Discovering professionalism through guided reflection

Abstract

Doctors need to identify and understand the professional behaviours of both themselves and others. In order for students to think critically about these issues we encouraged them to use the tenets of the General Medical Council's Duties of a Doctor as a framework in which to reflect on the actions of healthcare professionals at work. Although the critical incident technique is a well-known process for encouraging reflection, little is known about its usefulness for assessment purposes in this setting. We aimed to discover the validity, feasibility and educational impact of the critical incident as an assessment method for first year students undertaking guided reflection in the context of their first exposure to multi-professional health and social care experiences. First year medical students submitted two critical incidents they had observed during multi-professional health and social care attachments and an evaluation of their experiences. Students engaged in the reflective cycle on the professional behaviours of others providing evidence of a varied range of situations. With adequate preparation, junior students are able to reflect on social and healthcare experiences using the Duties of a Doctor as a framework. Critical incidents are a valid and feasible method for assessing students’ reflections on professionalism, with good educational impact.

Introduction

Doctors need to understand their duties as professionals and to be able to reflect on their own performance and that of other practitioners (GMC, 2001) to meet the expectations of the medical profession and the public. Until recently, many medical schools had focussed their assessment strategies on knowledge and skills objectives. However, there is increasing evidence (Sox, 2002; Papadakis et al., 2004; ABIM, 2003) that unsatisfactory performance in practice is more likely to be due to unprofessional behaviour, rather than knowledge or clinical skills. Consequently, there is a growing consensus that professionalism can and should be specifically addressed during undergraduate studies (Cruess & Creuss, 1997; Swick et al., 1999; Stephenson et al., 2001; AAMC, 2002; Whitcomb, 2002). This has been made explicit in the UK by the General Medical Council (GMC, 1993; 2002) which recommends that attitudinal learning objectives should be given equal importance in the curriculum to knowledge and skills objectives.

Professionalism has been defined as:

‘the extended set of responsibilities that include the respectful, sensitive focus on individual patient needs that transcends the physician's self-interest, the understanding and use of the cultural dimension in clinical care, the support of colleagues, and the sustained commitment to the broader, societal goals of medicine as a profession’ (Hatem, 2003).

Some aspects of professionalism, e.g. communication skills, ethics and confidentiality may be taught didactically. However, students need opportunities to participate in appropriate activities from which they may analyse what they see and do, consider the impact that those activities have on them and devise a learning plan to develop their own professionalism. Reflection helps students to integrate theory and their understandings gained from experience, whilst developing future practice (Boud et al., 1985; Schon, 1991). Embedding reflection in real multi-professional health and social care experiences early in the undergraduate course may encourage students to use the tool throughout their studies and career as part of work-based learning. At the University of Sheffield, such an opportunity for reflection on professional behaviours arose in the Intensive Clinical Experience (ICE) within the first year of the course.

Curriculum development

The new curriculum, commenced in 2003, is outcome focussed, highly integrated and organized around body systems. Outcomes of the course are based around clinical skills, interpersonal skills, professional behaviours, practical skills, and the appropriate underpinning basic medical sciences (Newble et al., 2005). We validated our professional behaviours outcomes by mapping them against the principles of Duties of a Doctor (GMC, 2001) (Figure 1), and the existing Professional Ethical Code for Sheffield medical students and found close agreement. ICE was initially introduced into year one of the old curriculum in 2000, in order to enhance vertical integration between basic clinical competence and basic sciences. Students spent three weeks with doctors, nurses and social services staff, observing them perform in practice. The ICE programme was modified in the light of previous evaluations (Bax et al., 2001) as part of the new curriculum in order to provide more guidance for students to engage in reflection on professionals at work as participant observers, in the context of Duties of a Doctor.

Figure 1. Duties of a Doctor (from Good Medical Practice GMC, 2001).

Assessing professionalism

Whilst it is difficult to assess attitudes to professionalism, it is possible to observe and assess their expression in the form of professional behaviours (ABIM, 2003) but there were few published methods of assessing professional behaviours to guide us.

The 15 tenets of Duties of a Doctor (Figure 1) offer a set of learning objectives for developing teaching and learning activities, which might be appropriately assessed to encourage the development of professionalism in students. Alternative approaches have been used. Within the postgraduate arena, the tenets of Good Medical Practice have been used to create a multi-source feedback tool to assess a range of generic skills, which cover aspects of professionalism in the workplace (Archer et al., 2005). Some medical schools are beginning to use this approach (Rees & Shepherd, 2004) in relation to professionalism. However, there are potential resource implications in collecting and analysing up to 12 ratings per student on potentially two or three occasions. We wished to use the portfolio approach with the purpose of marshalling evidence about the progress of students towards the specific professionalism outcomes of our course (Challis, 1999). This raised the question of how we might develop a valid and feasible assessment of the understanding professionalism within an integrated curriculum, which could be part of a portfolio but avoided the tick box approach of multi-source feedback.

Methods

This study aimed to discover the educational impact, validity, and feasibility of the critical incident as an assessment method for a class of students undertaking guided reflection in the context of their first exposure to health and social care professionals at work. In order to do this, we needed to decide whether the evidence of reflection presented in the critical incidents (Challis, 1999) was valid (showed what it claimed to show), was sufficient (detailed enough for the assessor to be able to infer that appropriate learning had taken place) and could be integrated into the school assessment strategy for professional behaviours.

The Intensive Clinical Experience (ICE)

First year medical students (n = 250) were randomly assigned to a nurse, a hospital consultant, and a member of social services staff for a single three-day attachment, in each of three consecutive weeks.

The learning objectives of ICE were:

• To encourage students to develop effective communication skills with patients/clients

• To enable students to meet, talk with and question professionals involved in health and social care

• To reinforce the Professional Ethical Code for Medical Students (University of Sheffield)

• To understand the Duties of a Doctor

• To enable students to reflect on experiences gained in ICE

Guidance on reflection

The ‘guided reflection’ method (Johns, 1994; Wilkinson, 1999) was adapted to prepare students to engage in reflective practice (Figure 2). This approach provides a series of prompts to help students develop reflective thinking. At a whole class briefing, prior to their attachments, we defined a ‘critical incident’ (Flanaghan, 1953) as any event that challenged them within the context of Duties of a Doctor. They practised the critical incident technique using a video taped nurse-patient and doctor-patient consultation as a trigger for small group discussion and reflection. Students were encouraged to develop personal learning goals from the simulated learning experience, which they would research, to add to their understandings of the issues raised. The results of the small group discussions were shared with the year group. Supporting materials about reflection, the Duties of a Doctor, the assessment, and the evaluation were made available on Minerva, the school's managed learning environment.

Figure 2. The guided reflection template showing the steps the students had to follow.

Outcome measures

We used two outcome measures to provide data for our study. These were:

1. The quality of student reflections. Students were required to submit reflections on two critical incidents. They were asked to choose meaningful but contrasting episodes from any of the attachments, which illustrated the principles within Duties of the Doctor and to reflect upon them using the template, illustrated in Figure 2. Assessment criteria for reflective learning outcomes have been suggested by a number of authors (Hatton & Smith, 1995; Richardson & Maltby, 1995; Pee et al., 2002) In this formative exercise the assessment criteria were largely task focussed: Were the two reflections submitted on time? Were the two reflections complete? Did both submissions demonstrate a degree of reflection (i.e. considered challenges to values, beliefs, understanding; consideration of alternative approaches; identification of personal learning) rather than being purely descriptive?

   One author (PS who is experienced in teaching and assessing reflective practice in undergraduate and postgraduate contexts) marked all the submissions according to the criteria (i.e. the work was submitted on time, in the correct format and showed at least a moderate level of reflection). A global rating of either satisfactory or unsatisfactory was given. Students with an unsatisfactory grade were seen by the Director of Teaching (NB) to discuss their underperformance and to receive guidance on how to resubmit work to a satisfactory standard. Those who failed to submit by the deadline were reminded within 72 hours, also by email.

2. Student evaluation of ICE. As part of an on-line evaluation, students were asked for free text comments to evaluate the students’ perceptions of the quality of their learning and teaching experiences. They were asked what worked well, what did not work well, and what could be improved in the ICE programme. Additionally, students listed the learning resources used to support their reflections.

Qualitative data analysis

The analysis was carried out anonymously within an ethical framework of research, which met the University guidelines on evaluations of curriculum development.

The text of all students’ critical incidents and their qualitative comments from the ICE evaluation was archived electronically in a database to which only the researchers had access. A content analysis using a constant comparative approach was used to provide a basis from which a conceptual framework could emerge in relation to our research questions (Strauss & Corbin, 1998). Each reflection was given a single code. Codes were merged into sub-themes and then condensed into themes. The coding process considered all elements of the Duties of a Doctor. Evidence of reflective learning was recorded where students used expressions like ‘As a result of … Now I understand’ (Mathers et al., 1999). Validity was assured by iterative consideration of the emerging explanations for the data. A second experienced qualitative researcher (CR) independently undertook the coding process on a sample of reflections, with >80% agreement. The number of times each code was evidenced in the full data set (Table 1) is given, allowing a relative comparison of different data (Miles & Huberman, 1994).

Table 1.  Frequency of codes

Codes	Number of times evidenced
Dr positive communication	76
Dr negative communication	61
Teamwork positive	44
NHS/Social Services resources	33
Patient beliefs/autonomy/dignity resources	30
Dr/senior student limit of competence	12
Social Services respect	12
Social Services positive care	12
Confidentiality negative	12
Dr negative professionalism/quality of care	11
Nurse positive communication	10
Nurse negative care/behaviour/knowledge	10
Nurses positive care/behaviour	9
Respect (all professions) for patients & students negative	9
Student overcoming/acknowledging prejudice	9
Hospital negative communication	8
Dr interest of patient positive	8
Dr interest of patient negative	7
Dr positive professionalism/quality of care	7
Respect (all professions) for patients & students positive	7
Patient or family decision?	7
IP communication	6
Culture/religion	6
Nurse negative communication	5
Social Services negative communication	5
Social Services negative care	4
Racism	4
Teamwork negative	3
Power of doctors	3
Students positive communication	3
Dr positive behaviour	2
Social Services ethics	2
Student unease	2
Institutional prejudice	2
Social Services positive communication	1
Dr up to date	1
Communication problems language	1
Student coping with death	1
Sexism	1
Student too much responsibility	1

Results

The reflections were analysed and 40 codes assigned. The codes were merged into 11 sub-themes (Table 2) and from those, five themes were identified: communication; professionalism; team working; organisation of care; and student learning issues. The data presented are illustrative of the analysis undertaken.

Table 2.  Sub-themes

Communication

Teamwork

Resources

Beliefs

Autonomy

Respect

Care

Competence

Confidentiality

Behaviour

Prejudice

Communication

The most frequent reflection was about communication (n = 175). Students reflected on examples of good and poor communication displayed by all three professional groups. Many described how professional communication affected not only the patients but also how they felt observing such interactions. Some students were able to move from being merely observers of practice by connecting the issues raised in the critical incident to events in their own lives, thus demonstrating ways in which they attended to their own feelings, in the line of duty, a key component of reflection (Bolton, 2001).

‘… This is the first time that I have ever listened to bad news like this being broken, I was impressed by the way it was done. However, I did begin to feel upset myself and I was surprised to see that the doctor wasn’t, even though he was sympathetic … I related this experience to when I was told that my Grandad had cancer and so I felt sympathetic towards her daughter as well as the patient herself.’

Professionalism

This theme encompassed the greatest number of sub-themes and included reflections on the behaviour, professionalism and the quality of care given by all three professional groups. The most frequent code was ‘dignity, autonomy and patients’ beliefs’ (n = 30).

Students moved from being aware of the importance of maintaining patients’ dignity, to understanding it within a real context. The student who said, ‘Maintaining patient's dignity and self respect is something I hope I will continue to be conscious of’ had reflected upon a patient's colostomy bag bursting in distressing circumstances.

There were reflections on all aspects of professionalism contained within Duties of a Doctor. For example keeping up to date with advancing medical knowledge, acknowledging the limits of competence, and ensuring the patient is the first concern of the professional and is involved in decisions about care, avoiding gossip about patients and negatively commenting on colleagues.

By reflecting on these aspects of being a healthcare professional, students identified for themselves what will be important to them as practising doctors.

They were able to do this by recognizing inappropriate behaviour and using reflection to think about how they might behave in a similar context.

Some students found that expectations of patient care challenged their own cultural and religious beliefs. However, through reflection they were able to deconstruct the incident in order to find a rationale or a solution to such personal conflict. For example, a male student from an ethnic minority said:

‘Then she [the patient] started taking her clothes off … I was confused on how to deal with this situation, and whether it was appropriate for me to stay and help. The patient was talking to me. I had no choice but replying and stayed and helped. When we went outside, the nurse then explained that I am on a duty to help people rather than feeling embarrassed. Then I explained about my cultural beliefs which left me embarrassed at the time when the patient took her clothes off, from my point of view, it would have been impolite to stay there. However, the situation made me feel that there was a duty which was beyond all that’.

Students were able to recognize stereotypical behaviours in professionals, and develop possible strategies for changing practice, whilst shaping their own future practice. There were examples of students from ethnic minority backgrounds reflecting on examples of unprofessional behaviours such as racism, where many students and doctors have just accepted the stereotyping (Kai et al., 2001) without reflecting on such issues.

‘The midwife announced that one of the patients had a particularly troublesome baby who cried a lot and that this was due to the fact that the baby was of mixed race. The other nurses burst out in laughter … I was frankly mortified at what I had witnessed and felt that these people were acting in a most unprofessional and insensitive manner …

I learnt that blatant racism and ignorance in the work place is not a thing of the past and also felt that there was a big flaw in the way which professionals can report such incidences. I being an Asian am unfortunately having to accept that I will be subjected to racial remarks and should prepare myself accordingly. I have to learn that not everyone has the same views about racism as me and will have to tolerate other peoples' views without compromising my level of care towards them’.

Other incidents, which students identified, included examples of discrimination against patients with mental health problems, and recognition of the role of training in shaping professionals’ behaviours.

‘… it made me realise the shortcomings of my understanding of mental health conditions and the lack of understanding I had … If I felt like that, then surely I couldn’t be the only one, which means that these individuals quite probably are discriminated against for these reasons, not only by the general public, but also possibly by medical personnel not equipped with the adequate training or life experience’.

Team working

Harden (1998) has drawn attention to ways in which effective working relationships in healthcare might develop through multi-disciplinary learning. In the context of ICE, whilst some students reflected on examples of poor practice, largely they observed good team working both between staff in the same and between professions.

Some of the reflections indicated the power of role modelling, in multi-professional working. In particular students were able to consider ‘a willingness to share, and indeed devolve, specialised knowledge and authority … if the needs of clients can be met more efficiently by others’ (Carrier & Kendall, 1995).

‘It was positive to see a doctor getting involved in the social side of a patient's care rather than merely concentrating on the medical management of the patient. The communication between all members of the team involved in the clinic was also very good and it provided a positive outcome for the patient’.

Organization of care

In addition to reflecting on the behaviour of individual professionals, students also considered how organizational and institutional issues impacted on the care of patients or clients, and the responsibilities of professionals in maintaining best practice:

Patients who had suffered from mental illness … had their case notes placed in a blue file, whilst [others] had theirs in buff files …. When these patients were admitted to general wards, nursing staff would recognise the patient's files as those with mental health problems, and as such would have a degree of scepticism regarding any information or complaints received from the patient … I have learnt that prejudice and labelling can occur in any area of patient care, unless staff and carers make efforts to prevent it’.

Students reflected on how workload and resource issues within the NHS, might account for behaviours, but recognized that professionalism should be maintained.

‘this should never develop into the situation that occurred where this frustration affected the care of the patient’.

Student learning issues

Students provided good evidence of their learning. Some revealed how they linked the situation they were observing to past experience and how this understanding would change future practice. Other students demonstrated how the learning resources, which included patients, families and staff, as well as reading materials from patient information leaflets, textbooks and the Internet, had increased their understanding. Few were able to offer learning plans in sufficient detail as to how they might achieve their learning needs in a way typical of portfolio learning (Challis, 1999). For example one student said:

‘I would like to learn more about the process of [mental health] sectioning and when it is appropriate to section a patient. I am going to look into patients’ rights and medical ethics related to this incident’.

There were several useful suggestions for making sure students were better prepared for engaging with patients and clients as other than passive observers. For example by ensuring all students had undertaken a moving and handling course, so they could be of direct help in the workplace.

Some students observed situations, e.g. involving drug abuse and abortion which many students ‘had previously [been] unaware of except from on the television’.

‘a young man … was dirty, unkempt and had a history of drug abuse … Suddenly his condition deteriorated … Perhaps it was seeing the medical team quietly but efficiently working to save his life with no-one uttering sounds of disdain or objection that made me realise that personal feelings and prejudices have no place in medical treatment and care. Minutes later the young man died and the reaction of the staff was of overwhelming sadness that his life had been lost … It was a very powerful lesson and one which illustrated perfectly the point in the duties of a doctor’.

In this instance, little was said about the degree of debriefing (Pearson & Smith, 1985) the student received from staff in such a challenging situation.

All 250 students in the year undertook the reflective critical incident component of ICE. Of those, 236 students’ reflections were regarded as satisfactory. The remaining 14 were unsatisfactory by virtue of non-submission (n = 10), submission of only one critical incident (n = 2) or failure to demonstrate reflection (n = 2). All students with an unsatisfactory grade subsequently submitted satisfactory work. The on-line evaluation was completed by 75% (n = 188).

Discussion

Guided reflection has a valuable educational impact on our students in the exploration of professionalism in a real work-based multi-professional setting. Our findings illustrate how the ICE programme provided a rich learning experience in which students were able to engage in a number of powerful learning activities in a diverse range of health and social care situations. All of the students were able to demonstrate engagement with the reflective cycle, with most students showing some reflective capacity (Boud et al., 1985; Schon, 1991). Reflecting on critical incidents encouraged students to understand and analyse professionalism, and recognize what it means to be a professional in the context of Duties of a Doctor. Students were able to demonstrate how they had engaged with and reflected on the real daily activities of health and social care professionals in a to create personal learning needs. They had related these to a variety of learning resources further enriching their experience. Although most students were able to identify future learning needs that emanated from their reflected experiences, their plans to fulfil them needed refining, suggesting the need for some additional support or changes in the guidance on reflection (Challis, 1999).

The assessment of the understanding of professional behaviours has undoubted face validity. We were satisfied that the evidence presented in the critical incidents by students was valid (Challis, 1999) as they consistently met the claims of the appropriate tenet from Duties of a Doctor. We had demonstrated through the broad range of material that was available that the critical incidents were sufficiently detailed enough for the assessor to be able to infer that appropriate learning had taken place (Challis, 1999). Some students witnessed things that were upsetting, challenging and even exposed them to a degree of risk. We accept that debriefing and feedback as part of closer supervision of students would be desirable (Pearson & Smith, 1985; Baernstein & Fryer-Edwards, 2003; Gordon, 2003) but this would require the investigation of additional resource.

Limitations of the study

This was on a pilot study exploring an educational innovation in the context of a major curriculum reform. Effects of particular educational innovations can be difficult to isolate from each other.

Implications of the study

How might this work contribute to an integrated strategy for the assessment of professional behaviours? The ability to understand professional behaviours is one of the expected learning outcomes of a medical course (GMC, 2002) and we have shown this can be assessed in a valid, feasible way, with good educational impact. The critical incidents were capable of being assessed more rigorously (Johns, 1994; Hatton et al., 1995, Richardson & Maltby, 1995) using more explicit measurement characteristics. Content validity can be assured by sampling widely across the range of expected professional behaviours. The reliability of the assessment has not been considered in this study. Additional assessors would have provided inter-rater reliability. However, we believe that the construct of professionalism is a part of clinical competence, the measurement characteristics of which have been studied for many years. An important finding is that an attribute has to be tested across a large sample of cases before a reliable generalization about competence can be made (Van der Vleuten, 1996). In relation to professionalism the reliability of the assessment can only be guaranteed through the use of multiple raters on multiple occasions.

The measurement construct we were most interested in ICE was reflection on the professionalism of others. Whilst ICE was sufficient to demonstrate this capability, it was insufficient to make judgements on students’ own professionalism.

Curricular impact

The curriculum management committee used a range of evaluation data, not just this study, in deciding to include guided reflection as part of the student selected component (SSC) programme in the new curriculum. The eventual format of ICE was as a component of the SSC programme. The ICE programme provided the first opportunity to collect some evidence about students’ capacity to reflect as a component of a portfolio of in-course assessments For the assessment of the student's own professional behaviours, we adopted the strategy of collecting and collating evidence about students’ professionalism at multiple points throughout the course using the global ratings of multiple observers, including those from ICE. Students are able to view their progress both of their professional behaviour grades and their in course assessments via their electronic portfolios, where their assessments were posted. Further work would be required to determine what educational impact this model of assessing professional behaviours had and whether it is an effective and sustainable curricular innovation.

Additional information

Notes on contributors

Patsy Stark

PATSY STARK is the Senior Lecturer in Medical Education and Co-ordinator of the SSC programme at the University of Sheffield. She has an interest in developing professionalism in medical students and, with Dr Chris Roberts, developed the reflection template used in ICE.

Chris Roberts

CHRIS ROBERTS is Associate Professor in Medical Education at the University of Sydney.

David Newble

DAVID NEWBLE is Emeritus Professor of Medical Education at the University of Sheffield. He returned to Australia in 2004 where he has appointments as Professorial Fellow at Flinders University, Honorary Professor at the new University of Wollongong Medical School and Educational Consultant to the National University of Singapore.

Nigel Bax

NIGEL BAX is Professor of Medical Education at the Academic Unit of Medical Education, and Director of Teaching, University of Sheffield.