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 Table of Contents  
REVIEW ARTICLE
Year : 2011  |  Volume : 24  |  Issue : 3  |  Page : 599

Assessing students' professionalism: Considering professionalism's diverging definitions


1 School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
2 School of Science and Technology, University of New England, Armidale, New South Wales, Australia
3 School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia

Date of Submission20-Dec-2010
Date of Acceptance26-Aug-2011
Date of Web Publication13-Dec-2011

Correspondence Address:
A E Aguilar
School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia
Australia
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Source of Support: None, Conflict of Interest: None


PMID: 22267355

  Abstract 

Context: Although most health education programs assess students' professionalism, there is little clarity within the health education literature on the definition of professionalism. This makes assessment of students' professionalism a potentially flawed activity. This literature review clarifies professionalism by bringing together diverging definitions from across a number of health disciplines and discusses the complexities and limitations of these definitions.
Methods: A search was conducted within the medical and health science education literature to identify articles that discussed professionalism and its assessment. Theoretical, qualitative and empirical research were included in the review.
Findings: The literature variably defines professionalism as upholding professional values, as demonstrating professional attitudes or demonstrating professional behaviours. Each of these perspectives influences how professionalism is to be assessed, with each perspective having its own limitations. The behavioural perspective is simple to assess, but it has been criticised for being too superficial. The values perspective has the potential to develop professionals who are motivated by philanthropic values, but values can be difficult to identify and assess. Attitudes are complex in their structure, but they are less superficial than behaviours and can be assessed with attitudinal scales.
Conclusion: Health professions educators should ideally assess all three perspectives of professionalism, however, this may not be realistic given the already laden curricula and the demands on educators. Educators may decide to only assess one perspective and given its advantages, the attitudes perspective may be a useful starting point.

Keywords: Assessment of professionalism, professional attitudes, professional behaviours, professional values, professionalism


How to cite this article:
Aguilar A E, Stupans L, Scutter S. Assessing students' professionalism: Considering professionalism's diverging definitions. Educ Health 2011;24:599

How to cite this URL:
Aguilar A E, Stupans L, Scutter S. Assessing students' professionalism: Considering professionalism's diverging definitions. Educ Health [serial online] 2011 [cited 2019 Dec 6];24:599. Available from: http://www.educationforhealth.net/text.asp?2011/24/3/599/101417

Introduction

Health practitioners’ professionalism can impact patient care, health outcomes, therapeutic relationships and the public’s perception and trust of a profession and its members1-3. The concept of professionalism has received significant attention within the health profession's education literature, sometimes prompted by publicised situations involving the unprofessional behaviour of health practitioners and consequent legal proceedings, as well as the commercialisation of health care practice1,3,4. The health profession's education literature is rich in discussion and debate on how professionalism should be defined1,5-7, fostered8-11 and assessed12-17. Despite the volume and scope of this literature, there is still no consensus on how professionalism should be defined6,18.  Diverging definitions create confusion for health professions educators who refer to research on the assessment of professionalism in students.

Professional competence is a notion closely aligned with professionalism, and poses similar problems in its assessment. Professional competence, defined by Epstein and Hundert19 as the 'habitual, judicious use of communication, knowledge, technical skills, clinical reasoning, emotion, values and reflection in daily practice', incorporates professionalism20,21. In discussing the assessment of professional competence, Crossley et al22. considered the difficulty one faces when deciding whether to assess 'structural competencies' (ie, values and attributes) or 'process competencies' (i.e., behaviours). Likewise, health professions educators may face difficulty when deciding whether to assess professionalism as a sole entity or as part of a broader assessment of competence.

This paper provides an elaboration and review of various definitions of professionalism to assist health professions educators in understanding the range of notions of professionalism, their complexities and their assessment limitations. 

Literature search

A search was conducted within medical and health science databases to identify articles that discussed professionalism and its assessment. The following databases were searched: AMED, CINAHL, Embase, Medline, PubMed, Scopus and Google Scholar. Combinations of the following search terms were used: professionalism, professional behaviour, attitudes, virtues, values, non-cognitive factors, assessment, evaluation, teaching, practice, medicine and health science. The references of identified articles were also reviewed to identify additional literature. The search was limited to articles written in English, however no limits were set on year of publication. The search yielded 134 articles and books, which were read to identify the perspective of professionalism that they researched or described. The identified articles were of empirical, qualitative or theoretical nature. Three main perspectives of professionalism were identified: professional values, professional behaviours and professional attitudes. 

This approach was considered suitable for the aim of this paper which is to contribute to health professions educators’ understandings on the perspectives of professionalism and the assessment limitations of these varying perspectives.

Findings

Professionalism as the demonstration of desired behaviours

Professionalism has been defined by some as the demonstration of desirable behaviours. Studies in medical education have identified behaving respectfully towards patients, treating patients equally and actively listening to patients as examples of professionalism in daily practice23-25. Table 1 provides a summary of professional behaviours from various sources. This perspective enables practical assessment of professionalism26, as desirable and undesirable behaviours can be identified and observed in students. This simplicity has enabled the development of several assessment tools designed to assess the professional behaviours of students15,18,23-25.

Table 1: Some of the behaviours that constitute medical professionalism identified from the literature.







Nevertheless, there are various limitations to assessing professionalism from this perspective. Behavioural assessments do not allow educators to assess students’ thinking processes or the motivations underlying the behaviour27,28. Van Mook et al18. believed that assessing behaviour encouraged the feigning of professional behaviours by students. Moreover, the attention given to the assessment of behaviour may lead students to view professionalism as merely an external expectation and not take it on as a personal expectation. Crossley et al22. also discussed the mistake educators make in assuming that a student will display the same behaviour in other settings or situations than the ones in which they were observed; they stressed the importance of assessing students’ behaviour in a variety of settings and scenarios. 

Hammer et al2. also argued that the behavioural perspective encouraged a superficial understanding of professionalism, and used the analogy of a bicycle wheel to make their point. At the centre of the wheel (hub) they placed core values of professionalism such as altruism, service, caring, duty and honour. The spokes radiating from the hub represented the resulting subtle behaviours such as respect, empathy and compassion, demonstrated by individuals acting professionally. The tyre itself represented the more observable behaviours such as dressing professionally, punctuality, good grooming, etc. These authors purported that only the superficial layers of professionalism are assessed through the behavioural perspective; they encouraged a stronger focus on the hub of the tyre, the core values of the individual.

Professionalism as upholding professional values

It has been argued that being a professional involves more than just demonstrating the required behaviours, that it also 'implies an affirmation of a certain set of fundamental values'29. From this perspective, professionalism can be defined as upholding and applying the values of a profession9,30 . A profession’s values are the 'basic and fundamental beliefs, the unquestioned premises upon which its [a profession’s] very existence rests' and to the public, these values promise competent and trustworthy professionals31,32. The American Board of Internal Medicine33 advocated six values—altruism, accountability, excellence, duty, honour and integrity and respect for others—which they believed underpinned the medical profession and which all medical professionals should be expected to endorse. The Royal College of Physicians of London34 also advocated the values of integrity, compassion, altruism, continuous improvement, excellence and working in partnership with members of the wider healthcare team.  

Interpreting professionalism from this perspective provides new insight into the principles that underpin a profession and highlight the importance of shared core values, which may have the potential to empower and unite a profession35 . These values become a declaration of what a profession holds true and what its professionals strive to practice each day. Low et al36. believed that persons motivated by 'an internal set of values' would consequently 'do right every time, regardless of sanction risks.' Moreover, a profession’s core values can act as intrinsic motivators, overtaking the external motivators of regulation, rewards and sanctions36. Therefore, it could be theorised that students and professionals who uphold the values of their profession move beyond merely complying with codes of ethics, as they have other humanistic motivators and goals guiding their practice.

Unfortunately, it can be difficult to assess values. Due to their centrality, people often do not consciously reflect on their values, and thus simply asking a student about their values may not yield a clear and precise account. Moreover, because various values often influence each other, it is difficult to assess the presence or absence of individual values37. There is also a lack of consensus on the values that should constitute professionalism and should therefore be assessed. This is evidenced by Van De Camp and colleagues’38 review of medical literature, which identified 90 distinct elements, mostly values, associated with professionalism.

There is a common assumption that if a person endorses a value, then the value will be demonstrated in all of that individual’s behaviours27. For example, if a student endorses the value of honesty, the assumption is that the student will demonstrate honesty at all times. However, several scholars argue that environmental influences and stressors can affect the values students demonstrate27,39,40. For example, a student may not openly share his observation of another health professional’s unprofessional behaviour because of the risk of being perceived as a ‘trouble maker’. Another person observing that student’s reluctance to speak out may conclude that the student does not value honesty. Thus, a student’s observable behaviour may not directly and accurately represent their core values and their core values may not be evident in what they say and do28,41. The relationship between values and behaviours is not predictable or direct42

Assessment of values is further complicated when they come into conflict. Value conflicts are a common occurrence as shown by Ellsbury et al43. who conducted focus groups with community-based physicians and found that they experienced many competing values such as, giving patients 'what they want' versus 'what they need.' In such situations, individuals may attribute different levels of significance to values35,44. The challenge is then to identify the values involved and those given priority. 

The difficulties associated with assessing values account for a lack of standardised assessment tools. Instead, qualitative assessments are used to identify and assess values including narrative reports, think-aloud exercises, responses to case studies and reflective pieces14.

Professionalism as the demonstration of desirable attitudes

Another perspective in the literature is that of professionalism being the demonstration of desired attitudes28. An attitude is defined as the 'disposition to respond positively or negatively towards an object, person, concept or situation'35. Attitudes have a closer relationship to behaviour and can be related to values, however these relationships are not direct and can be influenced by the surrounding context40,45. An attitude may include up to three components; cognitive (which consists of beliefs and ideas), affective (which includes emotional feelings) and behavioural (which consists of predispositions to act in a certain manner)46 . For example, an individual’s attitude towards the use of online social networks while at work could contain the following cognitive and behavioural components; it is unprofessional to use online social networks while on duty (cognitive), therefore I avoid using these networks while at work (behavioural).

There are various ways to measure attitudes. In their systematic review of 97 studies that explored the attitudes of medical students’ and doctors towards professionalism, Jha and colleagues47 identified several methods and tools for assessing attitudes, including scales, vignettes, questionnaires and interviews. The identified tools and methods assessed attitudes towards different aspects of professionalism, including ethical issues, academic/clinical integrity and the patient-physician relationship. The researchers concluded that more assessment tools were needed to measure attitudes towards professionalism as a whole. 

It can be argued that the values perspective provides a deeper understanding of professionalism as 'values are more deeply enclosed in the person' and occupy a more central position than attitudes40. However, a focus on attitudes could potentially facilitate the assessment of professionalism.

Environmental influence on professionalism

The environment can influence how professionalism is defined; which behaviours, attitudes and values are associated with the concept and are therefore assessed. Martimianakis et al48. commented that the term is perceived differently by individuals and organisations in varying societal, historical and institutional environments. Similarly, Van De Camp et al38. stated that 'depending on the context from which one tries to conceptualise professionalism, constituent elements will differ in abstraction level, relevance and importance.' This means that what is considered a core value or behaviour in a profession within one environment may not be recognised as being as critical in another49. This greatly affects the transferability of professionalism-related assessments, as their focus on particular values, behaviours or attitudes may not be applicable to other contexts and it highlights the importance of context-specific assessments. 

Discussion

Which perspective of professionalism should health professions educators assess? If the ultimate goal is to have health professionals upholding core values of their profession and demonstrating professional behaviours and attitudes in all situations, even given conflicting values and pressured environments, then ideally all three perspectives should be assessed within curricula. However, the assessing all three perspectives may be an unrealistic expectation given the already laden curricula of health professions and considerable workload for educators. It may be more realistic, and therefore appropriate, to focus on only one perspective of professionalism. In deciding on which perspective, educators need to consider the advantages and limitations of each perspective. For example, the behavioural perspective is simple to understand and assess, therefore it may be the preferred perspective amongst health professions educators. However, its superficial focus does not allow for exploration into the motivators behind the demonstrated behaviour. The values perspective has the potential to develop altruistic professionals by establishing philanthropic values that guide practice when ethical codes are unable to, but values are difficult to identify and assess. Attitudes are complex in their structure, but can be easily measured through attitudinal scales50. They are also less superficial than behaviours.

Given the advantages and disadvantages of each perspective, the attitudinal perspective may be a practical yet meaningful starting point for educators limited to selecting a single perspective of professionalism. Educators could begin by deciding which attitudes they want to assess and can refer to existing attitudinal scales for guidance13,47,51. Educators will need to ensure that there is consistency between the attitudes taught and those assessed within the curriculum52. The scales themselves will need to be valid, reliable, practical and inclusive of all the components of attitudes; feelings, beliefs and behaviours. If using existing attitudinal scales, educators will need to modify the assessments to suit their cultural, social and institutional environments as well as the broader standards of professional competence in their discipline. These factors also need to be considered in the assessment of professional values and professional behaviours.

Conclusion

Within health science and medical profession's literature, professionalism is variably defined as upholding professional values, exhibiting professional behaviours or demonstrating professional attitudes. Each of these perspectives influences how professionalism is assessed, with each perspective having its own advantages and limitations. In order to develop professionals who practice utmost professionalism, health professions educators should ideally assess all three perspectives of professionalism. However, this may not be realistic given the already laden curricula and the demands on educators and students. Educators may decide to only assess one perspective and given its advantages, the attitudes perspective may be the best starting point.

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