Behavioural elements of professionalism: Assessment of a fundamental concept in medical care

Figures & data

Table

Practice points

Professionalism is often cited as an essential part of medical performance. The Nijmegen Professionalism Scale is a suitable tool to evaluate professional behaviour in general practice. This study to validate the Nijmegen Professionalism Scale represents one further step. However, to construct a sound validity argument, a much broader range of evidence is required.

Table 1.  Factor loading matrix domain 1: Professional behaviour towards the patient

		Factors and item factor loadings
S. No.	Items	GP trainer factor 1* eigenvalue 5.42	GP trainer factor 2* eigenvalue 2.61	GP trainee factor 1* eigenvalue 5.91	GP trainee factor 2* eigenvalue 2.09
The GP trainee:
1.	Deals carefully with professional secrecy when talking to colleagues or acquaintances		0.44		0.51
2.	Deals correctly with legislative rules regarding informed consent	0.59		0.57
3.	Is able to bring up difficult subjects	0.51		0.59
4.	Respects the right of patients to inspect their medical records	0.41		0.46
5.	Does not give patients false hope		0.52	0.52
6.	Is able to show sympathy	0.49		0.48
7.	Takes care not to become part of the patient's system		0.72		0.44
8.	Takes care not to become too involved in the Patient's emotions		0.86		0.59
9.	Takes care not to become too intimate		0.72		0.46
10.	Takes patient's opinions seriously	0.51		0.40
11.	Takes patients’ embarrassment, shyness and reluctance into account	0.63		0.46
12.	During physical examinations, explains the aim of the procedures and what is expected of the patient	0.46		0.40
13.	Approaches patients with a different frame of reference (e.g. religion) openly	0.58		0.53
14.	Looks clean and tidy and dresses according to current norms	–	–	–	–
15.	Adjusts language to communicate with patients with little education	0.47		0.56
16.	Takes sex-specific differences into account	0.43		0.61
17.	Is able to deal with cultural differences in the presentation and experience of complaints	0.53		0.59
18.	Takes care not to be influenced by patients of high social status		0.59		0.40
19.	Is able to cope with the different expectations that patients have of their GP	0.40		0.53
20.	Involves the previous history of the patient in the provision of care	0.48		0.49
21.	Pays attention to the consequence of the treatment policy on the daily functioning of the patient	0.69		0.57
22.	Involves relevant aspects of the patient's home and environment in the provision of care	0.55		0.66
23.	Retains insight into the medical history of patients in order to act proactively if necessary	0.62		0.53
24.	If necessary, takes action after life events	0.65		0.52
25.	Respects patients’ self-determination	0.51		0.40
26.	Has difficulty taking decisions regarding diagnosis and treatment policy	–	–	–	–
Total variance explained (%)		30.9		30.8

Notes: Factor loadings less than 0.40 not shown.

Italicized items have been removed from the instrument.

n = 116.

*Factors: 1 = respecting patient's interests; and 2 = professional distance.

Table 2.  Factor loading matrix in domain 2: Professional behaviour towards other professionals

		Factors and item factor loadings
S. No.	Items	GP trainer factor 1* eigenvalue 7.22	GP trainer factor 2* eigenvalue 1.88	GP trainee factor 1* eigenvalue 7.88	GP trainee factor 2* eigenvalue 1.84
The GP trainee:
1.	Is able to mediate with other care providers in the interests of the patient	0.48		0.51
2.	Consults other care providers with targeted questions	0.43		0.53
3.	Discusses bottlenecks in cooperation with others directly		0.58		0.48
4.	Complies with multidisciplinary working agreements	0.63		0.44
5.	Ensures structured information transfer with other care providers	0.57		0.50
6.	Deals correctly with targeted questions from other care providers	0.77		0.64
7.	Is able to write a good referral letter with direct questions	0.47		0.57
8.	Is able to discuss a difference of opinion with a specialist directly		0.65		0.53
9.	Is able to manage the mutual demarcation of tasks between GP and specialists		0.49	0.57
10.	Is able to influence specialist care (e.g. during consultation at hospital visits)		0.48		0.72
11.	Ensures coherence in first and second line medical care		0.40		0.57
12.	Is able to motivate support personnel	0.58		0.61
13.	Chooses the correct time and place for comments about functioning	–	–	0.47	0.45
14.	Conducts structural consultations with support personnel				0.57
15.	Makes clear agreements with support personnel	0.56		0.61
16.	Listens to the contributions of support personnel	0.77		0.64
17.	Is able to distinguish between professional and personal interests in negotiations		0.63		0.53
18.	Is able to deal constructively with conflicts		0.55		0.54
19.	Is able to take policy decisions		0.67		0.73
20.	Is able to conduct job evaluations		0.63		0.60
21.	Is able to help seek solutions if a colleague has too high a workload	–	–	–	–
22.	Is able to provide emotional support for colleagues	–	–	0.56
23.	Transfers services correctly	0.69		0.62
24.	Shirks tasks	–	–	0.59
Total variance explained (%)		37.9		40.4

Notes: Factor loadings less than 0.40 not shown.

Italicized items have been removed from the instrument.

n = 116.

*Factors: 1 = collaboration skills; and 2 = management skills.

Table 3.  Factor loading matrix in domain 3: Professional behaviour towards society

		Items factors and item factor loadings
S. No.	Items	GP trainer factor 1* eigenvalue 5.49	GP trainer factor 2* eigenvalue 2.16	GP trainee factor 1* eigenvalue 6.75	GP trainee factor 2* eigenvalue 1.87
The GP trainee:
1.	Bears the consequences of his/her own conduct	0.67		0.61
2.	Is able to justify deviations from rules and guidelines	0.53		0.62
3.	Keeps promises and agreements	0.62		0.57
4.	Does not hide behind others (give others the blame or responsibility)	0.64		0.61
5.	Is aware of how his/her own norms regarding disease influence disease management	0.51		0.59
6.	Does not impose his/her own norms and values upon others	–	–	–	–
7.	Deals meticulously with moral requests for care (e.g. abortion, euthanasia)	–	–	0.58
8.	Is able to set priorities in the choice of topics for quality improvement		0.65		0.76
9.	Is able to signal suboptimal care within the practice		0.67		0.72
10.	Is able to work out a quality-improvement project		0.58		0.80
11.	Is able to estimate which problems are suitable for a quality-improvement project		0.76		0.79
12.	Is able to name the tasks to be, or that he/she would like to be, delegated to the assistant		0.64		0.49
13.	Has perceptions about how form can be given to means of contact (telephone services, diabetes surgery hours, etc.)		0.76	0.60
14.	Is able to justify indications for making home visits		0.49	0.66
15.	Has perceptions about how repeat prescriptions can be written in a responsible manner	–	–	0.65
16.	Is aware of the meaning and relative value of scientific evidence in decision-making	0.55		0.48
17.	In decision-making, weighs scientific evidence against factors related to the patient or the circumstances	0.67		0.45
18.	Is able to justify choices made on the basis of scientific evidence	0.63		0.46
19.	Is able to explain his/her own norms and values regarding the application of scientific evidence	0.52		0.56
Total variance explained (%)		40.3		46.0

Notes: Factor loadings less than 0.40 not shown.

Italicized items have been removed from the instrument.

n = 116.

*Factors: 1 = responsibility; and 2 = quality management.

Table 4. Factor loading matrix in domain 4: Professional behaviour towards oneself

		Factors and item factor loadings
S. No.	Items	GP trainer factor 1* eigenvalue 12.07	GP trainer factor 2* eigenvalue 2.62	GP trainee factor 1* eigenvalue 12.52	GP trainee factor 2* eigenvalue 2.40
The GP trainee:
1.	Is able to name reactions, thoughts and feelings that patients evoke	0.70		0.75
2.	Asks questions about his/her own role in relationships (patient, group, gp trainer, etc.)	0.74		0.72
3.	Uses specific practical situations as starting points for critical self-reflection	0.78		0.82
4.	In a specific situation with a patient, is able to analyse his/her own behaviour and adjust it if necessary	0.74		0.61
5.	Dares to express and act upon his/her own point of view	–	–	–	–
6.	Is able to mention differences of opinion	0.60		0.47
7.	Discusses his/her shortcomings and failures without losing belief in his/her own competence	0.50			0.57
8.	Makes a realistic estimation of his/her own strong and weak points	0.63			0.60
9.	Is able to balance work and private life	–	–		0.53
10.	Is able to mention aspects of work that increase satisfaction	0.54		0.48
11.	Is able to seek timely professional help when experiencing personal problems	0.52		–	–
12.	Is able to cope with feelings of powerlessness in the care process	0.43			0.57
13.	Is able to give positive as well as negative feedback	0.62		0.47
14.	Is open about feelings provoked by feedback	0.79		0.58
15.	Attaches importance to what others think about his/her behaviour	0.68		0.60
16.	Is able to make feedback concrete and specific	0.70		0.56
17.	Adheres to agreements made during feedback	0.67		0.65
18.	Sets priorities in learning	–	–	–
19.	Does not resist being judged	0.59		0.66
20.	Has an enquiring mind (asks questions and takes initiative)	0.59		0.66
21.	Is able to figure things out for him/herself	0.53			0.41
22.	Is able to adapt when patients change their minds about a treatment	–	–	–	–
23.	Is able to adapt and keep control of the situation if patients unexpectedly need to be seen during other activities		0.51		0.66
24.	Recovers rapidly after an unpleasant consultation		0.60		0.64
25.	Is able to admit his/her own mistakes	0.48		0.44
26.	Takes action to rectify his/her own mistakes	0.52		0.47
27.	Withdraws from the consequences of his/her own mistakes	0.41		0.46
28.	Is able to cope after making a mistake		0.66		0.63
29.	Learns from mistakes	0.51			0.65
30.	Is able to let a mild disorder (e.g. tiredness) run its own course even though the correct diagnosis is a mystery		0.58		0.61
31.	Makes rational deliberations about whether it is necessary to request specialist or other advice		0.62		0.44
32.	Is able to deal with the possibility that a treatment decision may be unsuccessful		0.63		0.49
33.	Expresses strong emotions by means of words instead of actions	–	–	–	–
34.	Is able to deal with difficult or angry patients		0.59		0.59
35.	Is able to conduct interventions that lead to a decrease in aggression from the patient		0.52		0.60
36.	Is able to formulate his/her own opinion in a clear and inoffensive manner		0.61		0.53
37.	Keeps an eye on his/her own safety adequately		–		0.52
Total variance explained (%)		39.7		39.2

Notes: Factor loadings less than 0.40 not shown.

Italicized items have been removed from the instrument.

n = 116.

*Factors: 1 = reflection and learning; and 2 = dealing with emotions.

Table 5.  Cronbach's α associated with each factor

Domain: Professional behaviour towards	Factor	Number of items	Cronbach's α GP trainers	Cronbach's α GP trainees
The patient	Respecting patient's interests	20	0.88	0.87
The patient	Professional distance	5	0.82	0.72
Other professionals	Collaboration skills	10	0.91	0.86
Other professionals	Management skills	9	0.94	0.87
The society	Responsibility	10	0.78	0.82
The society	Quality management	7	0.89	0.87
Oneself	Reflection and learning	23	0.95	0.91
Oneself	Dealing with emotions	9	0.79	0.86
	Total	93