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

3. Facilitating professionalism

This chapter explores the key influences and contexts in which professionalism can thrive, recognising that the particular influence of a culture, system, framework, standard or patient encounter will vary. Strong leadership, committed organisational support, empowered staff, partnership working and a commitment to securing patient/service user feedback to inform activity are among the positive influences on professionalism observed in the work environment: these may have the greatest potential for revitalising professionalism among healthcare staff in the future.

Standards for professional practice

(This subsection focuses specifically on NMAHPs, rather than the wider healthcare workforce).

Regulatory body standards of practice are set by UK-wide regulators such as the Nursing and Midwifery Council (NMC) and the HPC. They describe how professionals are expected to behave towards patients, service users and colleagues in the practice of their profession and are considered key to safeguarding the health and well-being of the public and protecting their interests. They determine personal responsibilities for all individuals who are governed by the standards to ensure they act by them but also reflect wider organisational responsibilities to ensure that individuals are supported to meet the standards.

Regulators have robust legal powers to take action against those who do not adhere to their standards, including removal or suspension from the register and restrictions on practice. Behaviours that could lead to the regulator taking action against professionals relate to practice and conduct and include financial exploitation of a vulnerable patient or service user, conducting an inappropriate relationship with a patient or service user, and serious or persistent failure to meet a standard of competence. Further examples are set out in annual fitness to practise reports such as those from the NMC^[26] and HPC (see Annex 2).^[27] These incidences occur in a very small minority of health professionals but have a profound effect on both the individuals concerned and levels of public confidence in the professions.

A range of contracts, guidelines, standards, protocols and codes has been developed for NMAHPs in Scotland and across the UK. These include professional and regulatory body standards, the Royal College of Nursing's Principles of Nursing Practice,^[28] national guidance developed at government level and local standards, and procedures and protocols at NHS board level. As has already been mentioned, Scotland also has a mandatory code of conduct for healthcare support workers with induction standards for those entering the workforce and a code of practice for employers .^[29]

These standards and codes provide the parameters within which NMAHPs and support workers must practise and are positive drivers of service excellence. Failure to act in accordance with them may result in practice or actions that not only put patients, service users and possibly colleagues at risk, but also place practitioners at risk of disciplinary action from their employer, sanction by their regulator and, in extreme cases, prosecution under the legal process.

Environmental/cultural influences

Different organisational and professional systems and frameworks interact with, and potentially shape and sustain, professionalism. Facilitating professionalism can therefore be explored on a number of levels.

Establishing a culture that values all contributions will help to maintain feelings of pride and motivation in staff. Recognising that all staff make an essential contribution to an individual's experience of healthcare can help to build a team ethos and equitable work culture. If the workforce does not feel engaged or valued, this can affect motivation, culture, attitudes and behaviours and could impact on manifestations of professionalism. Work being taken forward in Scotland on shared governance recognises the importance of this.

In addition to the national codes and standards developed by government departments, regulatory bodies and professional associations discussed above, a range of workplace drivers also influence professionalism. These include:

• clinical governance
• care governance
• staff governance
• professional leadership and career frameworks
• general management frameworks
• partnership-working frameworks
• individual performance management frameworks
• education, training and personal development planning frameworks.

Team cultures and norms exert a significant influence, positively or negatively, on the ability of individual staff to adopt and embed professionalism within their practice. A positive team culture will nurture professionalism, whilst a negative culture, in which innovation is stifled, care approaches are not person-centred and development and learning are not ingrained, may mitigate against the development of professional behaviour, particularly in less experienced team members. A key element in facilitating professionalism within services is therefore to identify where team cultures are hindering professional behaviour and take action to nurture more positive approaches. The aim must be to create consistency in approach to professionalism across teams by raising the bar for those who are not functioning in accordance with the principles of professionalism, rather than lowering it for those who are. It is therefore important to be clear about expectations of team cultures and define what is non-negotiable.

Recommendation 4. Implement measures to enable a professional culture to flourish across NHSScotland.

Support and review mechanisms

The NMAHP workforce has a strong culture of mutual support that includes the provision of mentorship, preceptorship, coaching, personal development planning and review and clinical supervision. For instance:

• students access mentorship from experienced staff in clinical placements
• new registrants undertaking the Flying Start NHS^®[30] programme commonly benefit from mentorship from a more experienced colleague
• healthcare support workers undertaking mandatory induction and assessment of compliance with the code of conduct receive support and review of progress against the required standards
• practitioners in many services, particularly midwifery, mental health and learning disabilities, engage in forms of clinical supervision with peers
• senior staff often organise individual mentoring and coaching schemes to support their personal and professional development
• all NHSScotland staff have access to annual personal development planning and performance review as part of their employment contract.

Clinical supervision is seen as integral to lifelong learning and is an important part of clinical governance and improving standards of care. It is described as a range of processes centred on enabling practitioners to reflect on their practice, identify possible solutions to problems and improve standards. All profession-specific regulatory and professional bodies promote clinical supervision as a means of supporting practitioners to work effectively and to enable professional and personal development. Midwives are distinct in that they have a separate statutory requirement to access supervision, given the more autonomous nature of their practice.

There is, however, significant variation across the country in terms of opportunities for staff to access support schemes such as these. They are nevertheless important in relation to promoting professionalism and could usefully be organised around the underpinning principles of professionalism; these would serve as benchmarks for personal development planning and performance review with a view to identifying ongoing development needs.

Recommendation 5. Develop existing support measures to facilitate and embed professionalism across NHSScotland.

One of the aims of the NHS Knowledge and Skills Framework (KSF) is to provide a fair and objective basis for review and development for staff employed in the NHS. The KSF is primarily focused on knowledge and skills, although the addition of a professionalism strand into the personal development planning and review process would appear attractive. There is a need to consider how this could be achieved and integrated into current processes without creating an unnecessary and overly bureaucratic burden.

Recommendation 6. Incorporate the requirements of professionalism within personal development planning and review processes.

Recruitment and selection

Healthcare organisations' mechanisms for recruitment and selection at all levels should be sensitive to the key underpinning characteristics of professionalism and should be capable of identifying these in potential recruits, both within written and online submissions and in interview and assessment processes. Similar considerations should govern processes for recruitment and selection to education and training programmes.

Potential applicants should be made clearly and explicitly aware of what is expected from those who are recruited. The aim is to ensure that, as far as is possible, an "upstream" approach to embedding professionalism in the workforce is adopted by service and education providers, with the aspiration of avoiding problems "downstream". This reflects a proactive approach to promoting professionalism.

Recommendation 7. Explore and implement mechanisms for selection and recruitment that incorporate the requirements of professionalism.

Leadership and role modelling

It is acknowledged that individual healthcare workers have responsibility for demonstrating the values and behaviours commensurate with professionalism, however leadership is a key influence on their ability to adopt professional behaviours. The Chief Nursing Officer for Scotland has introduced a model of shared governance across NHSScotland to support a dynamic staff−leader partnership that promotes collaboration, shared decision making and accountability for improving quality of care, safety and enhancing work life.

Leaders at all levels in organisations, throughout practice, management and education areas, nurture engagement through which the meaning of professionalism can be revitalised. Alimo-Metcalfe's Model of Engaging Leadership^[31] is an example of a model that may have relevance here; it identifies 14 dimensions that may support leaders in this endeavour (Table 3).

Table 3. Model of Engaging Leadership

Engaging with individuals showing genuine concern being accessible enabling encouraging questioning	Engaging the organisation suporting a developmental culture inspiring others focusing team effort being decisive
Engaging the stakeholders - moving forward together building shared vision networking resolving complex issues facilitating change sensitively	Personal qualities and values being honest and consistent acting with integrity

The NHSScotland Delivering Quality Through Leadership strategy,^[32] which includes an appendix detailing "leadership qualities and behaviours", will also support leaders to project professionalism within their organisations.

Styles of leadership have been shown to be an important factor in improving staff motivation, job satisfaction and commitment, and reducing work-related stress. As highlighted by the King's Fund,^[33] leaders play a key role in role-modelling professional behaviours. Professionalism in action can be demonstrated by leaders who "walk the talk" and are visible role models, inspiring those who work alongside them. This is at the heart of the Leading Better Care^[34] programme.

The impact of poor or weak leadership and management has been highlighted in recent reports into severe system failures in care settings.^[35],[36] These reports reveal a consistent pattern of leaders and managers failing to: provide training for staff; ensure adequate staffing levels; provide effective supervision of staff; ensure effective care planning; respond to and learn from serious incidents; notify relevant authorities of safeguarding incidents; and involve people in decisions about their own care. Where leadership fails in such ways, it makes it more difficult for professional behaviours to be adopted and embedded within clinical practice.

Positive leadership and instilling a sense of responsibility and accountability in all staff will assist in building a sense of team contribution and will promote the principles of professionalism. Leaders can:

• ensure that individual personal development plans within their services are influenced by the principles of professionalism, and that individual and team objectives instil a sense of collective contribution to achieving excellence
• establish a culture that values all contributions and promotes feelings of pride and motivation in staff
• celebrate achievements and success
• ensure that agreed performance management processes are used to identify and assist those who do not display the behaviours of professionalism.

These factors, and many more related to leadership, can affect culture, attitudes and performance among the workforce and impact on the development of professional behaviours.

Recommendation 8. Promote positive role modelling and leadership across NHSScotland as a means of promoting professionalism.

Education, training and learning from others

There is broad agreement across the healthcare sector that personal responsibility for learning and a commitment to lifelong learning are core aspects of professionalism. Continuing professional development (CPD) is fundamental to the development of NMAHPs and all healthcare staff and is a mechanism through which high-quality care is identified, maintained and developed.^[37] Organisations should aim to support and reinforce individuals' commitment to lifelong learning and ensure the provision of ongoing CPD opportunities that focus on issues of conduct as well as knowledge, competence and skill to support their development. This need not necessarily come at financial cost, as development opportunities can be secured through workplace and exchange activities.

Recommendation 9. Reinforce personal responsibility for lifelong learning as part of professionalism, facilitated by organisational support.

Recommendation 10. Focus NHSScotland learning and development activity on issues of conduct as well as knowledge, competence and skill.

Research with doctors in the United States^[38] found that those who did not display professional behaviour or fulfil course responsibilities during their pre-registration education were far more likely to subsequently be subject to disciplinary action by a state medical board. The correlation was particularly strong for repeated instances of certain behaviour such as unreliable attendance at a clinic, not following up on activities related to patient care and repeated instances of diminished capacity for self-improvement, such as failure to accept constructive criticism, argumentativeness and displaying poor attitudes. It is not unreasonable to assume that these findings could extend across other health professions. This is currently being investigated by researchers at Durham University.

Pre- and post-registration education and training programmes provide opportunities for students to explore the concept of professionalism for their practice. Studies have shown that clinical role models can have a significant impact on how professionalism is perceived by students. The concept of professionalism needs to be embedded in such programmes, including undergraduate and postgraduate curricula, with support provided to mentors to promote awareness of its principles among students and other learners.

Regulators work with education institutions to ensure that students understand the significance of professionalism to practice. Demonstrating the importance of professional values and the principles embodied in regulatory standards will help students and other learners to carry these values and principles through into their clinical practice.

Recommendation 11. Incorporate professionalism as a central concept within all training and education programmes, including undergraduate and postgraduate curricula.

There has been a strong evidence base since the 1980s showing the positive correlation between the learning environment and the clinical environment.^[39] A good place for learners has been shown to be a good place for patients, service users and staff. The Profile of Learning Achievements in Care Environments (PLACE) project^[40] demonstrated that the relational aspect of care is central to the experience of teaching, learning and communication and, ultimately, to the quality of care delivered to patients and service users, and job satisfaction for staff. Equally important is the learning that takes place among peer groups, whether formally through conferences, journal clubs, action learning sets and peer review processes, or informally through day-to-day role modelling and feedback.

Learning from patients and service users is another key influence on the development and maintenance of professionalism. Learning can arise through compliments and complaints from patients, service evaluation feedback, public meetings, service user involvement in student education and training, and from research into patients' views. The Better Together^[41] programme is a positive example of how patients' expectations and experiences can influence professionals at many different levels and in a variety of contexts. Patient and service user feedback can be undertaken through formal and informal activity and should be perceived as a key driver of change.

Promoting and communicating professionalism

The aim of this work is to embed professionalism in the everyday practice of all members of the NMAHP and wider healthcare workforce in Scotland. The dialogue about how professionalism is promoted and communicated is therefore an important consideration.

As this report has described, professionalism runs as a thread through mandatory codes and standards and most local and national policy and strategy in Scotland, including the Healthcare Quality Strategy for NHSScotland^[42] and mandatory standards and codes for healthcare support workers.^[43] It also features as a central tenet of clinical and operational standards and is increasingly recognised as a key quality indicator. However, the task of revitalising professionalism within the conduct, performance and ethical underpinnings of the healthcare workforce will be greatly assisted if the concept is promoted and communicated in a clear and meaningful way.

This is a challenging undertaking that requires more than the production of leaflets and other written materials. It calls for a multi-faceted approach that will address different communication needs and different levels of motivation to ensure that the key messages reach their intended audiences (managers, educators, practitioners, patients, service users and the general public). Various forms of research, including that related to psychology and educational experience, can show the complexity of behavioural change and the influence of attitude and motivational factors. Such research should be used to support any promotional work that may be taken forward.

Recommendation 12. Secure all relevant research input into any promotional and communications work.

This report has been developed to inform the NMAHP Co-ordinating Council: further work is now needed to develop resources on professionalism to engage the NMAHP and wider healthcare workforce and to reassure the public.