ORIGINAL RESEARCH

 

Can professionalism be measured?: evidence from the pharmacy literature

Puede medirse la profesionalidad? Evidencia de la literatura farmacéutica

 

 

Paul M. Rutter¹, Gregory Duncan²

1 PhD, MRPharmS. Principal Lecturer. Department of Pharmacy, School of Applied Sciences. University of Wolverhampton. Wolverhampton (United Kingdom).
2 BPharm, MPH. Senior Health Services Research Fellow. Eastern Clinical School, Faculty of Medcine, Nursing and Health Sciences. Monash University. Melbourne (Australia).

 

 

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SUMMARY

The need to ensure the future pharmacy workforce demonstrates professionalism has become important to both pharmacy educators and professional bodies.
Objective: To determine the extent to which Schools of Pharmacy have taught or measured student professionalism.
Methods: Review of the healthcare literature on teaching of professionalism at an undergraduate level
Results: Two-hundred and thirty one papers were retrieved but only 45 papers related specifically to pharmacy. Of these a further 25 were narrative in nature and did not report any findings. Nineteen papers were reviewed (one was excluded as it reported the same data). Papers could be broadly categorised in to those that have tried to create a tool to measure professionalism, those that are in effect pedagogical evaluations of new initiatives or longitudinal studies on student perceptions toward aspects of professionalism.
Conclusion: A growing body of literature exists on pharmacy and professionalism. However, to date, very few Schools of Pharmacy appear to formally teach it let alone assess students´ acquisition of professionalism.

Key words: Education, Professional. Students, Pharmacy.

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RESUMEN

La necesidad de asegurar el futuro de los trabajadores de la farmacia demuestra que la profesionalidad se ha convertido en importante tanto para educadores de farmacia como para entidades profesionales.
Objetivo: Determinar el grado en que las Facultades de Farmacia han enseñado o medido la profesionalidad de los estudiantes.
Métodos: Revisión de la literatura sanitaria sobre enseñanza de profesionalidad a nivel de pregrado.
Resultados: Se encontraron 230 artículos pero sólo 44 trataban específicamente de farmacia. De estos, 25 eran narrativos por naturaleza y no comunicaban ningún resultado. Se revisaron 18 artículos (uno fue excluido porque comunicaba los mismos datos). Podría clasificarse los artículos en los que habían intentado crear un instrumento para medir la profesionalidad, los que son realmente evaluaciones pedagógicas de nuevas iniciativas y los de estudios longitudinales sobre las percepciones de los estudiantes hacia aspectos de la profesionalidad.
Conclusión: Existe un cuerpo de publicaciones creciente sobre farmacia y profesionalidad. Sin embargo, hasta la fecha muy pocas Facultades de Farmacia parecen enseñarla formalmente y dejan que los alumnos evalúen su adquisición de profesionalidad.

Palabras clave: Educación de profesionales. Estudiantes de Farmacia.

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Introduction

The occupations of law, theology and medicine have been traditionally recognised as being "true" professions.¹ However, over time many more occupations have aspired to professional status, including pharmacy. Much debate has taken place over what constitutes a profession, a professional and the concept of professionalism.^2-9 Attacks by sociological theorists in the 1960s and 1970s challenged occupations with professional status and the monopoly they hold over society.^10,11 Pharmacy was not immune to this, with the profession being labeled a quasi profession, in as much it had some but not all characteristics of a profession.⁴ Subsequently, the pharmacy literature saw many commentators discussing the profession in terms of becoming ‘deprofessionalised´ or the need for it to "reprofessionalise" to maintain its professional status.^12,13 At this time the first research in pharmacy was being conducted to determine the concept of professional socialisation at an undergraduate level.^14-18 Pharmacy though was not alone in the process of navel gazing; medicine had been particularly targeted by sociologists and they too were grappling with how best to ensure that doctors of the future possessed the necessary attributes required to continue to be held in esteem by society. This culminated in medical organizations in the US and Europe collaborating on the medical professionalism project, which sought to establish a set of principles that included 6 tenets of professionalism.¹⁹ This was followed in 1998 with recommendations for professionalism to be included in core curriculum and then in 2002 instruction on how this could be assessed.^20,21 Pharmacy organizations in the US also considered this approach and in 2000 a joint APhA-ASP/AACP-COD white paper on pharmacy student professionalism was published²²; further publications followed, including a pharmacy professionalsim toolkit for students and faculty.^23,24 These publications gave US schools of pharmacy a "blueprint" in which to tackle the teaching and assessment of professional traits at an undergraduate level. This paper examines what progress has been made in relation to the teaching and assessment of professionalism within undergraduate curricula.

 

Methods

Papers were initially identified via searches on electronic databases that included EMBASE, MEDLINE, CINAL, PsycINFO, Australian Education Index, British Education Index and International Pharmaceutical Abstracts. No limits were set on when the papers were published. A range of search terms were used that combined various derivations of the word profession, medicine and pharmacy and limited to the fields of title or abstract. In addition, reference lists from those articles identified as relevant were searched and any papers deemed appropriate were also reviewed.

Only papers that involved some element of teaching or assessment in an undergraduate context were included. Papers excluded were those of non-English language; papers that were predominantly descriptive in nature and did not report on any research findings; and, personal or professional body opinion. Papers were reviewed and data extracted independently by the first author and two research assistants before being data entered in to Excel.

 

Results

A total of 231 papers were retrieved. However, not all met the defined inclusion criteria as depicted in figure 1.

 

The eighteen papers identified were reviewed by the authors, and details of each paper are shown in Annex 1.

Authorship

Fifteen of the eighteen papers originated from the US. The remaining three papers were from Israel¹⁵ and Thailand (same author).^25,26 Seven papers were published prior to the APhA-ASP/AACP-COD paper on student professionalism.^14-18,27,28 The remaining eleven papers were published post the white paper,^25-26,29-37 with most seemingly using this, and subsequent position papers, as a catalyst for their work.^29,30,32-37

Student Perceptions

Seven papers focused on varying aspects of student opinion.^14-18,28,36 All but the study by Paik et al36 were conducted prior to the 2000 white paper on student professionalism²², with five of these papers looking at student opinion as they progressed through the course.^14-18 General findings from these papers show more negative attitudes; Schwirian et al¹⁵ and Smith¹⁶ both found students had a decrease in professional identity, and Shuval¹⁴ saw students´ expectations become lower as they progressed through the course. Knapp et al¹⁷ also found that students in the latter part of the course held more negative views toward their chosen occupation than those at the start of the course. Only the study by Hatoum et al¹⁸ described any positive findings portrayed by students as they progressed through the couse, however, these findings were not consistent between years or across the different variables measures and indeed scores from one particular subscale on professionalism saw students from all years attain low scores.

PaIk et al also conducted a longitudinal study, but unlike the previous studies that looked at general attitudes of students toward pharmacy, this study concentrated on just one behavioral trait of professionalism, civility.³⁶ Student opinion remained relatively unchanged through the course with offensive remarks, prolonged chatting, cheating and use of mobile phones/bleeps being classed as the most uncivil behaviors. The final study by Yang was retrospective in nature and asked about how professional values were attained²⁸; faculty faired poorly compared to clinical experience and influence of the family, and called in to question the undergraduate faculty experience.

Promotion of Professionalism

Various attempts have been made to introduce the concept of professionalism to undergraduate students. Berger et al²⁹ report on re-engineering their program to not only recruit more able and committed students, but to instil a greater sense of what it is to be a pharmacist from the very beginning. Feedback from students was positive, although only just over a quarter stated that they had learnt about what it meant to be a professional. This theme of imprinting professional identity from the outset of study was also explored by Fung et al who provided students with a practitioner mentor.²⁷ Findings however appear to show that students were less receptive to the mentorship scheme than the mentors themselves. Bumgarner et al³² took a different approach using literature to highlight professionalism. This study had a comparator group and the authors suggest that those enrolled in book reading did show greater tendency to a sense of personal mission and calling to serve. The study by Brehm et al³¹ allowed students from different health backgrounds to explore and define professionalism in the classroom before attending experiential placements. Students felt the orientation program had increased their awareness of professionalism with almost all believing it to be important.

Measuring Professionalism

No study before 2000 had attempted to measure professionalism, and of the papers subsequently written many reported on evaluation of their initiative and did not assess professionalism.^{29,31,32,34,36} Three authors have however constructed a survey tool to measure professionalism.^25,26,33,35 All authors made attempts to create a reliable and valid survey tool. Lerkiabundit²⁶ revised a previous scale, whereas Hammer et al developed their tool from an amalgamation of student evaluation forms.³⁵ Chisholm et al took a different approach conducting focus groups to define survey items but using the American Board of Internal Medicines´ six tenets of professionalism as a reference point.³³ All three papers report extensively on refining the survey tool to improve reliability and validity. Both Lerkiabundit and Chisholm et al also report on the findings observed within the student population as regard to measuring professionalism.^25,33 Both studies looked at if student perception toward professionalism changed over time; Chisholm et al found no differences between new and graduated students and Lerkiabundit noticed differences between year groups, especially those in the freshman year.

In addition to survey tools that assess professionalism globally, Boyle et al introduced a measure of professionalism whilst students were on experiential placements.³⁰ The study reports on a process of refining professional rating scales that can be used to independently pass or fail a student irrespective of academic performance. The system has shown that a small minority of students does fail solely on their professionalism ratings but the authors acknowledge that preceptors are inclined to give the student the benefit of the doubt.

Benchmarking

Two studies have looked at faculty progress in relation to student agreement with faculty competency statements³⁴ and implementation of student professionalism white paper recommendations.³⁷ The study by Duke et al found that students were in agreement with the competency statements devised by faculty and Sylvia found that nearly all responding faculties had implemented some (eg white coat ceremonies) but not all (e.g. mentoring schemes) recommendations.

 

Discussion

During the literature review it quickly became evident that the topic of professionalism was widely discussed and debated both in medical and pharmacy circles. It appears that interest in the subject was triggered by the erosion (actual or perceived) of medicine´s professional status within the US, which made other professions re-examine their status. This is reflected in the body of literature that has been written on the subject. Most medical papers from the nineties and early part of the next decade emanate from the US, although over the last ten years a growing number of professional reports and research papers have been of UK origin.^38-40 This in contrast to pharmacy where papers, including commentary-type papers, (only 1 of the 25 descriptive papers listed was from the UK) are almost exclusively from the US. The lack of peer-reviewed papers from outside the US is intriguing given that other Western countries such as the UK, Australia and New Zealand have similar undergraduate programs and broadly similar practising roles. Differences in legal frameworks, healthcare systems and structures and social identity may partially explain the lack of research in this area outside the US. Perception of pharmacists and their roles by the wider community in different settings may be a driver for such discourse, based on a perceived need. In the UK and Australia where there is little of this discourse, polls are conducted regularly by media and other agencies to evaluate public trust in a wide range of professionals. Pharmacy constantly ranks in first or second place in both countries as the professional in the community that people trust most.^41,42 The result of this may be a perceived acceptable level of professionalism implying that educational and other processes are adequate for student preparation for professional life. One concern is that this allows for educators and regulators to "rest on their laurels" in these settings risking complacency and confusing public perceptions of a profession as a whole with attitudes and behaviors of individual members. It may be this lack of measured perception of the profession in the USA that has led to wider discussion and more structured recommendations there. A second concern about such "de facto" measures of professionalism is that the outcomes reflect on the profession as a whole and provide no indication of student capacity to "be professional" at the point of registration. Inevitably some newly qualified pharmacists will provide the basis of pharmacy professional experience for some survey respondents and their attitudes and behaviors will inform perceptions but it is not possible to determine if this trust is a reflection on undergraduate learning or observation and behavior modelling once in a professional practice setting.

However, traits associated with professionalism, such as student conduct and fitness to practice, are now being incorporated in to pharmacy schools in the UK at the behest of the UK professional body.⁴³ In addition, in various jurisdictions of Australia, pharmacy students are required to register with the regulatory authority as early as their second year of undergraduate study.^44,45 The reasons for this increase in regulator intervention is not clear but does point to growing acceptance, on the regulators behalf, that aspects of professionalism in the UK and Australia is not all it could be.

The majority of pharmacy literature centers on talking about professionalism rather than measuring students attainment of professionalism. This is understandable given that there has still yet to be a definitive definition of professionalism as it relates to the pharmacy profession which has been universally endorsed. Many commentators have put definitions forward and attempted to unpack the differing elements of what constitutes professionalism⁷, yet this lack of consensus is exemplified by the most recent American College of Clinical Pharmacy (ACCP) white paper on again defining what student professionalism constitutes.⁴⁶ Even in those papers that have reported findings (Annex 1), all shy away from truly trying to determine whether attempts by faculty to teach and/or measure professionalism have succeeded. Boyle et al is the only paper which uses certain traits of professionalism (e.g. appearance, commitment, attire) as a means to stop academic progression.³⁰ However, the traits singled out are a best a proxy measure in determining if someone is acting professionally. Survey tools have been developed to try and measure some if not all dimensions of professionalism but they do not appear to have been widely adopted and tested on student populations other than those in which the tools were developed.^25,26,33,35 Therefore, for these tools to have credibility they need to be more widely used. A further development in determining professionalism has recently been put forward by Brown et al.⁴⁷ The authors propose a taxonomic model involving three domains of professionalism where the emphasis is on performance and not learning. This, as of yet, untested model may provide faculties with a way forward for future measurement and assessment of professionalism.

Work has been conducted on gauging student opinion over time. Unfortunately, the majority of these are old and lack currency. It may be worth repeating these longitudinal studies again especially as most US faculties have now incorporated many of the 2000 white paper recommendations. Perhaps the negative attitudes of pharmacy students would be different given changes to the pharmacists´ role since those early studies and the greater emphasis placed on professionalism. However, there is a danger that qualifying students may become disillusioned in the legitimacy of their own profession when the "ivory tower" representation of what they will doing as pharmacists does not match with the reality of technical responsibilities of many pharmacists in practice. Hence, one of the challenges of professionalizing pharmacy students is to make them aware of this possible disparity as their education is equipping them for present and future roles, the latter which may not yet be widely practised.

It is certainly evident from these studies and other commentators that professional socialisation was, and continues to be, important in imparting the attributes of a practising pharmacist.^2,28,48,49

 

Conclusions

Professionalism is a complex composite of structural, attitudinal and behavioural attributes and is therefore clearly difficult to measure, and is reflected in the lack of studies that have attempted to do so. However, if educators are to progress beyond reliance on role models or inculcation then a universally agreed definition of professionalism would be beneficial. From which teaching and learning strategies can be devised that incorporate appropriate assessment tools. The experiences from the US literature serve as a useful platform from which to move forward in a co-ordinated way.

 

Conflict of interest

The authors declare that there are no conflicts of interest associated with the submitted manuscript.

The work received no financial support from any granting body or outside organization.

 

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Received: 02.09.09
Accepted: 17.01.10