Developing professionalism in students

Numerous strategies have been employed in pharmacy and medicine curricula in an attempt to develop professionalism in individuals. These efforts have been hindered by the difficulties in assessing a student’s level of professionalism at a given time, and therefore determining whether an intervention has had a positive effect.

In the White paper on student professionalism (APhA-ASP/AACP-COD, 2000) the APhA-ASP/AACP-COD identified several challenges in the development of professionalism in pharmacy students. Hammer et al. (2003) were also able to identify many challenges to the development of student professionalism. They suggested that students had a lack of peer pressure to develop as professionals, and that their peers found it difficult to challenge unprofessional behaviour. They also described how both the academic and practice environments that students found themselves in produced inconsistent socialisation, by having inconsistently applied policies, staff demonstrating unprofessional behaviour, poorly planned and communicated activities and assessments, and conflict between the roles of a pharmacist and of an entrepreneur. They suggested that a lack of respect by patients and other healthcare professionals makes it difficult for pharmacists to continue to feel a desire to serve. It is important to note that these assertions are the beliefs of Hammer and her colleagues (Hammer et al., 2003) and they do not present any evidence to justify them, however they are helpful when considering interventions to increase professionalism in students.

3.5.1. Recommendations

for

the

development

of

professionalism in students

In their White paper on student professionalism (APhA-ASP/AACP-COD, 2000) the APhA-ASP/AACP-COD also made some recommendations for educators to help enhance student professionalism. They identified four phases where changes could be made; recruitment, admissions, educational programs and practice. These are echoed by Hammer et al. (2003) who also state that

students’ educators must “exude professional expectations and excellence”

(p16), and that the culture of the school must reflect these expectations of

students and staff at all levels. A holistic approach to professionalism is required to get buy in from staff and students, and they make several suggestions about how this can be done.

On recruitment they made recommendations to strengthen the development of professional identity of students before they have even accepted a place on the course. These included attendance at school open days and encouragement of prospective students to join professional organisations (APhA-ASP/AACP-COD, 2000 and Hammer et al., 2003).

Considering the admission of students to the course the APhA-ASP/AACP-COD White paper (2000) focused on ensuring that places were given to students who had existing high levels of professionalism or great potential. They suggest that these could be measured with the use of interviews and essays to assess professional qualities.

Both the APhA-ASP/AACP-COD (2000) and Hammer et al. (2003) refer to the importance of both the school and practice environments that students are exposed to. The APhA-ASP/AACP-COD (2000) also proposed a list of 11 steps that pharmacy schools could take to incorporate professionalism into their course, including the encouragement of discussion of professional issues, of involvement in voluntary organisations, and in state, local and national professional organisations. They also strongly encouraged the use of the ‘Pharmacists Code of Ethics’ (American Pharmacists Association, 1996), the ‘Oath of a Pharmacist’ (AACP, 2007) and ‘Pharmacist’s Pledge of Professionalism’ (APhA-ASP/AACP-COD, 2000) although they did not indicate any research that demonstrated that these result in an improvement in professionalism (APhA-ASP/AACP-COD, 2000; Hammer et al., 2003).

In addition, Roth and Zlatic (2009) suggested that students must be held accountable for their behaviour and be guided towards developing their own sense of professionalism. They should also be helped to identify examples of poor professionalism as well as true professionalism and guided to internalise

appropriate attitudes and values. Whilst Wilson et al. (2010) acknowledge the challenge of integrating the more complex aspects of professionalism such as values, empathy and altruism they do suggest that the more basic terms could be easily included in the curriculum of a pharmacy school.

3.5.2. Developing professionalism in pharmacy students;

the evidence

Despite the above recommendations for developing professionalism in pharmacy students, there remains relatively little evidence to indicate what strategies can be used achieve this aim.

In their systematic review of studies of professionalism in medicine Jha et al. (2007) found 17 studies reporting on interventions aiming to improve professionalism. These interventions included headings such as; courses, personal teaching sessions and incorporation of professionalism into curricula. Fourteen of the studies reported a change in attitude as a result of the intervention, however only two of the studies that were reviewed in depth measured attitudes longitudinally, and these showed no long term benefit of the intervention.

Thompson et al. (2008) suggested that using methods from all four frames of the ‘four-frame leadership model’ (Bolman and Deal, 2007) could be an effective way to teach professionalism. The four frames are firstly, ‘structural’ relating to rules, policies and the environment, secondly, ‘human resources’ relating to skills and relationships, thirdly, ‘political’ relating to power, conflict and competition, and finally ‘symbolic’ relating to culture, ritual and ceremony (Bolman and Deal, 2007). Thompson et al. (2008) used a grounded theory approach and interviewed students, mentors, faculty members and academic administrators (e.g. dean or chancellor) to determine the different themes in the perceptions of professionalism. They then mapped these themes to the four- frame leadership model. The authors found that while many themes spanned multiple frames, there was not equal representation of each frame. Most of the themes belonged to the structural or symbolic frames, with the political and human resources frame receiving less attention. When students were asked

how professionalism should be included in the curriculum, their answers fell into the under-represented political and human resources frames, with examples such as role modelling, more interactions and feedback, demonstrating that these are important areas that should not be forgotten when designing teaching for professionalism.

Bumgarner et al. (2007) described how they used short stories to develop professionalism in first-professional year pharmacy students. They chose to use the definition of professionalism described by the Association of American Medical Colleges Professional Task Force as they felt the “calling to serve” was the core aspect of professionalism. It is of note that this study was undertaken at Samford University, which had a Christian mission (Samford University, 2016). Four short stories, specifically selected for the student population and the topic of professionalism, were sent out to students as preparatory reading (Bumgarner, 2007). Students then took part in a facilitated discussion on the stories in their student orientation. Students were asked for their opinions on use of the stories to teach professionalism, with results showing that the students had found the stories engaging and found the program personally meaningful. Students were later given a professionalism survey to try and establish the effect of the program. The authors reported an upward trend in results in areas such as the calling to serve and relating their spiritual life to their profession. These increases were relatively small however, and the professionalism survey appears to have been devised solely for the purpose of this study, and as such had not been validated. There is currently insufficient evidence therefore that this strategy would have a significant effect on the professionalism of pharmacy students.

It is apparent therefore that currently evidence to support interventions to improve professionalism is weak and renders the task of devising such interventions incredibly difficult.

3.6.

Summary

This chapter has explored the different approaches taken to defining professionalism amongst the healthcare professions. Medicine, pharmacy, nursing, occupational therapy and physiotherapy have all engaged in debate about how professionalism can be defined, measured and developed in students.

Most of the definitions relating to professionalism within pharmacy originate in the USA. For the purpose of this study, which was particularly focused on professionalism in pre-registration pharmacists, the most recent and useful definition of professionalism in pharmacy in the UK was proposed by Elvey et

al. (2011). This was developed as a result of interviews, and focus groups with

newly qualified pharmacists and pre-registration tutors and so is likely to resonate with participants in this study.

Validated tools to assess professionalism however, are still lacking, as are reliable, evidence-based methods of developing professionalism in individuals studying pharmacy.

Experience in the workplace has been employed as a way to develop students’ sense of professionalism and professional socialisation. The evidence for this will be examined in Chapter 4.