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

1. Introduction

This report was commissioned by the Chief Nursing Officer of the Scottish Government and the NMAHP Coordinating Council as part of wider NMAHP Contribution to the Quality Strategy programme. It was supported by the Scottish Government Chief Health Professions Officer and chief nursing officers in the three other countries of the United Kingdom.

The report seeks to explore the complex issue of professionalism and is focused primarily, but not exclusively, on the NMAHP workforce in NHSScotland. It was produced by a working group of experts in the field of health and social care and representatives of the Scottish and UK governments, professional bodies, regulators, academics and lay members, and chaired by Dr Frances Dow, a lay member. Terms of reference and membership of the group can be found at Annex 1.

The working group recognised that services are delivered by multidisciplinary and multi-agency teams and that professionalism is equally relevant to the wider healthcare workforce, including support workers and, in the future, to the social care workforce. Drawing on a wide range of sources, the group took account of patients' and carers' perspectives gained from the Better Together^[1] programme and the diverse experiences of individual members of the multi-professional working group. Views of participants at the 2011 National Regulatory Conference were also incorporated.

This work parallels work in relation to the medical profession^[2] that has been progressing since the 2009 Scottish Medical and Scientific Advisory Committee report to the Chief Medical Officer.^[3] They are complementary in that each recognises the values necessary to underpin the moral contract between the healthcare professions and society and seeks to promote the concept of professionalism in everyday practice.

Overview

The report:

• offers an overview of professionalism within modern healthcare settings
• explores perceptions of what professionalism looks like
• suggests ways of facilitating and developing professionalism within health service organisations
• provides options for its recognition and measurement.

It sets out:

• the changing context in which professionalism operates (Chapter 2)
• the positive behaviours and principles associated with professionalism (Chapter 2)
• factors that may enable and inhibit professionalism (Chapter 3)
• possible means by which professionalism may be measured (Chapter 4)
• recommendations for action for the NMAHP Quality Coordinating Council and the UK chief nursing officers to consider within their jurisdictions (Chapter 5)
• what will happen with the report (Chapter 6).

Why professionalism, and why today?

The context in which NMAHP practice takes place has changed profoundly over the last 30 years. Changing social attitudes and advances in science and technology have increased the public's knowledge and, consequently, their expectations. Care contexts are much more diverse and, in some cases, virtual as the balance of care inexorably shifts from acute inpatient activity to settings close to where people live. Professional and occupational roles have also changed along with the shape and size of the healthcare workforce, with conventional professional and organisational boundaries increasingly becoming blurred or erased. Traditional public service and professional values now exist alongside a strong business ethos, and greater transparency and accountability at all levels of the system means there is greater scrutiny on performance and outcomes.

The need to match increasing demand for healthcare with the finite resources available is creating an even more dramatic shift in the approach to healthcare delivery. In Scotland, this has contributed to the development of an ethos of mutuality and shared responsibility for health and health services involving the NHS and local communities, a planned move to health and social care integration, a shift of resources towards health prevention in all its forms and a drive to reduce unnecessary variation, harm and waste in the system through innovation and improvement.

Participative patients and service users

The public, patients and service users are now much more active participants in healthcare than in previous times. Examples can be seen in the degree of patient and public involvement in volunteering, board elections and "expert patient" programmes throughout the country. Access to performance and health data is also unprecedented, as is access to the knowledge traditionally "owned" by healthcare professionals. People expect the same sort of service from the NHS that they get in other areas of their life in which their needs are considered paramount and their responses personalised.

The policy drive is to shift from approaches that focus on deficits and gaps to those that value assets and personal capacity building, with people as co-producers of their health and care. By focusing on the outcomes people want to achieve in terms of their health and well-being, people can be empowered to take control of their lives and to build the foundation for lasting and sustainable change in their communities. This requires a shift in the balance of power from health service-controlled to person-owned care (a practical example of this is person-owned and controlled health records) and a development in professional skills from narrowly defined functions to more encompassing roles that enable and facilitate health and well-being.

The challenge of social media

As we move through the decade, it seems certain that elements of healthcare will increasingly be delivered through electronic means. The IT and digital revolution has already had a significant impact on the context in which NMAHPs operate, however growing reliance on social media (such as Skype™, Facebook and Twitter) will further increase the complexity. Social media represents much more than a tool for communication. It changes how people work and interact, how relationships are formed and how people complain, celebrate, discover and create. It does so on people's own terms and, as such, cannot be controlled.

Currently, examples of the use of social media in healthcare include NHS 24, NHS Education for Scotland and the Scottish National Blood Transfusion Service, however most NHS boards are exploring its potential as a means of providing information and posting messages. National work on staff governance issues is also likely to consider and address the challenges posed by social media. Its use goes beyond the world of work, of course, and its potential to conflate the personal with the professional is fast becoming apparent. NMAHPs, patients and service users are empowered to use social media; this needs to be encouraged and promoted in a responsible and secure way, with the personal and professional implications made clear.

Generating pride and passion through professionalism

Although there may not be a robust empirical base to demonstrate a direct link between pride, passion and professionalism and the importance of these factors in delivering quality, an initial review of the "grey" literature reveals a wealth of evidence from many different professions and groups showing that the link is present at practitioner level. Reports of severe system failures^[4],^[5] in care settings show that "unprofessional behaviour" does exist and that levels of morale and job satisfaction among NMAHPs vary. It is therefore essential to consider how pride and passion can be generated, sustained and harnessed, particularly in difficult circumstances.

Setting the direction

Irrespective of the changing nature of healthcare and the complexity of the context in which it operates, NHS staff, patients, service users and the general public still place a high premium on the notion of professionalism, the ethos of trust it represents, the degree of accountability it confers, and the role it plays as a driver of quality and the benchmark for the attitudes, actions, behaviours expected from all.

To remain relevant, any modern and pragmatic description of professionalism must articulate the intention to shift from the traditional 20^th Century model of healthcare towards a model that reflects the complex and challenging realities set out above. This includes the intention to provide person-centred care, do "with" rather than "to" patients and service users and reject paternalistic notions of "the professional knows best" in favour of a greater emphasis on relationship-based care, mutuality, partnership working and shared decision-making. It also means ensuring that advocacy is in place for those who need it (or is available when required) so that the right balance between autonomy, empowerment and risk is maintained.

In addition to respecting the law and practitioners' individual rights, contemporary professionalism places the interests of the public, patients and servicer users above practitioners' self-interest, their political, cultural or religious beliefs, and any professional or occupational allegiances. Part of this, but by no means the only part, is the will and determination to challenge poor practice and to tackle safety issues. Few would argue that public confidence has been severely dented by recent severe system failures in care settings, the failure to tackle problems within teams and the propensity of leaders and managers to focus on objective data and performance at the expense of quality and people.

Consequently, this is an opportune time to provide a contemporary vision of professionalism for NMAHPs and support workers, with associated principles and behaviours that are clear to all. This aims to help restore the confidence in (and of) the healthcare workforce that has arguably been diminished as a result of negative publicity and adverse media coverage Closely aligned with the aspirations of the Healthcare Quality Strategy for NHSScotland for the consistent delivery of care that is safe, effective and person-centred, the focus for professionalism should be on the following priorities:

1. improving patients', carers' and service users' experiences through professionalism
2. looking at opportunities to kindle a sense of pride and passion in those who are part of, support or have recently joined the NMAHP professions.

Every opportunity should be taken to embed contemporary professionalism in everyday practice and to instil and encourage professionalism in others. Identifying where professionalism is not apparent and taking appropriate action is therefore essential. Although organisational policy and procedures support staff to challenge and report poor practice and raise safety concerns, their translation into practice is inconsistent and organisational responses to expressions of concern is variable. NHS boards may consider undertaking further work on this with the royal colleges, partnership forums and regulators, who may also wish to take this opportunity to review their guidance.

This report posits that awareness of professionalism among healthcare staff should be promoted through selection, induction and ongoing performance review processes (to reinforce the central role of professionalism in healthcare practice) and professional behaviours and values should be recognised and reinforced in day-to-day practice and within workplace cultures. It also identifies environmental and organisational factors that impact on the projection and demonstration of professional behaviours, highlights the importance of team and organisational culture as a major influence in promoting professionalism, and recognises the role of strong and effective leadership and the impact of positive role-modelling, each of which will go a long way to supporting the delivery of professionalism across the healthcare workforce. To that end, the behaviours and actions of board executives, professional leaders and managers are central.