students and educators commissioned by the Health Professions Council (HPC) as part of a wider research programme exploring aspects of professional practice:^[12]

"Professionalism ... was not seen as a static well-defined concept, but rather was felt to be constructed in specific interactions. Consequently, definitions of professionalism were fluid, changing dynamically with changing context."

Consistently high levels of professionalism are important to patients and service users. Research has shown that what they understand as professionalism has always been valued and, indeed, is expected. For them, professionalism seems to incorporate a range of attributes and characteristics that include technical competence, appearance, image, confidence level, empathy, compassion, understanding, patience, manners, verbal and non-verbal communication, an anti-discriminatory and non-judgemental attitude, and appropriate physical contact. Absence of, or inconsistency in, the projection and manifestation of these characteristics underpins many of the complaints patients, service users and carers make about care.^[13]

Healthcare workers also identify professional behaviour as a key element of good practice. In the HPC study into perceptions of professionalism, good clinical care or "doing the job well" included interacting and communicating in ways that were appropriate to patients and service users. Being self-aware and adhering to codes and protocols were also considered to be "professional behaviours", with professional self-awareness identified as influencing participants' desire to keep up to date and to maintain high standards of care.

Finding ways of projecting professionalism in practice is therefore desirable for both users and providers of care, with a greater focus on relationship-based care, mutuality and partnership working ("doing with" rather than "doing to" patients and colleagues) and with an emphasis on the "how" as well as the "what" of care delivery.

Literature, codes and standards across the healthcare workforce define some of the characteristics that underpin professional behaviour. Self-awareness, understanding and managing "self" in the work context, reflective practice, technical competence and a clear professional identity are identified as essential elements of professional and inter-professional practice. Maintaining professional boundaries when engaging with patients and service users in highly emotional contexts is also recognised as important, while not losing the essential elements of a caring relationship.

The HPC study of perceptions of professionalism^[14] found that interpretations of "professionalism" encompassed many and varied aspects of behaviour, communication and appearance. The study included the following summary of "what professionalism looks like".

• Professionalism has a basis in individual characteristics and values, but is also largely defined by context. Its definition varies with a number of factors, including organisational support, the workplace, the expectations of others and the specifics of each patient/service user encounter.
• The personal characteristics underlying professionalism may develop early in life as well as through education and work experience, but role-modelling is also important in developing the necessary awareness of appropriate action in different contexts.
• Views of professionalism did not diverge widely, regardless of professional group, training route or status as student or educator. All saw the interaction of person and context and the importance of "situational judgement" ("the ability to judge circumstances in order to identify the most appropriate way of acting/responding/communicating in a particular context, whilst still following a code of conduct") ^[15] as the key to "professional behaviour".
• Professionalism may be better regarded as a metaskill comprising situational awareness and contextual judgement that allows individuals to draw on the communication, technical and practical skills appropriate for a given professional scenario. The true skill of professionalism may be not so much in knowing what to do, but when to do it.

If healthcare staff are to display the behaviours, attitudes and values that are the core of quality health care and to develop respectful and effective relationships with patients, service users, carers and fellow professionals across many organisational boundaries, the underpinning principles that will support these desired characteristics need to be clearly laid out. There is a strong argument in favour of a single set of shared behaviours and values to focus the efforts of all staff.

Consequently, the working group has opted in this report to consider Stern's principles^[16] as a useful starting point. Stern's principles provide a foundation from which a wider consideration and development of a pragmatic expression of professionalism can be progressed. This does not imply that Stern's principles should be universally adopted or, indeed, that they should be adopted in their entirety, but rather that they provide a foundation from which a wider consideration of the principles of professionalism can be launched. The group could equally have chosen another source as a starting point, such as the insightful practice model: the main priority was to identify a model that assisted understanding of the concept of professionalism and acknowledged the challenges that need to be addressed around, for example, dignity, respect, compassion, empathy, honour, integrity and acting in the best interests of patients and service users.

Stern identifies four principles as encompassing the notion of professionalism. Although valuable, these principles are considered by some to be subject to individual and cultural interpretation and are therefore limited in their application. Accordingly, they are outlined below alongside contextualised definitions and related concepts developed by working group members with a view to illustrating their applicability in a practical setting (Table 1).

Table 1. Stern's principles, contextualised definitions and related concepts

Stern's principle	Contextualised definition	Related concepts
Excellence	Demonstrating practice that is distinctive, meritorious and of high quality	Commitment to competence Commitment to exceeding standards (in education and practice) Understanding of ethical principles and values Knowledge of legal boundaries (and practice) Communication skills
Accountability	Demonstrating an ethos of being answerable for all actions and omissions, whether to service users, peers, employers, standard-setting/regulatory bodies or oneself.	Professional:patient contract (including acknowledgement of unequal "power" relationship) Professional:social contract Self-regulation (including standard setting, managing conflicts of interest, duty, acceptance of service provision, responsibility)
Humanism	Demonstrating humanity in everyday practice.	Respect (and dignity) Compassion Empathy Honour Integrity
Altruism	Demonstrating regard for service-users and colleagues and ensuring that self-interest does not influence actions or omissions.	Opposite of self-interest Acting in the best interests of patients

There may be value in disseminating a vision for professionalism, with further exploration of its application in a changing healthcare world.

Recommendation 1. Develop and publish a vision for the delivery of professionalism in the changing healthcare context and test with a range of stakeholders.

Projecting professionalism

As previously alluded to, all healthcare staff, including support staff, are expected to demonstrate behaviours that support optimal care, project confidence and competence, and provide reassurance to all who come into contact with service providers. There is also increasingly a suggestion that staff should empower, enable and support service users to be in control, be suitably informed and take ownership of their care. This begins with the positive presentation of self, meaning strict compliance with national uniform policy or professional dress code where appropriate, clearly displayed identification and clean, tidy and modest appearance.

Professionalism, however, is about much more than appearance. Projecting the concept of professionalism requires recognition that care is not restricted to external technical tasks (the "what" of care delivery) but is also, importantly, about internal human qualities (the "how" of care delivery). This starts from the first moment of contact with patients or carers who, by virtue of the fact that they are having to access health services, are liable to be anxious and in need of a kind, courteous, reassuring and comforting response.

Professionalism is understood to be driven by internal drivers such as personal values, attributes and a sense of personal responsibility: these personal attributes are considered core to professionalism,^[17] and several studies^[18] have illustrated the ways in which they influence how practitioners behave towards one another and towards patients. They are influenced by organisational values and are supported by external drivers such as environmental and cultural influences, engaged leadership and facilitation of learning, and through feedback from patients, carers, service users and colleagues. Empathy is not the same as sympathy, and being able to put oneself in the patient's, service user's or carer's position can be a hugely impactful reflective approach.

Activities associated with reflective practice are key influences on professionalism. Regular reflection on practice is recognised as a way of developing and improving performance^[19] and practitioners who regularly review and adapt their practice accordingly are more likely to be receptive to new developments in their field and new ways of working. They are also more likely to be responsive to feedback and more willing to adapt and change their practices and behaviours. The desire for self-development and the motivation to keep up to date is recognised as an important influence on professionalism in practice.

The imminent review of the Staff Governance Standard^[20] is likely to focus not only on the rights of staff (as is the current focus) but also on their responsibilities, mirroring the approach taken in the forthcoming Patient Charter of Rights and responsibilities introduced in the Patient Rights (Scotland) Act 2011. This work provides an opportunity to ensure that the requirement of professionalism is explicitly stated within the standard.

Recommendation 2. Incorporate professionalism within all staff governance and employment activity.

The cost of professionalism

There are enormous advantages and privileges for healthcare staff in being recognised as professional, but with these come responsibilities. Those who behave according to the principles of professionalism are required to devote a measure of their own time to developing their knowledge and skills and need to accept that the public, employers and, where appropriate, professional regulators expect them to uphold the principles of professionalism and display good character at all times, even when not "on duty".

Providing empathic, personal and respectful care also carries a price. The concept of "emotional labour" conveys the practical manifestations of this price and describes some of the challenges that healthcare staff face on a daily basis. Emotional labour is described as hard skilled work and is "an integral yet often unrecognised part of employment that involves contact with people". ^[21]

Early indicators of the emotional and psychological effects of caring may often be seen by colleagues but may not be acknowledged, leaving staff feeling lonely, unsupported and under stress. This can exact a heavy personal toll on staff as individuals, causing physical and mental health problems and deterioration in professional standards, performance and behaviour. It could also lead to them leaving the job or the profession. This negative spiral of events can be arrested if the emotional and psychological impacts are recognised and acknowledged and appropriate support is offered.

A study focusing on compassionate care within inpatient settings^[22] identified "caring conversations" as an enabling influence for compassionate care and a means of providing support to staff. Caring conversations involve staff, patients, service users and carers "discussing, sharing, debating and learning" about how care is provided. The approach fits with relationship-centred care and draws on the collective wisdom of the team.

A similar approach to providing support to offset the emotional cost of professional healthcare practice is that of Schwartz Center Rounds^®[23]. These have been recommended by the King's Fund^[24] as a viable and effective means of counteracting stress in healthcare staff, reinforcing positive professional principles of empathy and compassion and building positive team cultures. The technique involves supportive, facilitated groups in which staff are encouraged to explore their feelings in relation to their contributions to the care of individual patients and service users; participants ask questions, share experiences and reflect on the challenges of care. If applied appropriately, this can result in practitioners gaining insight into their own practice, behaviours and attitudes and those of others - in effect, learning to see themselves as others see them.

Participants involved in research on Schwartz Center Rounds^® in the United States reported that their ability to provide compassionate care improved and they felt better supported in caring for patients. A pilot evaluation study in the UK^[25] found that similarities between the UK pilot sites and the United States were more marked than any differences.

Mechanisms such as these above should be investigated and adopted to enable staff to deal with the emotional and psychological impacts of healthcare practice. Failure to do so may impact significantly on the ability of individual practitioners to continue to function in a professional way.

Recommendation 3. Introduce supportive mechanisms to enable staff to deal with the emotional and psychological impacts of health care.