Professionalism : An attempt to measure definition and understanding

Professionalism is under scrutiny in all service-providing professions. Healthcare is one of them. There are rules and regulations mentioned from professional bodies that place the foundations of the definition of professionalism which have to be followed. A prospective study was conducted in a District General Hospital, with the aim to establish if professionalism was clearly defined. A questionnaire with open questions was given to 242 individuals from different disciplines including healthcare workers, students and members of the public. Their answers were grouped and then categorised using the points that the General Medical Council (GMC) uses to characterise professionals. The participants were divided in different groups according to their discipline and their grade of seniority and the findings were then analysed. The majority of the answers support that Teamwork is one of the fundamental criteria that constitute professionalism. On the other hand, Health, meaning the wellbeing of the health worker, had the lower preference between the participants’ answers. Senior clinicians’ group scored high and in general the Clinical group performed better than the Non-Clinical one. Students were divided into two sub-groups (Group A and Group B), according to their discipline. Group A performed at a similar level to Junior Clinical group. Group B achieved lower scores in certain categories such as Audit and Evaluation of Practice. In conclusion, all groups demonstrated a good understanding of the definition and factors that influence professionalism. Findings supports that an educational programme with an emphasis on the significance of all criteria the GMC mentions, will give a better outcome in future studies and this will help the community that the healthcare workers serve. In addition, educational programmes for the wider community would improve the relationship between healthcare workers and the public. A future study to include larger numbers of public members will better define their understanding about professionalism.


Information for the project Thank you for taking the time to participate in this study
The purpose of the study is to establish the degree of your understanding on the definition of "Professionalism" and how this affects the health care practitioner Do all health professionals (clinical and non-clinical disciplines), despite their training and their regulatory bodies, as well as members of the public; have the same or a similar opinion about the meaning of Professionalism?Furthermore, the aim of the study is to establish if there is a need of further education for health professionals or the community which they are serving Your complete honesty is valued.The whole data is and will remain anonymously collected and will remain confidential.It will only be used for the purpose of the study By agreeing to this information you give your consent to receive a questionnaire and take part in the study You understand that you can withdraw from the research at any time without giving a reason Law, Ministry and Education (De Rosa, 2006).In Healthcare, professionalism is gaining an increasing attention (Swick 2000;De Rosa 2006;Talbott and Mallott 2006).Doctors' regulatory body, in their guidance, is emphasising that all professionals need to be very attentive towards their behaviour to their patients and the members of patient's families, as well as other health professionals and colleagues.Professionalism is one of the fundamental criteria of every doctor's appraisal and revalidation (American Board of Internal Medicine (ABIM), 2001; Irvine, 2005;General Medical Council (GMC), 2009;Scottish Government, 2012;Health Care and Professions Council (HCPC), 2014).
Professionalism is not only based on behaviour, but also reflects the professional competence of a physician (Swing, 2007).Professional competence is more than a demonstration of isolated competences and skills, and has to be examined as a whole entity.A competent clinician is able to think, feel and act, like a proper physician (Gale and Marsden, 1982;Eraut, 2000).Professional competence includes communication, knowledge, technical skills and clinical reasoning.It is more than the factual knowledge and includes the ability of solving problems with clear cut solutions.It can be defined by the individual's ability to manage problems, make decisions with limited information given and tolerate uncertainty.It includes the possession of knowledge, attitude, ethical behaviour, altruism, belief and application of the profession's codes, integrity and honesty, respect to others and self, self-regulation and maintenance of competence (Schon, 1983;Swick, 2000).It is measured by reviewing the individuals' cognition, technical skills, scientific, clinical and humanistic judgement as well as use of time, team work, teaching, respect, learning, handling conflicts and willingness to recognise and correct possible errors (Epstein and Hundert, 2002).Professionalism can be described as "the practice of doing the right thing, not because of how one feels, but regardless of how one feels" (De Rosa, 2006).
Professionalism in Medicine must be the natural base of a physician's work.Society expects health professionals to have and demonstrate a professional manner in their conduct with the people they serve and to each other.All health workers have to understand in depth the meaning of the word "professionalism", and how the lack of it will lead to negative consequences in their career and professional life.Misbehaviour which clearly affects their responsibilities towards the public, their colleagues, but also towards the wide community, leaves Medicine tarnished (Swick. 2000;ABIM, 2001;GMC, 2009).As professionalism is part of the educational curriculum in undergraduate level, there is an anecdotal feeling that more senior professionals would not have the same understanding on the subject.
The purpose of this study is to find out how different groups of different backgrounds, training, experiences and regulatory bodies define professionalism, and to find out if further education and training would be necessary, so individuals should be aware of the profession's and mainly the community's needs.

METHODOLOGY
This is a study that was carried out in a District General Hospital.The choice of the institution was random as it was the place of work for the individuals who participated.Different groups of health workers (doctors from different grades of seniority, nurses, administrators, managers, health care assistants, and others as well as students) were included.Members of the public were asked to participate too.Unfortunately there was some resistance to the willingness of individuals from this category to participate when they were asked.Within the members of the public group, some individuals were patients.All individuals were randomly selected as they volunteered to participate when they were asked and took part in the study freely.As all members were volunteers randomly and conveniently selected there was no plan or possibility to have a randomised study with similarly selected matched groups.The opinions and answers of all individuals were included.Verbal consent was obtained from all participants after an information sheet was given, explaining the aims, objectives and the rational, was given and read to them (Table 1).Ethical committee approval was obtained (University of South Wales).
The questionnaire was given to them with five questions (one with limited demographic details and four open questions), to be completed (Table 2).This was discussed and passed through a If you wish to offer additional information, please do so below: small group of senior clinicians who gave their opinion and agreed on the questions and the criteria on which the "professionalism" will be quantified.As such, the criteria included in the GMC's publication were considered as relevant ( 2009).This group of clinicians did not participate in the study.
From the first question, the grade, position and properties of every participant was established.The participants were divided into clinical and non-clinical groups, as well as a separate group for healthcare (medical, nursing and chiropractic) students.The category of the clinical group was divided into two sub-groups (Senior and Junior Clinical Staff) according to their experience and their grade.The Student group was also divided into two subgroups, Group A (medical students and student nurses) and Group B (chiropractic students).Members of the public were asked to take part, forming a very small group.
All replies were analysed by using the GMC's twelve criteria points that characterise professionalism, and were grouped accordingly (GMC 2009).These criteria were quantified according to the frequency of their presence per group and the total percentage was calculated.Further grouping was performed to assist with the quantification of the factors that can improve professionalism in healthcare.The frequency was calculated.

RESULTS
All 242 participants answered the questions in the questionnaire.The different categories and subgroups were tabulated (Table 3).The opinions of all participants were grouped and analysed using the GMC criteria (GMC, 2009) as basis, for the definition of professionalism (Table 4).The clinical group was subdivided into senior and junior sub-groups (Table 5) for the reason to analyse the differences and understanding of professionalism in these separate sub-groups.There is an anecdotal feeling that seniors, due to their undergraduate and core training being carried out a long time ago, are not familiar with the "scientific" definition of professionalism, in comparison to the juniors who have just finished their undergraduate training.The definition of professionalism is taught as part of their curriculum.By creating these two sub-groups, there is an opportunity to analyse their knowledge.The five participations from the public, although they were included in the initial analysis for the GMC criteria, were excluded at a later stage because of their small number.In some criteria it was obvious that they were not able to give any clear opinion.Following the numerous answers and feedback in every GMC criteria, it was found that participants from the clinical and student groups had a better overall understanding of professionalism than non-clinical staff.To achieve a better understanding of professionalism within the student group, two sub-groups were created.Group A consisted of the Medical and Nursing students whereas Group B consists of the chiropractic students.All findings are demonstrated in Tables 6. Detailed tables of the different groups are in the Appendix.
In all groups there are some criteria that scored lower than other.The most prominent is the limited understanding that the criterion of "Health" (a person has to keep and look after own health) is important to determine a professional individual.This criterion was recorded to be low in all groups.Senior clinicians though performed better than all other groups (92.3%), whereas the worse participants were the students (27.8%),only outperformed by junior clinical staff (42.8%).
On the contrary, everybody agreed that "Teamwork" is paramount to professional behaviour (ranging between 90 to 100% in all groups).It came as a surprise to see that "Teaching" scored high only in the Senior sub-group (100%), but all other groups did not think that it helps )."Communication" was picked more by the non-clinicians (88.4%) than all others (averaging to 71.8%).Despite that the "Health" criterion gained a low amount of points, as it is one of the criteria rarely mentioned by them, on the other hand it was noticed that "Audit and Research" was picked up in the Junior staff group (97.1%), meaning that as soon as they were involved in clinical practice, they were stimulated and became aware of the importance that research has to their professional development.Student of Group A showed a higher rate in the categories of "Training" and "Audit" (55.6% in both) in comparison with Group B (chiropractic students) (40.8% and 30.6%), but both scored low in "Health" (Group A 27.8%, Group B 20.4%).The Non-clinical group scored lower than the Senior Clinical in the "Health" category but considered it as an important factor (58.1% in comparison with 92.3%), but if the junior staff is included they are almost in similar levels as the combined clinical score is 56.25%.
These finding also influenced the opinions of the participants in establishing the factors which can improve professionalism.The criteria categories of audit, feedback, appraisal and teaching, continuing professional development (cpd) and education both scored low (range 58.2% and 73.2%) while teamwork mentoring was the highest scorer (98.7%) for all participants (Table 7) and the same pattern seen in Clinical (Table 8) and Student (Table 9) groups.

DISCUSSION
A profession in general is more than a job.It is the activity and commitment of someone to serve others while simultaneously serving one's self.A professional has to be dedicated to the chosen profession.A doctor for example, takes the Hippocratic oath and binds to the commitment of using the obtained knowledge and skills for the service and treatment of all confronted illnesses.To do this, one has to demonstrate moral and ethical excellence.This person has to inspire trust, honesty and compassion to others and must have the courage to confront all difficulties that may arise.
To learn all this, the doctors must have cognition or pre-cognition of these properties, but must also train themselves during their professional journey as well as to follow another wiser person's steps and learn the ethics of the profession.The presence of a mentor will be necessary.Learning is paramount for continuous progress and improvement (De Rosa, 2006).In case that human weakness may surface, a doctor, and in extension a proper professional, has to ask for support and will need to visit the mentor for more advice.A mentor is useful as some of the information that is necessary for further development is hidden and it has to be identified, bringing it up on the surface and in real life (Hafferty and Franks, 1994).
Professionalism is under increased scrutiny across all professions, and mainly those in subjects that have a direct service towards other persons, like health, law, ministry or teaching.(De Rosa, 2006;HCPC, 2014).Professionalism, though, is not clearly and well defined.A lot of scholars and organisations place their criteria and regulations of what the word means and what characteristics a professional should have.Some of these criteria are common among the published work, but other criteria are not well defined (ABIM, 2001;Swing, 2007;HCPC, 2014;GMC, 2009GMC, , 2015)).The problem does not seem to be the definition that is coded by the different organisations, but the understanding of it that every single individual has, and how this individual will interpret the information or practice it.There are barriers that are threatening professionalism and these are lack of confidence, stress, fatigue, overwork, lack of experience, conflicts or tensions between professionals or arrogant superiors.Due to this, a healthcare worker has to be supported with more training, obedience to policies, reflection and mentoring (Gale and Marsden, 1988;ABIM, 2001;Epstein and Hundert, 2002).
There is a consensus among scholars and organisations that training for the definition of professionalism has to start early in a health worker's life.A lot of educational institutions have curricula in which professionalism is taught.The definition codes are well explained; as they are well controlled and assessed within the educational programmes and courses, but it is stressed that it would be necessary to stimulate the personal cognitive knowledge, bringing the person to think and perform according to the rules.The educators have to be aware of their students' different backgrounds and "adjust" their behaviour (Haffery and Franks 1994;Eraut, 2000).Professionalism is a combination of values, behaviour and relationships (Engel et al., 2009).The professional competence is part of the professionalism (Eraut, 2000;Swick, 2000; Redfern  , 2002;Scottish Government, 2012).As professionalism is considered an important part of a health worker's contract with society, every individual has to continue improving by constant training and exposing themselves to different experiences (Kirk, 2007).There are voices calling that the selection of health workers or health workers to be, have to start even on the admission process to the institution (Passi et al., 2010;Waheet et al., 2011;Scotish Government, 2012).Professionalism is necessary to be assessed by using a multitude of methods (Salvatori, 1996;Redfern et al., 2002).
The fear that all educational institutions have, is the unprofessional behaviour of students, which if present, may lead to negative behaviour at their future professional life.There was a warning of erosion of medical professionalism.People from different backgrounds may influence this.Students on the other hand are welcoming the diversity of different backgrounds of either their learners or educators, but they demand the need to follow ethical professional rules at all time.They have blamed the influence made upon them by the unprofessional behaviour of their educators, who were meant to be their mentors.Such behaviour can have a devastating effect on them as it leads to confusion and bad habits (Swick et al., 1999;Roberts et al., 2004;Brainard and Brislen, 2007).
It has been suggested that students with unprofessional behaviour need to undergo mental health evaluation (Bennett et al., 2001).Students may demonstrate unprofessional behaviour if their teaching is insufficient and becomes impossible to them to fully understand the subject (Roberts et al., 2004;Reed et al., 2008).Due to the growing interest and emphasis on professionalism, there is the suggestion that psychiatrists need to be involved directly in the education of these matters, such as definition of professionalism (Talbott and Mallott, 2006).On the counts to tackle unprofessional behaviour, the implementation of measures such as, reflection, self-assessment and role model are thought to be more helpful in encouraging professional development, but it would be necessary to "ring-fence" the time allocated to the learners and release the pressure from the educators (Swick, 2000;Reed et al., 2008;Engel et al., 2009).
In the present study, the participating healthcare workers are of different grades and disciplines, trying to throw light on the understanding that people have on professionalism.The GMC criteria of characteristics defining professionalism were used (GMC, 2009).From the findings it emerged that senior clinicians were highly aware of the criteria, despite that the subject was not present at the time of their undergraduate study.Junior staffs were aware in a quite comparable way.
Medical students and student nurses (Group A of the student group), performed in a similar way as the junior clinical staff, re-enforcing the finding of the professional body's review (GMC, 2015).It will not be possible to know how the senior clinicians would perform if the questions were place to them immediately after their graduation, as this would directly compare the understanding they have with that of the junior staff.This way, someone could argue that it will be the ultimate test to validate if teaching of professionalism in the undergraduate level is helping or not.The similarities of the answers between the junior staff and Group A students compared with that of the senior group makes clear evident that the inclusion of the subject within the curriculum helps a lot and as soon as the juniors are connected in a professional level with the seniors they are improving their understanding.
The only striking difference is that the criterion of "Health", meaning the healthcare workers wellbeing, is not something that members of the junior staff group thought of as frequently as the senior staff which as a necessary criterion to indicate professionalism.The differences in the "Health" category scores between the combined student and junior clinical groups and the senior clinical group is thought to have resulted due to the age difference.Young people in general are known not to consider health decay as important.They perceive themselves as being strong and will live a lengthy healthy life.Seniors on the other hand have different views.
Small differences between student Group A and Group B in Audit or Evaluating Practice may result to the customary professional habit of chiropractors to practice as sole practitioners.This may have influenced their views.It is interesting to see that the members of public who participated, scored high in the majority of criteria.Interestingly, the majority of the participants in all groups agreed that working in harmony in a team and applying successful mentoring is a way that individuals can improve their professional life.

LIMITATIONS
The study has some limitations: 1.The participation of non-clinical staff in comparison with clinicians is low in numbers.2. The participation of public failed to reach acceptable numbers.
3. The criteria used were based on GMC regulations and possibly other people apart from doctors were not fully aware of the different characteristics.This may have resulted in lower scoring marks in groups other than the clinicians.4. In the Student group, Group A was considerably underpopulated in comparison with Group B.
5. The open questions led to "vague" answers which had to be interpreted accordingly and possibly in retrospect closed questions could give clearer results for a quantitative analysis.6.The ambition to include a large and equal number of individuals of a variety of groups was not materialised due to the random and volunteer selection of the individuals.

Conclusions
It was proven, within the limitations, that healthcare workers have a clear understanding of professionalism, according to the GMC definitions and within the barriers of their practices.Students performed well and the difference separating senior clinicians from their core training did not influence their comprehension of professionalism, which suggests this could be due to their increased experience.The inclusion of professionalism teaching within the undergraduate curriculum helps the understanding of the term, but only after contact on the juniors with the seniors the former improve their understanding in some of the criteria.
Further education may be useful to be conducted for the junior and student groups to emphasis the significance of the different factors influencing the professional development.Effort to educate sole practitioners may be useful to help them understand the different criteria other health practitioners use to define professionalism, and how this will be important to patients' benefit.Education of the wider community could be beneficial, and this way may be more willing to take part in a future study.
A further study has to be performed with grouping similar numbers of participants for all categories, and encourage more involvement of the general public.

Table 1 .
Given and read information.

Table 3 .
Participants categorised in groups.

Table 4 .
Grouped answers according to GMC criteria; All Participants (n 242).

Table 6 .
Comparison of all groups answers

Table 7 .
Ways to improve professionalism (Grouped answers of all healthcare participants).

Table 8 .
Ways to improve professionalism (Grouped answers of clinical group).

Table 9 .
Ways to improve professionalism (Grouped answers of students).

Table B .
Answers of non-clinical group (n=43).

Table D .
Comparison of answers between Group A (n=18) and Junior Clinical Staff (n=70).