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Research report

Professionalismin healthcareprofessionals

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Foreword 1

Acknowledgements 2

Executive summary 3

1 Introduction 5

1.1 The current study 6

1.2 Participating organisations 7

2 Method 8

2.1 Ethical approval 8

2.2 Participants 8

2.3 Focus group format 9

2.4 Analysis 9

3 Results 12

3.1 Ways of understandingprofessionalism 13

3.2 The role of regulations and codesof conduct 20

3.3 Professionalism as a fluidconstruct 22

3.4 Experience and role modelling 28

3.5 Achieving professionalism 30

3.6 Differences betweenprofessions 31

3.7 Implications for selectionand education 33

4 Discussion 35

4.1 Limitations 38

4.2 Questions arising and futureresearch directions 39

5 Conclusion 40

References 41

Appendix A – Letter of invitationto prospective participants 43

Appendix B – HPC letter ofsupport sent to prospectiveparticipants 44

Appendix C – Focus groupinformation sheet 45

Appendix D – Consent form 47

Appendix E – Codes anddefinitions used in frameworkanalysis 48

Appendix F – Raw data givingexamples of professional,unprofessional and ambiguousbehaviours 51

Contents

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I am delighted to welcome this monograph asthe fourth in a series on research relating to theprofessions registered with the HCPC. It is partof our commitment to building the evidencebase of regulation and being innovative in ourapproach. We will produce further publicationsover the coming years, each of which willexplore different aspects of the regulatory andprofessional landscape.

We hope that over time these pieces of workwill contribute not only to our ownunderstanding of regulation in the health andsocial care sector, but also to a wider audiencewith an interest in this area.

More than a century ago, George BernardShaw famously observed that all professionswere ‘a conspiracy against the laity’. Since thattime, much has been written about the natureof professional practice and the contribution ofprofessionals to society. In the health andsocial care arena today, patients, service usersand their families want the professionals theyinteract with to offer specialist skills but also totreat them with respect, communicate clearlyand behave in a way that reflects highstandards of personal probity. The HCPCstandards reflect this requirement, and muchof the work we do centres around upholdingstandards of conduct and behaviour as wellas competence.

There is, however, very little published researchon ‘professionalism’ in the professions weregulate, or any that explores the perceptionsof students and educators in this way.This report is therefore an importantcontribution to increasing understanding ofwhat professionalism means and how itmight be promoted and enhanced amongstfuture generations of health and socialcare professions.

This research was conducted by DurhamUniversity and I am grateful to the authorsfor their contribution to this agenda.This research was funded from a grantby the Department of Health.

This research was carried out before our namechanged from the Health Professions Councilto the Health and Care Professions Council inAugust 2012. As such, we are referenced asthe Health Professions Council throughout thebody of the report.

Anna van der GaagChair

Foreword

Professionalism in healthcare professionals 1

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Acknowledgements

This final reseach report for Study 1 –Perceptions of Professionalism, was preparedby the following members of the MedicalEducation Research Group, Durham University,for the Health Professions Council (HPC).

– Gill Morrow

– Bryan Burford

– Charlotte Rothwell

– Madeline Carter

– John McLachlan

– Jan Illing

The authors would like to thank the followingfor their support in developing andconducting research.

– The institutions and individuals whosupported this research and enabled thefocus groups.

– All the students and educators who tookpart in focus groups.

– Paul Crampton, Research Assistant, forsupport with data collection.

– Tracy Straker for secretarial support.

Views expressed in this report are those of theauthors and not the HPC.

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This study was commissioned by the HealthProfessions Council (HPC) as part of a widerresearch programme exploring aspects ofprofessional practice. Many fitness to practisecases referred to professional regulators arelinked to a broad range of behaviours, oftendistinct from technical ability, and generallytermed ‘professionalism’. Similar trends havebeen observed early in training for somehealthcare professions. Identifying whatprofessionalism means, and how lapses canbe identified in practice, is also important toany future decisions about revalidationprocesses. Whilst the desirability of addressingand improving professionalism is relativelyunchallenged in the literature, the concept of‘professionalism’ is not well-defined,conceptually or methodologically.

The current study sought to increaseunderstanding of professionalism within threeHPC regulated professions (chiropodists /podiatrists, occupational therapists andparamedics), to explore what is perceived asprofessionalism by both students andeducators, and why / how professionalism andlack of professionalism may be identified.

Four organisations delivering trainingprogrammes to the three professions wererecruited. Two paramedic trainingorganisations were included to reflect thedifferent training routes in that profession.

Twenty focus groups, with a total of 112participants, were conducted, addressing:

– interpretation of the term‘professionalism’;

– sources of understanding ofprofessionalism;

– indicators of being professional orunprofessional; and

– the point at which people are perceivedto become ‘a professional’.

Participants’ interpretation of ‘professionalism’encompassed many and varied aspects ofbehaviour, communication and appearance(including, but not limited to, uniform), as wellas being perceived as a holistic conceptencompassing all aspects of practice.

The data indicates that professionalism has abasis in individual characteristics and values,but is also largely defined by context.Its definition varies with a number offactors, including organisational support,the workplace, the expectations of others,and the specifics of each service user / patientencounter. Regulations provide basic guidanceand signposting on what is appropriate andwhat is unacceptable, but act as a baseline forbehaviour, more than a specification.

The personal characteristics underlyingprofessionalism may develop early in life aswell as through education and workexperience, but role modelling is alsoimportant in developing the necessaryawareness of appropriate action indifferent contexts.

Views of professionalism did not divergewidely, regardless of professional group,training route or status as student or educator.All saw the interaction of person and context,and the importance of situational judgement,as key to ‘professional behaviour’.

Rather than a set of discrete skills,professionalism may be better regarded as ameta-skill, comprising situational awarenessand contextual judgement, which allowsindividuals to draw on the communication,technical and practical skills appropriate for agiven professional scenario. The true skill ofprofessionalism may be not so much inknowing what to do, but when to do it.The role of the educator is to raiseawareness of this.

Professionalism in healthcare professionals 3

Executive summary

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Executive summary

Employers and regulators have an importantrole to play in supporting professionalism,and enabling it to flourish and develop.The relevance and role of professionalismneeds to be presented positively andproactively.

Professionalism may be further developedthrough employer-led initiatives aimed atproviding supportive environments in whichprofessionals feel valued – this should be in theform of management support, and therecognition of other professions. Professionswhich are newly ‘professionalised’ may find itharder to gain this support and recognitionthan more established ones. The context-specific nature of professionalism means thatfurther work in this area should address thedevelopment of professionalism as a dynamicjudgement rather than a discrete skill set.

Professionalism in healthcare professionals4

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1 Introduction

‘Professionalism’ is under increasing scrutinyacross the health and social care professions,with many of the issues that emerge later inpeople’s careers being linked to a broad rangeof behaviours distinct from their technicalability. Fitness to practise cases heard byregulators such as the Health ProfessionsCouncil (HPC) and the General MedicalCouncil (GMC) often include components ofinappropriate or unprofessional behaviourwhich would not be captured by competencytesting. These behaviours are not trivial,including issues relating to substance abuse,theft or sexual assault against patients orservice users. Identifying and addressing theseissues is also a problem to be faced bypossible revalidation processes. However,there is evidence from medical professionalismresearch that issues presenting in later careersmay be associated with similar concerns intraining. For example action against doctors bystate medical boards in the United States wasfound to be predicted by factors such asdisciplinary action in medical school1 and a lowsupervisor rating of their professionalismduring their residency year.2

This potential association has value if theidentification of concerns early in trainingallows early remediation to be attempted,in the form of targeted training, or inextreme cases counselling away from thatprofessional role:

“Attempts to identify… risk of subsequentprofessional misconduct should beencouraged because this offers theopportunity for support and remediation ifpossible, or if not, redirection of the studentinto a more suitable area of study. This isnot just a matter of public protection;students deserve support and assistanceand must have realistic careerexpectations.”3, p.1041

However, while the desirability of addressingand improving professionalism is relativelyunchallenged in the literature, the concept of‘professionalism’ is not well-defined,conceptually or methodologically: “the word isfull of nuance and as with words such as ‘love’or ‘quality’, perhaps each of us is clear whatwe understand by the term, but we find itdifficult to articulate.”4, p.2. This difficulty inarticulation extends to the academic literatureand to attempts to engage withprofessionalism as a theoretical construct.

Much of the recent literature around medicalprofessionalism has focused onprofessionalism as a competency, orsomething which can be taught, developed,measured and assessed.5, 6, 7 One recent reviewof this area8 identified many measures andapproaches, but found no clear consensus onvalidity. It outlined five ‘clusters ofprofessionalism’ found in existing measures,which were:

– adherence to ethical practice;

– effective interactions with patients andservice users;

– effective interactions with staff; and

– reliability, and commitment toimprovement) which illustrate thebehavioural focus of many ofthese approaches.

A study with paramedics,9 one of theprofessional groups involved in this study,found a similar range of dimensions, fromintegrity through teamwork and careful deliveryof service, to appearance and personalhygiene. The variation in the precisedimensions identified in the literature illustratesthe semantic difficulties in labelling such broadconstructs, but there is a common pattern ofidentifying attitudes and ideals,communication, and good practice.

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1 Introduction

Professional behaviours are seen to be theexpression of professional attitudes – andsignificant work in medical professionalismliterature in recent years has stressed theimportance of assessing observablebehaviours rather than attitudes,10 withattention to the contextual framing ofthose behaviours.11

However, there is another level toprofessionalism, related more to professionalidentity than to behaviour: individuals’perception of themselves as professionals.Professional behaviour in this view may arisebecause it is a performative element of theidentity, rather than because it is explicitlyprescribed: “Identities are what we do.”12, p44

Professional identity may be reinforced byperformance – doing what is expected of aprofessional can make people feel moreprofessional.13

Professional identity may be related in part tothe status accorded to the historical notion of‘a profession’, as a role which has high socialstatus and value, high entry requirements anda degree of social responsibility. This is referredto often in the medical professionalismliterature. For example Swick’s14 ‘normativedefinition’ of professionalism stresses elementsof professionalism which may be seen as‘virtuous’ rather than grounded in practice.

Whether an occupational role is described as‘professional’ may be in part determined by itslegal status, such as whether it is subject toregulation: “A key marker of professional statusis professional regulation”. 15, p536 The currentstudy includes three professions –chiropodists / podiatrists, occupationaltherapists and paramedics – which have verydifferent histories.

While all have developed relatively recentlycompared with medicine or law, chiropody /podiatry and occupational therapy date backseveral decades, whereas paramedics havehad a professional organisation since 2003(the College of Occupational Therapy was

established in 1978 with precursororganisations dating back to 1932; the Societyof Chiropodists and Podiatrists wasestablished in 1945 from constituents datingback to 1912; in contrast the BritishParamedic Association, latterly the Collegeof Paramedics, was established in 2003).All three professions were regulated by theCouncil for Professions Supplementary toMedicine (CPSM) before the establishment ofthe HPC in 2003 – chiropodists / podiatristsand occupational therapists were regulatedfrom the 1960s, paramedics from 2000. This isnot surprising when considering that the term,‘paramedic’, was not coined until the 1960s,and only associated exclusively withemergency medicine much later. It serves toillustrate the difficulty of applying structuraldefinitions to modern professions.

1.1 The current study

The study reported here is a component of aproject commissioned by the HPC, whichexplores professionalism in the healthcareprofessions. Study 1, reported here,investigated healthcare professionals’understanding of professionalism, whileStudy 2 is exploring ways to measure thebreadth of the construct and its associationwith short-term career outcomes.

The stated aim of Study 1 was ‘To explorestudent and educator perceptions ofprofessionalism, and what constitutesprofessional and unprofessional behaviour’,with four objectives:

– to explore what constitutes ‘professionalism’in three health professions;

– to identify how professional identity andan understanding of professionalismdevelop;

– to clarify what is perceived asprofessional and unprofessionalbehaviour, and the role of context inthat perception; and

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1 Introduction

– to identify indicators and analogues ofprofessionalism which may informquantitative data collection.

To answer these questions, research with threeof the fifteen professional groups regulated bythe HPC – chiropodists / podiatrists,occupational therapists and paramedics wascarried out. These were identified asrepresenting a range of the professionalgroups registered with the HPC. In 2009 – 10these groups represented 29 per cent ofregistrants (7.3%, 6.2% and 15%respectively)16, and over 40 per cent (21.1%,9.8% and 10.1%) of fitness to practise casesheard by the HPC.17

1.2 Participating organisations

Organisations were recruited to reflect thetraining routes for the different professions.While for chiropody / podiatry andoccupational therapy this was more uniform,more care was taken in the selection ofparamedic organisations, where morevariation was anticipated.

Paramedics historically have had an in-servicetraining route, and a degree-level qualificationhas only become an option in recent years.Different regions employ different trainingroutes: some are all Higher Education (HE)(although with a range of diplomas, foundationdegrees and honours degrees), while othersuse short, in-service training courses, oftenfunctioning as conversion courses for non-regulated technician staff.

Some examination of the different routes wasdesirable in this study, to reflect the differentpopulations and different training experiences,and while limitations of time and resourcesmeant that comprehensive coverage was notpossible, two organisations were recruited.One (‘University A’) was a higher educationinstitution delivering two routes to qualification:a three-year foundation degree, and afour-year sandwich honours degree. On both

programmes students spend time as staff withone of two ambulance trusts, but spend atleast the first year (the first two years of thehonours degree) in the University. The majorityof students were school-leavers and few hadworked in the ambulance service before.

The second organisation was an NHSAmbulance Trust (‘Ambulance Trust B’) whichdelivers a two year Foundation Degree entirelyin-service. The degree is awarded by a localuniversity, but most classroom teaching takesplace in the Trust’s education centre. Alltrainees must be employed by the Trust beforeadmission to the Foundation Degree, andmany are existing staff – technicians,emergency care support workers (ECSWs) orcontrol staff – before entry.

Chiropody / podiatry and occupational therapyon the other hand have had long establishedHE qualification paths, and a degree is theonly route to registration. One institution wastherefore recruited for occupational therapists(‘University C’) and one for chiropodists /podiatrists (‘College D’), reflecting the relativehomogeneity in training across the country.

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2 Method

2.1 Ethical approval

Once access to the organisations involved hadbeen negotiated and meetings held with keypersonnel, the proposal and draft materialswere reviewed by the Durham UniversitySchool of Medicine and Health EthicsCommittee. Once University ethical approvalwas obtained, it was necessary to follow NHSresearch governance processes, as someparticipants were NHS employees.A favourable ethical opinion for both studieswas obtained from the Leeds (West) ResearchEthics Committee in September 2010, andwith this in place registration with the Researchand Development Department of AmbulanceTrust B was also obtained in advance of anydata collection.

2.2 Participants

Participants were recruited from the trainee /student and trainer / lecturer populations ineach organisation. Where possible, thoseresponsible for trainees in practice were alsoinvited to separate focus groups. Whiledifferent organisations used different terms, forsimplicity the terms ‘student’, ‘classroomeducator’ and ‘placement educator’ will beused in this report to refer to these threegroups. Students in first and final years wereinvited to take part, to capture the breadth ofstudent experience.

Information sheets and letters (Appendices A,B and C) inviting potential participants to focusgroups were distributed through the trainingorganisations. Where appropriate a choice ofdates was provided and in other cases asession was timetabled. Educators were alsooffered the opportunity to have a telephoneinterview instead, but in practice none werecarried out. It was thought that telephoneinterviews would be appropriate for placementeducators, but other than indicated in Table 1it was not possible to obtain the necessaryinformation in the timescale available.

Table 1 summarises the number of focusgroups which were conducted in the differentorganisations. Altogether twenty focusgroups were conducted, with a total of112 participants.

Professionalism in healthcare professionals8

Table 1 – Number of focus groups carried out with each participant group

Organisation StudentsClassroomeducators

Placementeducators

University A 5 (3 first year*, 2 final year) 1 0

Ambulance Trust B 4 (final year) 1 0

University C 1 (final year) 1 3

College D 3 (2 first year, 1 final year) 1 0

*Two of these were conducted as interviews, as only one participant attended the session. The format was the same asfor the focus groups.

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2 Method

2.3 Focus group format

All focus groups followed the same format.Participants were given the information sheetto re-read, and a consent form (included inAppendix D) on which they were asked toagree to the audio recording and transcriptionof the group discussion, and to the use ofanonymised quotes in reports andpublications. No participants declined togive consent, or raised any concerns aboutthe recording.

The first part of the session involved theparticipants individually considering fourquestions (see Table 2), derived from theresearch questions stated in the introduction.These were printed on sheets on the table,and on flip-chart paper on the walls.(Questions 3a and 3b were presentedtogether, so as not to bias participants towardspositive or negative responses).

Table 2 – Focus group questionsprovided as prompts – X was replacedwith the professional group in question.

Participants were asked to write down theirindividual responses to each of the questionson Post-it notes. These were then collected bythe group facilitator(s) and put on the flipchartpaper under each question. The facilitator thensummarised any key points on the flipcharts.Post-its were retained at the end of thesession and transcribed. The intention of thisstage was to ensure that all participants hadthe opportunity to respond to all questions,without being influenced by the specificgroup dynamics or the direction thediscussion may take.

Each of the questions was then discussed.Standardised prompts were used to developthe discussion if needed, and to move thediscussion on. In some cases the discussionorganically developed to address the differentquestions, and the questions were notnecessarily addressed in the order they werepresented. The Post-it responses were alsoreferred to, to ensure any novel or ambiguouspoints were developed in discussion.

Groups took between 50 and 110 minutes –the duration varying with the amount ofdiscussion generated, and the time available.

2.4 Analysis

All recordings were transcribed verbatim, andcoded using NVivo qualitative data analysissoftware18 to aid the data analysis.

A ‘framework’ approach to analysis wasadopted.19 This involved an initial familiarisationwith the data by repeatedly reading thetranscripts to identify the main themes inrelation to the research questions. Responsesgenerated on Post-it notes were also used inthis stage of the analysis.

The second stage involved the discussion ofthese codes between the researchers to agreethe framework to be used.

1: In relation to the profession of X whatdoes the term ‘professionalism’ mean toyou?

2: In relation to the profession of X wheredoes your understanding of‘professionalism’ come from?

3a: In relation to the profession of X whatwould make you think someone wasbeing ‘unprofessional’?

3b: In relation to the profession of X whatwould make you think someone wasbeing ‘professional’?

4 (students): Do you feel like aprofessional X now?

4 (educators): When does someonebecome a professional X?

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2 Method

Considerable consistency was found betweenprofessional groups, and between studentsand educators, and so the framework wasdeveloped to be applicable to all transcripts.A single transcript was coded jointly to

establish the usability and relevance of theframework. All transcripts were then codedusing this framework. The codes used aregiven in Table 3, with definitions provided inAppendix E.

Professionalism in healthcare professionals10

Table 3. Codes and sub-codes used in framework analysis

Code Sub-code

Definition of professionalism Adherence to codes / regulations / protocols

Appearance

Appropriate behaviour / attitudes /communication

Context

Development over time

External perceptions

Good clinical care

Holistic construct

Ongoing development (keeping up to date)

Other definition

Part of self

Role boundaries

Source of professionalism Education / training

Learning on the job

Media

Organisational environment

Other source

Personal background

Previous employment (paid / voluntary)

Regulations as source

Role models

Examples of professional, unprofessional andambiguous behaviour (separate top-levelcodes for each)

Appearance

Clinical practice

Communication

Conscientiousness

Other example

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2 Method

The next stage of analysis was theidentification of the emergent themes fromthe coded data – that is, synthesising theresponses to provide the most explanation andelaboration in response to the researchquestions. This analysis was again agreed indiscussion between the researchers analysingthe data, and reviewed during the draftingand revision of the results section, withconstant comparison to the data to ensurethe results accurately reflected the meaningfound in the data.

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3 Results

The analysis identified a great deal of variabilityin people’s understanding and interpretation of‘professionalism’. While some participantswere able to provide straightforward responsesto the question ‘What does professionalismmean to you?’, there was no overallconsistency in the specifics of their definitions,reinforcing the findings from the literature that itis a complex and problematic concept.However, despite this variability, the data doesprovide some insight into the dimensions orparameters of professionalism.

A dominant theme was that professionalism isa highly contextual concept, and what isclassed as ‘professional’ will vary with anumber of contextual factors, including theorganisation, the workplace, and the specificsof each clinical encounter. This contextualvariability was coupled with a sense thatprofessionalism is based on well-established,or even innate, personal qualities and values.This creates a dynamic tension for developingand assessing professionalism, as it is bothan extremely personal, internalised belief,while being very much situated in theimmediate environment.

Views of professionalism came from a widevariety of sources – from upbringing, throughexperience in education and work beforejoining the profession, to explicit teachingwithin their training (including codified rules andregulations), and role modelling fromcolleagues. Table 4 illustrates some of thespecific sources mentioned. The interactionof these different sources may in part explainthe complex picture of professionalism thathas emerged from this study.

Table 4 – Examples of sources andexperiences informing people’sprofessionalism

The following sections describe differentdefinitions, and ways of approaching theconcept or construct of professionalismidentified by participants. These includeviewing it as an holistic construct, as anexpression of self, as a set of attitudes andbehaviours, including appearance, and as afluid, contextually defined concept. Quotesfrom focus group participants are included toexpand and illustrate the points made. Inparallel, the boxes distributed through thesepages illustrate how these views wereexpressed as discrete examples of behaviour –including ‘good’ examples of professionalbehaviour, examples of unprofessionalbehaviour, and examples of behaviour whichwas ambiguous, or explicitly identified ascontextually dependent.

Professionalism in healthcare professionals12

Personal experiences around timekeeping (eg missing flights whentravelling, school)

Personal experience at work (timekeeping, working to appointments incommunity care)

Observing other professionals in anotherwork context (before starting training)

Experience of interacting with patients

Experience of meetings and being part ofa team

Documentation such as a studenthandbook and policies such as manualhandling policies

Role models in placements, or tutors inclassroom

Peers

Models encountered in the media

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3 Results

More examples of raw data from the focusgroups, illustrating how the themes werepresented in the discussions, are includedin Appendix F.

While there were no substantial differences inthe views of the different professions whenconsidered thematically, some differencesrelated to specific professional contextswere identified. These are summarisedin Section 3.6.

3.1 Ways of understandingprofessionalism

The data highlighted that there was no singledefinition of professionalism; rather it is aconcept that can mean different things todifferent people, in different contexts. Thiscomplexity was linked to the diversity of thesources and influences which lead toindividuals’ perceptions of professionalism.

3.1.1 Professionalism as anholistic construct

Several definitions did not break down theconstruct of professionalism into components,but presented it as an holistic, all-encompassingconcept (‘everything you do’), an overall way ofbeing which comprises a range of attitudesand behaviours.

“It’s everything really, it’s the way from theminute you get to the station to the minuteyou get home, it’s the conduct of work.”(FG1, paramedic student)

Some definitions were similarly holistic,but more explicitly focused on the clinical ortechnical elements of practice, withperformance of the clinical role being themain definition of professionalism.

“It comes down to basically doing the jobcorrectly, that and intermingling it with yourpatient contact and not being a robot andjust reading everything out of a book.”(FG3, paramedic student)

Several respondents defined professionalismreflexively, by thinking of it as the standard oftreatment they would want for themselves or afamily member. This could be a way ofexpressing an holistic view of professionalism,and also a ‘benchmark’ for their ownbehaviour.

“I think we’re in a caring profession, acaring role, so you’re treating people howyou want to be treated and earn the respectof people and being quite intent whenlistening to their kind of worries.” (FG13,occupational therapy placement educator)

3.1.2 Professionalism as goodclinical care

Good patient care was, in this sense, theessence of the job and therefore howprofessionalism was interpreted. Specificattitudes and behaviours were identified whichconstitute this competence: the knowledge,skills and ability to do the job, followingprocedures and protocols, putting the patient’sinterests first, and maintaining standards ofcare at all times. Good practice was linked toan awareness of limitations, of knowledge andskills, and acting appropriately.

“There’s no shame in actually admitting attimes that you don’t know everything butyou will go and look something up or youwill consult with another colleague, andthen by the next time they come in for aconsultation you’ll have an answer forthem.” (FG15, chiropody / podiatry student)

“I think it’s about insight as well...it’s abouthaving the skills and choosing theappropriate level or the appropriate skill atthe right time so that you’re not over thetop, but additionally you’re not taking anyrisks with doing something incorrectly.”(FG6, occupational therapy classroomeducator)

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3 Results

Box 1: Demonstrating clinicaljudgement and competence

Professional behaviours: ”I think it isimportant because if you are not auditingthe right information or like drawing out theright information from assessments, that’simportant to share, that wouldn’t be veryprofessional would it, if you weren’t sharingthe right information?”(FG19, occupational therapy student)

Unprofessional behaviours: ”...I followedhim [podiatrist] on visits in and out ofhouses, it was get in, get out, finish asearly as I can, not checking if the patient’smedication had changed or anything likethat down to really poor infection controlwith instruments... the whole time I wasthere he never changed his instruments,apart from the actual blade itself, he neverchanged his blade handles, he used thesame scissors for every patient.”(FG15, chiropody / podiatry student)

Ambiguous: ”You can be over meticulousand you can be, not over professional butover kind of thorough and a lot of peoplelike that they can spend two hours on ascene and I think there’s again, there’s gotto be a point where you’ve got to say weare actually just here to treat what we’veseen and take to hospital or leave at homebut some people do spend a lot of time onscenes...” (FG9, paramedic student)

This awareness and insight was related tothe motivation to keep up-to-date withdevelopments in good practice, to ensuregood patient care and to engender trust andconfidence in the patient. Both students andeducators highlighted reflection on practice askey to professional practice.

“I think it’s very important that we all keepourselves updated... so that the informationthat we are giving our patients is up-to-date, it is most current, so that if they do goback and look on the internet, they will think‘oh, hang on, yeah, I remember him sayingsomething about that’ and it gives them theconfidence to come back to us.”(FG15, chiropody / podiatry student)

3.1.3 Professionalism as anexpression of self

Many behavioural and attitudinal descriptionsof professionalism, such as those reflectingempathy and caring, framed it as anexpression of fundamental, inherent qualitieson the part of the professional. When talkingabout this personal level of construct, withprofessionalism as a ‘part of the self’, therewere many references to people’s own moraland ethical codes, their ‘core beliefs’ (such asa belief in helping people) or their ‘standards’(such as standards of ‘decent behaviour’ andhow people treat each other), underpinningpractice. In this way professionalism was seenby both educators and students as ‘intrinsic’,referring to qualities which may be innate or atleast pre-existing, exemplified by statementssuch as ‘you have it or you don’t’ and ‘youshould just know’.

“To me, people’s values underpin everythingthey do as a professional... and so, from mypoint of view, professionalism has comefrom before I even entered the profession…it’s not about the job you do or anything likethat, it’s about what is decent behaviour toanother person.”(FG18, paramedic classroom educator)

“I think you have a core belief as well, it’syour core standards of what you think isacceptable and not acceptable.” (FG13,occupational therapy placement educator)

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“When I said intrinsic I meant I just thoughtthat you should know what a professionalshould be, you should know how aprofessional should act because it’s a termthat’s just like, you should know… how tobe a professional. If you don’t, you’re not.”(FG9, paramedic student)

A similar idea presented by some educatorswas that professionalism is ‘a way of life’,implying that it is external to work. One feltthat it involves an alignment between theself and the expectations of the profession.In this sense, rather than being inherent orpre-existing, professionalism becomes part ofthe professional.

“Even when I […] did an apprenticeship, Ihad the same values as I do have nowreally, you know, I don’t ever change.”(FG18, paramedic classroom educator)

“It’s about an alignment of who you are withthe expectations that are placed onyou… and it’s become a part of who theyare and therefore it’s represented in everyaspect of their own life.” (FG6, occupationaltherapy classroom educator)

This was identified in the potential for studentsto express their professionalism by theirattitudes and behaviour outside work as wellas within. Some students were seen byeducators as professional in their wholeapproach to life because of their values, whilstsome others were seen to display a distinctionbetween work and personal life. There was atacit, and sometimes explicit, assumption thatprofessionalism should be maintained at alltimes, even away from the workplace.

“I think there’s a level of communication andof respect for other people that comes outin their whole lives and I find it really hardwith the people who turn it on at work andturn it off at home.”(FG18, paramedic classroom educator)

Box 2: Outside Work

Unprofessional behaviours: “When I was atuniversity Facebook was sort of flagged upas a big no-no when we were onplacements, we were told we weren’tallowed to even mention we’re onplacement... there had been someincidents in the past where people had sortof mentioned educators or said orcomplained about what a horrible time theywere having and it just obviously themessage that gives for the people it comesacross as very unprofessional...” (FG13,occupational therapy placement educators)

Ambiguous behaviours : ”If you bump intoone of your patients... I think that might bedifferent if you bump into a patient, you’dhave to say ‘oh hello’ and you would haveto try and look sober and but apart fromthat, you don’t think about your job whenyou are out and about do you.”(FG15, chiropody / podiatry students)

Participants spoke of either a merging /blurring or a distancing between theirprofessional and personal selves – how farprofessionalism should or did extend into theirpersonal life and the implications for behaviouroutside work, including on social networkingwebsites. This relates to the perceivedimportance of external views of the healthservice and of individuals working within it,and awareness of the public health role, asattributes of professionalism. There weremixed views about the separation betweenwork and private life, and the professional andprivate self, and how far people consideredthemselves to be defined by their job. Somerecognised that they needed to be able toseparate work from their personal lives for theirown wellbeing, to ‘let their hair down’.

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“That’s one of the big problems I have withit, I want to do the job, I’m really happyabout doing the job but I don’t want it tocross into every single part of my personallife, I don’t define myself as a paramedic,I define myself as a person that does thatjob... and I don’t want my whole life to bedefined by that, I think it’s really hard, that’sa massive problem because it does reachout into your personal life so much.”(FG11, paramedic student)

“It kind of goes with you all the time doesn’tit, like I don’t think it’s something that I canswitch on and off, I don’t think that anythingI do or put on Facebook could ever beconsidered totally separate from what I amand who I am as a professional because it’spart of who I am.”(FG19, occupational therapy student)

The view of professionalism as being anaspect of the individual, rather than somethingwhich is gained in the professional role,was linked to feelings that the image ofprofessionalism was gained early in life, withpeople mentioning their culture, upbringing,parents and grandparents, and the values anddefinitions of acceptable behaviour they werebrought up with (eg politeness, manners andrespect). However, participants’ views werealso influenced by experiences and rolemodels encountered during training andpractice.

3.1.4 Attitudes and behaviours

Box 3: Attitudes

Unprofessional behaviours: “If people areturning up late for work what are theygoing to be like going on a home visit orseeing someone in their home that it’s notconveying a good image to other peoplegoing to meetings and case conferences,it needs to be on time” (FG13, occupationaltherapy placement educator)

Many specific elements of professionalismwere described as reflecting attitudes – goodand bad. ‘Attitudes’ were discussed in termsof attitude to study (such as willingness tolearn and to question), attitude to the job,attitude towards colleagues (such as displayingrespect), as well as attitude towards patientsor service users themselves. A professionalattitude to the job included ensuring being fitfor work (eg not being hung-over, ensuring thatyou get enough sleep during the day when onnight shift). Educators identified attitude asimportant in relation to students’ relationshipswith patients, and enthusiasm for their work.

“[The] attitude of my personal presentationbefore I get to work, attitude towards mywork once I’m there, and attitude towardsmy patients, again for me it’s attitudemore than anything else.”(FG2, paramedic student)

“I think it is something about people that arewilling, and I think it is about having thiscaring about how you are perceived to bebehaving to people around you, and havingthat little bit of pride and… genuinelythinking I want to join in with the rest of thegroup, I want to participate in this, and thenwhen you get out into professional practiceyou think, oh yeah, I do want to do this, Iwant to engage with my patients, I want todo the best I can.”(FG18, paramedic classroom educator)

Communication was a common area in whichattitudes – to the job and to patients andservice users – could be expressed.Politeness, being trustworthy and honest,acting calmly and confidently, beingpersonable, and treating patients as individualswere all seen as reflecting underlying attitudes.These behaviours could affect howrelationships were established with patients,how patients responded and ultimately patientcare.

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“If you get it wrong you’re unlikely to get afull history from them which means that thehospital don’t have all the information oryou’ve got egg on your face when you turnup at the hospital and the patient thenreveals the rest of their history to the nurse.”(FG11, paramedic student)

Box 4: Written Communication

Professional behaviours: “…you have towrite your notes so that anyone canunderstand them but even the patientbecause the patient is allowed access tothe notes….”(FG19, occupational therapy student)

Unprofessional behaviours: “It [writtencommunication] needs to be polite andrespectful and appropriate […] I get thestudents that email me, all in small lettersand it’s got like kisses at the end andthings like that, to me that’s reallyunprofessional...”(FG18, paramedic classroom educator)

Verbal, non-verbal and written communicationwere linked to building relationships withpatients, and to good patient care. Poorcommunication and attitude could bedisplayed through gestures, shrugging,crossing arms and hands in pockets.Professionalism meant being ‘a goodcommunicator’, listening and being receptiveto patients, displaying sensitivity, and anappropriate use of medical terms. It meantsharing information and health messages in amanner appropriate to the individual, forexample checking understanding and howmuch the patient wants to know, as well asbeing polite and not condescending, andmaintaining confidentiality.

“The way that you speak to people and thegestures that we use, we’re not kind ofrushing people in and rushing people outagain.” (FG15, chiropody / podiatry student)

“Using medical terms in front of somebodyand they are just… looking at you like‘What are you talking about?’. Yeah,appropriate use of language in front ofpatients.” (FG2, paramedic student)

Professionalism was also discussed in regardto communication with colleagues, for examplebuilding positive relationships, showing respectand not being rude, and helping, instructingand explaining to others as appropriate. Poorcolleague relationships were also seen as afactor in patients’ perceptions of the team, andgood relationships were seen to impactpositively on good patient care.

Box 5: Treating people equally

Professional behaviour: ”But it is quite hardwhen you’ve done a job where you’ve hada real abusive [patient] and then you go toyour next job and it’s the same and you goand you get the same again, it doesn’thappen all the time but it does happenwhere you’ve been Saturday night, Fridaynight, whatever, you’ve had a load of abuseand then you go to the next one andbecause you’ve had it 20 minutes, you goin with a professional [attitude] but theneverybody does it, you do get a bitagitated.” (FG3, paramedic student)

Professional behaviours: ”...you’ve got totreat everyone equally, I mean say even ifyou go to someone who has just murderedsomeone else, you’ve still just got to treatthem just as a person and don’t worryabout any of the other things in their life.”(FG10, paramedic student)

“Well you know my team leader, he alwaysasks your opinion of everything and healways appreciates anything you do for him,anything. He always thanks you for it andhe always values your opinion and if hethinks your idea is better than his he’ll useyour idea.” (FG4, paramedic student)

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“I think most people in our [team] enjoyworking with each other... I think that’sprobably when we get the best patientcare.” (FG11, paramedic student)

Another expression of professional attitudeswas in relation to treating patients equally andwithout prejudice in terms of politeness,equality, dignity and respect (including for othercultures and religions, and for gender issuesduring treatment). This could also include notbecoming jaded within a shift, and treating thelast patient the same as the first. Within this,there were some references to not displayingprejudice, and hiding feelings, suggesting thatthe appearance of professionalism, what itlooks like to others, and the reputation of theprofession, were a consideration. Patience andunderstanding were important (for example,with inappropriate 999 calls), as well asappearing knowledgeable anddisplaying confidence.

“It’s keeping away from stereotypes andtypes of patients and types of people... nobias or prejudice there, you know, everyperson is new each time round.”(FG2, paramedic student)

“Making sure you are treating peoplewith respect, treating people as people,not thinking of them as patients but asindividuals with their own set of prioritiesand needs.”(FG19, occupational therapy student)

3.1.5 Appearance

Appearance (including cleanliness, hygieneand neat hair as well as uniform and suitableclothing) was considered important for publicperception of the profession. For example, itcould impact on a patient’s or service user’sfirst impressions of the individual and theprofession, and on patient or service userconfidence in the individual and the standardof care they will receive. Students were givenguidelines about appearance and presentation.

It is interesting that while the three professions’use of uniform varied, all identified appearanceand presentation as an important element ofprofessionalism. There were also a smallnumber of references to appropriate dressextending beyond work, highlighting theirawareness of public perception of the role andthe need to distinguish between the personaland the professional.

“You can be as skilled as anything, but ifyou’re walking into somebody’s houselooking like a right tramp it just doesn’t lookprofessional.” (FG2, paramedic student)

“I think that gives the patient confidence. Ifyou come along looking a bit grubby and abit scruffy they’re going to worry about howclean your instruments are… and if youdon’t have a standard in your ownappearance then what’s your standard oftreatment going to be?”(FG16, chiropody / podiatry student)

“It’s not just uniform, it’s your vehicle, yourequipment and everything else that youhave to look after, it’s all part of yourprofessionalism isn’t it?”(FG5, paramedic, classroom educator)

For some, uniform was regarded as playing apart in feeling like a professional, in giving asense of identity, and in representing theprofession. In the latter sense, care of uniformand behaviour whilst in uniform were thereforeparticularly important. Uniform provides amarker to separate the professional andthe personal.

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Box 6: Uniform

Professional behaviours: “I wouldn’t dreamof now going into the NHS and turning upin a pair of jeans and a t-shirt and treatsomebody, it’s just not something youwould think of, even if I was stuck out inthe wilds in the middle of nowhere, I wouldstill turn up in a uniform because I wouldwant people to see me as a professional.”(FG15, chiropody / podiatry student)

“... uniform has to be clean, pressed,you know, hair tied back, no bigchunky jewellery.”(FG15, chiropody / podiatry student)

Unprofessional behaviours: ”We have thisuniform now which we’ve had for two orthree years, [there are] people on the roadwith the uniform they [have] had [for] fiveyears, totally different... I blame themanagement for letting that person wearthe uniform, that’s an old uniform.”(FG3, paramedic student)

“For me it really helps because I’m quite ashy person, I always kind of see it as amask if you’ve got this uniform on, it’s sortof creating this invisible barrier where I’msort of taking my personal self, obviouslyelements of that, into my professional self,but kind of, you know, any kind of worries Ihave of what’s happening in my personal lifeyou kind of keep that inside, then I’ve gotmy uniform projecting a professional imageand sometimes that helped.” (FG13,occupational therapy placement educator)

“You felt more professional when you werewearing a uniform… I’ll put this on and thisis who I am, kind of feeling. Whereas whenyou come to work in your own clothes youdon’t have that.” (FG13, occupationaltherapy placement educator)

For occupational therapists, who in manycases do not wear uniform, the use of clothingto present a different professional image indifferent situations, with colleagues and clients,illustrates a similar importance placed onappearance. For example, there wasawareness of sensitivity regarding clientconfidentiality and privacy, whereby being seenwith an occupational therapist in uniform in thecommunity or home would draw attention tothe client and was also potentially intimidating.However, for a client attending multi-professional meetings, uniform can helpservice users identify different roles.

“It links in with confidentiality that you don’twant to necessarily advertise to the wholeworld that you are working with this personin the community, that maybe your IDbadge etc is best in the work setting.”(FG13, occupational therapy placementeducator)

“I think the patients [on the ward] quite likeyou to be in uniform because […] they canidentify you instantly as a member of staff.”(FG13, occupational therapyplacement educator)

Box 7: Public health messages

Unprofessional behaviours: ”Well I thinkgrossly overweight don’t you? Paramedicsespecially. I think that’s extremelyunprofessional because we are kind ofpromoting, well I think as self careprofessionals we are promoting healthylifestyle and we turn up and they’rehorrendously obese, you now, and thepatient is just going to look at you and justgo ‘oh what on earth is that?’.”(FG9, paramedic student)

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There were elements of appearance relateddirectly to practice. For example dressingsmartly could also serve as behaviour to berole modelled for some occupational therapyclients. For chiropodists / podiatrists, therewere pragmatic elements around dress – suchas the wearing of appropriate footwear, toprovide a consistent public health messageand model good behaviour.

“We use it as well for social rolemodelling… there is this expectationbetween us as OTs in our service to reallythink about what we’re wearing, how we’representing ourselves, particularly becauseour client group […] difficulties with personalcare and so on and so forth, it’s about us…dressing in a good way for them to feel theycan dress in a good way too.”(FG13, occupational therapy placementeducator)

“If you’re going to go into somebody’shouse and say those shoes aren’t anygood, with 15 inch heels on.”(FG16 chiropody / podiatry student)

The wearing of uniform can help create aboundary defining appropriate distancebetween professional and client; however itcan also create a barrier which may hindercare. One paramedic participant noted that theassociation of uniform with authority can havea negative connotation for some service users.

“I’ve never liked uniforms and I sort of seethem as a bit of a boundary sometimeswhen you’re working with service users.I never want to look too smart because Iwant to be approachable… some expectyou to dress a certain way and act a certainway whereas others would see that as quitean intimidating thing, so it’s that boundary.”(FG13, occupational therapyplacement educator)

Attitudes to uniform and appearance werepartly influenced by individuals’ previousbackground (in particular a military backgroundfor some paramedics) and their personalstandards. Pragmatics tended to be learnedon the job as well as through collegeguidelines (eg leaning over patients in a low cuttop; hair getting in the way). In all threeprofessions, attitudes to appearance were alsorelated to awareness of a public health role, toeducate or model good behaviour to the public(with chiropodists / podiatrists the wearing ofinappropriate footwear; with occupationaltherapists the social modelling describedabove, and with paramedics smoking while onduty, and being overweight to an extent that ithinders their work).

3.2 The role of regulations andcodes of conduct

There are a number of sets of regulations,standards, protocols, codes of conduct andethics, and trust policies providing parametersfor safe and ethical practice. Some areas ofprofessionalism are also framed by law – theft,substance misuse, racism may all be subjectto criminal action as well as professionalsanction – for this reason they did not form asignificant part of the discussion. These sets ofrules serve two functions as identified byparticipants – to provide a guide for theminimum standards of practice, and to providesanctions when practice falls short.Regulations acted as a baseline level ofprofessionalism that would not be breached,but behaviour beyond that level was viewedas adaptable to the situation. Interestingly,the focus of educators was often on the roleof regulations as examples to be followed,and of students on regulations as rules notto be breached.

“If [trainee paramedics] follow the code ofconduct, then they should beprofessional all the time.”(FG5, paramedic classroom educator)

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“It’s like meeting HPC standards isn’t it?You meet the standards but you wouldstrive to it or excel, or at least you wouldargue that you should. You can meet thethreshold, or you have to meet thisparticular standard, but I think were you togo over and above it demonstrates yourprofessionalism.” (FG7, chiropody / podiatryclassroom educator)

“You’ve got to cover your own back andthat’s why really doing everything by thebook, if you do everything by the book,then they [HPC] can’t get at you for goingoutside your scope of practice and it’slearning really to work within theselimitations, to them [sic] standards.”(FG3, paramedic student)

Students in all professions had some explicitcourse content on professionalism. They weregiven relevant guidelines and handbooks, andhad some teaching sessions onprofessionalism, although in some cases itseemed these focused on transgressions andtheir consequences in disciplinary terms.

“We’re trained to standards and protocolswhich we are duty bound to stick to, soconsequently if we are dealing with apatient then we’ve got to remain withinthose parameters, and obviously to go outof those parameters would lead todisciplinary action, so really you’ve got tohave a good understanding of where youstand.” (FG1, paramedic student)

The various guidelines did not appear to bepresented in such a way as to address thepersonal and contextual elements ofprofessionalism. However, individualsrecognised that regulations and rules must becontextualised in practice to defineprofessionalism. The innate, personal qualitieswhich define professionalism were viewed asat least as important as the regulatoryprescription of behaviour. The individual’sprofessionalism is, for these people, their owncreation within the parameters of regulations.

“It’s being able to read between the lines ofthose documents [statutory or professional]and understanding how we should behavebased on that, but it’s much more thanthose few rules there.” (FG6, occupationaltherapy classroom educator)

“It’s an inner drive really to be the best thatyou possibly can at something, and thatkind of sums it up really, people who areactually motivated to actually be that wayand for a reason, as opposed to juststicking to the guidelines.”(FG2, paramedic student)

The role of context in establishing theboundaries of professionalism, even wherecodified rules are clear, was identified by oneparticipant as potentially problematic if thoseboundaries are adjudicated by otherprofessions who may not be aware of thesituated context of that profession. This wasstated in relation to HPC disciplinarycommittees, but there may be other situationswithin trusts (for all professions) where theissue may be relevant.

“If you go to an HPC disciplinary committeethere’s one paramedic on that and the restof them are other professionals, so what wewould define as professional in anambulance service environment might beone thing, what other people who are notambulance service might define as beingprofessional might be totally different.”(FG2, paramedic student)

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3.3 Professionalism as a fluidconstruct

Professionalism therefore was not seen as astatic well-defined concept, but rather was feltto be constructed in specific interactions.Consequently, definitions of professionalismwere fluid, changing dynamically with changingcontext. The following sections describe howthis contextual influence was perceived, bothin terms of the clinical, patient-centred context,and of the organisational and inter-professionalcontext. The expectations of patients, and ofother professions, were key influences.

3.3.1 The influence of the patient-centred context

Participants felt that the important quality ofprofessionalism when interacting with patientsand clients, particularly in the area ofcommunication, was the appropriateness ofbehaviour to the specific context, more thanspecific behaviours or attitudes. The contextmay vary in many ways: the physicalenvironment (eg a hospital, a patient’s home, apub car park), the specific clinical demands ofeach case, and patients’ personalities andexpectations of a professional.

“What may or may not be appropriate willdepend on circumstances and things thatmay occur in a community situation and aperson’s own home may not be whatnecessarily happens within a departmentwithin a hospital… intrinsically you are thesame person but your behaviour may adaptaccording to the circumstances within thesevery thick boundaries.” (FG6, occupationaltherapy classroom educator)

An important aspect of professionalismtherefore is situational judgement, meaningthe ability to judge circumstances in orderto identify the most appropriate way ofacting / responding / communicating in aparticular context, whilst still following acode of conduct.

Box 8: Communication in context

Ambiguous behaviours: ”what I sort ofstruggled with is who makes thatjudgement because what’s inappropriatefor one person is not inappropriate to […]I’ve been to a patient’s house wheresomeone has said to us I don’t like beingcalled that, I don’t like being called darlingand stuff like that. So is that inappropriatebehaviour or might someone, you knownot mind being called that and in their agegroup they might think that is totallyappropriate… it’s the patient thatmakes that decision for you.” (FG2,paramedic student)

“It is difficult for us and it’s difficult forstudents because it can get confusingbecause we’ve got again a young clientwho works on black humour and you knowjokes and some of that and it’s hard for,because sometimes you do joke withpeople and if you step back from and listento it it’s not PC but it’s how they’re dealingwith their injury...” (FG8, occupationaltherapy placement educators)

The ability to ‘read’ patients and clients aspeople, as well as clinical cases, was oftendescribed as important for assessing theappropriate register for communication, forexample identifying how patients and serviceusers would prefer to be addressed, in termsof the level of formality they would like, theappropriate vocabulary they would understandand respond to, and the appropriateness ofusing humour. More clinically it also related togauging what information they needed, andwanted to know about their situation, and thebest way in which to convey that information ina way they could understand.

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“It’s a really big part of it... you go in, youlook at the patient and you’ve got to judgehow the patient is going to react to youbeing in their house within a couple ofseconds and you need to make a goodestimation of whether you can actually talkto that patient using sir or madam, whetheryou can use first names or Mr, Mrs,whatever, so you’ve got to be a reallygood character assessor, and it’s a bigpart of it because then, once you talk tothe patient and you know how far youcan go with them, or if you can crack ajoke, get them smiling, laughing, morerelaxed, which eases the patient.”(FG1, paramedic student)

For paramedics particularly, the need to read asituation in terms of potential physical dangerwas highlighted. A potential need for selfdefence – verbal or physical – was mentioned,which would in normal circumstancesbe unprofessional, but if threatened wouldbe essential.

“If it came to it and you had to use someform of self-defence, that’s not droppingyour professional standards, that’s self-defence and if a patient is swearing andbeing aggressive and abusive at you andyou have to get them off the ambulance incase they cause some injury to you that’snot dropping your professional standards,that’s all about being professional with thelevels that we’ve got... it doesn’t matterwhat’s wrong with them, if they are going tocause an injury to you or your crewmate theprofessional thing is to look after oneanother.” (FG1, paramedic student)

Box 9: Gift Giving

Ambiguous behaviours: “Yeah because itdepends on the setting, like some you cando it where you accept it as a team gift, agift to the team so then it’s not singling outanybody individually but it depends what itis as well to what the gift is and what rulesare in different places.”(FG19, occupational therapy student)

“...there isn’t a notice up, there isn’t a clearsign in a department to say please don’tgive these things and I think when patientscome and they’ve thought aboutsomething they’ve wanted to buy you thenyou feel it’s a personal insult to them if yousay no and it’s a really awkward situationand again it’s not always clear indepartments anyway to say you can or youcan’t isn’t it.” (FG8, occupational therapyplacement educators)

“We don’t know how many take moneyfrom patients and don’t tell. Not that wehave a problem with that if a patient was togive a, if a patient wants to give a student atip, they can. We don’t have any rule tostop it... it’s usually a couple of quid and ahairy humbug.” (FG7, chiropody / podiatryclassroom educators)

The use of humour was a particular area raisedby all professions, recognising it as a means ofdeveloping a relationship and putting a patientat ease, but also a potentially risky approach.

“Some paramedics do joke around andinvolve the patient, but I think they sort ofassess the situation as to whether it’srelevant or not, because like if someone istrapped in a car you don’t sort of bring upjokes but if someone is sort of muckingaround and they are with a few friends andthey’d fell over or something, justsomething quite silly, you know, you’d seewhether it was worth putting a joke in, butthen actually it depends entirely on thepatient.” (FG10, paramedic student)

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“Some people would be very professionaland very formal and that approach doesn’twork for everybody, sometimes you have tobe able to be a bit more informal and jokeyand chatty, and that’s what works for thatrelationship doesn’t it, between the clientand yourself.” (FG8, occupational therapyplacement educator)

“Sometimes language can be used todiffuse a situation... I don’t mean like at theexpense of a patient but having a bit of alaugh, it’s fine but sometimes it’s the way it’sdone or if it’s at the expense of somebodyelse.” (FG17, chiropody / podiatry student)

Communication was also important inmaintaining appropriate boundaries betweenprofessional and patient or client. ‘Reading’the patient and the situation could often berequired in order to establish appropriateboundaries and maintain safe practice.Negotiating boundaries could be moredifficult in some contexts, for example whenbuilding trust with service users with mentalhealth issues. The appropriateness ofshowing emotion was also discussed interms of situational judgement and thetherapeutic relationship. Participants fromchiropody / podiatry and occupationaltherapy, professions that may involve buildinglonger-term relationships with clients thanparamedics, spoke of the importance ofmaintaining boundaries with patients andservice users whilst still engaging them inconversation. The balance between showingempathy but not giving personal details suchas home address / location or developingfriendships was something students seemedto have been well informed about duringtraining. Building a trusting and longer-termrelationship with patients or service userssometimes meant being offered gifts by them,which could be awkward for students and,although there were Trust and organisationpolicies, was something they had to learn todeal with in each situation.

“You’re told you shouldn’t kind of do thatthing [give a client a hug] but sometimes ifyou know your client well and... you have afrail old lady who is very upset it might beappropriate to just put your arm aroundthem because we’re human, it’scompassion... it’s kind of knowing yourclient.” (FG13, occupational therapyplacement educator)

“I think you have got to keep a balance,because you don’t want to be like toostandoffish and just like, well, you know, theold ‘I’m a professional’... I think you’ve gotto have some kind of a rapport withpatients in order to do the job effectively, soI think it’s a fine line.”(FG19, occupational therapy student)

“Disclosing something about yourself canbe a good sort of breaking the ice, so it’skind of knowing that level of what you’rewilling to disclose, so I mean for exampleit’s ok to say ‘Oh I also like that TVprogramme’ or something like that, butwhen it becomes really personal informationthat’s when you kind of put yourself at risk.”(FG13, occupational therapy placementeducator)

The issue of disclosure also arose foreducators with regard to the staff-studentrelationship and was seen by some as a greyarea. Regarding relationships with colleagues,some spoke of the importance of behaving in away which would not lose their respect.

The internet and social media were discussedas a threat to the boundary betweenprofessional and private selves, and thisextended to privacy, and the boundarybetween practitioner and patient.

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“I think most professions now, or even anyjob, the boundary between your work lifeand your social life is blurred with things likeFacebook and things like that... you can’tkeep your private life private now becauseyou see things in the media and things likethat and you have to be always in yourmind that actually I am supposed to be aprofessional and I’ve got my job.”(FG11, paramedic student)

“It also goes as far as Facebook, wherepatients have been known to look you upon Facebook to find out where you live,you’re married, you’ve got children, andthen they’ll come into the clinic next week,‘oh, I’ve had a look on your Facebookpage’, there’s got to be a line drawn butwhen a little old dear is sat in the chair andshe just wants a little chat, you can’tdismiss them because I think that’sunprofessional.”(FG17, chiropody / podiatry student)

3.3.2 Patient and public expectations

Participants were conscious of wanting topromote a good image of themselves and ofthe profession as a whole to patients andservice users in order to gain respect and toinspire trust and confidence in their ability andprofessionalism.

“Having that awareness that you can sortof, not necessarily intentionally, but youcould do something that could be seen asabusing your position of power as well, Ithink a lot of professionalism is about howyou are viewed by other people… howyou’re representing the profession andrepresenting yourself.”(FG19, occupational therapy student)

There was a feeling that the level ofprofessionalism expected by patients andservice users could be shaped by a number offactors, including previous experience of aservice. There was a sense that it wasimportant to overcome any negativeperceptions and set a standard or an examplethrough appearance, behaviour andinteractions. Participants from all threeprofessions commented on professionalismbeing linked to their public health responsibility.

“We are the face of the ambulanceservice... the only thing the patients see fromthe ambulance service is people like us, andif you go in there into somebody’s house andyou’re larking around or, you know, even ifyou are just in a bad mood and you’re justnot interested that’s all they see and they tareverybody with the same brush, and you’vegot to keep a standard applicable to aprofessional service, you know, we’reresponsible for a professional service.”(FG5, paramedic classroom educator)

“Making a good impression, promoting agood image is what I think it comes downto, is the first port of call.” (FG13,occupational therapy placement educator)

The relative infrequency of exposure to theseservices compared to other professions (egdoctors and nurses) may mean that anynegative examples are more easily establishedand harder to overturn. A single occupationaltherapist may be the only exposure to theprofession a patient has, while a single nurse islikely to be one of many.

“Because there’s so few of us you can liveor die by those that have gone beforeyou… there’s a whole host of nursing staffaround all the time… but if you get a badOT and there’s only one of them, then thatbecomes occupational therapy is a load ofold nonsense… I think that is a problem forus as a profession sometimes.” (FG13,occupational therapy placement educator)

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It was also suggested that it can take years forthe public to perceive a role as ‘a profession’,and there is a possibility that patients may notreadily identify the expertise of newerprofessions. Consequently they may notprovide the appropriate information to them,but rather save it for a professional whoseclinical expertise is more familiar to them.The changing roles and / or titles of theprofessions involved may not yet be fullyunderstood by patients and service users oreven other healthcare professionals. Forexample, there are now many levels ofqualification and skill within the ambulanceservice, but the out-dated perception of allstaff as clinically unskilled ‘ambulance driver’was felt to persist amongst the public.Similarly, with regards to chiropodists /podiatrists, some in the profession havemoved away from the term ‘chiropodist’ andso feel that the continued use of the termindicates limited awareness on the part ofpublic and healthcare professions alike.

“I think even though they are registeredprofessionals now, it still takes a long timebefore the public hold you in the esteem ofbeing a professional, a lot of years.”(FG11, paramedic student)

3.3.3 The influence oforganisational context

Professionalism, both in its definition and thebehaviours that demonstrate it, was felt to beinfluenced by the organisational context. Thisis distinguished from what was termed the‘patient-centred’ context above, as itdescribes the organisational andmanagement structures within which theprofessions work, as well as their interactionswith other professions.

Respondents indicated that it was importantfor organisations to support professionalism,and provide an environment in which it canflourish. Paramedics particularly identifiedmanagement support as important, but theother professions identified relationships withthe wider health and social care system asproviding a context within whichprofessionalism may or may not easily develop.There was a feeling that professionalismshould be set by management example, andthat the way staff are treated elicits theappropriate response in attitude andbehaviour. This was not in terms of modellingexplicit behaviour, but management displayingwhat was seen as appropriate behaviour fortheir role.

“The organisation as a whole should comeacross as professional from the top man allthe way down, and if you’re not getting theright image from above how can you beexpected to present the right image tothe members of the public?”(FG4, paramedic student)

“If you haven’t got the correct support, youdon’t feel like you are being looked after,none of your ideas are being listened to,whatever, from an organisational basis,then you tend to be moreunprofessional... it’s when people lookknackered or they’re disillusioned that theytend to let their behaviour slip, so it’s aboutcatering to the people underneath you aswell, professionalism breedsprofessionalism, you lead by example.”(FG20, paramedic student)

Management were also felt to be responsiblefor the working environment and resources,which could impact on morale and, potentially,performance. Pressures of work and targetswere also seen as an influential factor.

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“I’m lucky I’m on a nice, brand new stationbut you go to other stations, they’re darkand dingy and… things don’t work, nothingever gets fixed, you put in a request for thatlight to be fixed and six months down theline it’s not done.” (FG1, paramedic student)

All groups felt the demands of the healthservice overall impacted on professionalism.There was a concern amongst some studentsthat the pressures of working in the NHS weredetrimental to professionalism, and that thedemands of timed appointments may impacton their professionalism.

“I would [like to] do this, this and this, but inthe NHS you have not got time to do that,that and that, you’ve just got time to dothis, so your professionalism from beingsuch a very high level when you leave herewill certainly drop to a level that’sacceptable within the NHS, but you’re stillbeing professional.”(FG15, chiropody / podiatry student)

The expectations of other professions werealso significant. There were comments thattheir treatment by other professions couldundermine professionalism, or act as anincentive to appear more professional withother groups. This may be related to aperceived lack of understanding from doctorsand nurses of what other healthcareprofessions are qualified to do. For example,some chiropodists / podiatrists felt their roleand / or skill level was not understood by otherhealthcare professions, including the GPs whomay refer patients to them.

“My [relative] is a doctor and I explained toher some of the things that you do out onthe road and she’s, like, ‘Do you do that?’.People just don’t know, that’s the problem,and I think it takes a long time before you’reheld in regard.” (FG11, paramedic student)

“The HPC want us to be professionals andif we can't be given the tools to beprofessional, ie we have to treat patients ina cupboard on a box, how on earth do theyexpect us to be professional? And thatpatient can easily turn round and say ‘right,that treatment was poor’.”(FG15, chiropody / podiatry student)

“If I go into a meeting [with otherprofessions] that I know is going to bechallenging I may actually dress moreformally to present a more formalprofessional image. I think about thelanguage I’m using and the way that I’mcommunicating kind of really to sort of upthe stakes in professionalism to be seen asa professional, whereas with the clients Iwant them to see me as [name deleted] theOT.” (FG14, occupational therapyplacement educator)

3.3.4 Workplace environment

Some more localised elements of theworkplace environment were also important inthe framing of behaviour as professional orunprofessional. The difference between thepatient environment and other workingenvironments was important in defining theacceptability of some behaviours, particularlyaround humour. Behaviour with colleaguescould be seen as ‘unprofessional’, butcould be beneficial in allowing de-stressingand ‘letting off steam’, or simplyinformal debriefing.

“It’s a coping mechanism... you have a badjob, you know, whatever the outcome maybe, but you need to talk about it or have acrack on about it, but somebody looking infrom outside would think ‘how can theymake a joke about what’s just happened?’and it’s that kind of thing, so it’s the waythings are perceived I suppose.”(FG5, paramedic, classroom educator)

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“Without realising there was still a patient inthe next cubicle we started to talk aboutwhat we’d done and the treatment, andthen realised there was someone still sittingthere which is you know completelyunprofessional but it was just theexcitement and lack of experience thatmade us do that... we were talking aboutwhat we had just experienced andobviously that’s not professional in front ofanother patient who’s in the next cubicle... itcertainly wasn’t malicious or deliberate or itwas just thoughtlessness I suppose.”(FG16, chiropody / podiatry student)

Some paramedics spoke of reducedopportunities for this de-stressing in themodern ambulance service, commenting thatthey spent less time at their work base than inthe past. However, norms on such behaviourwere not universal, and there was a need toknow which behaviour was appropriate withwhich colleagues.

“Some colleagues you can have a laughwith and other colleagues you’re a lot moresort of serious with, but you never doanything that is completely derogatory oranything like that.”(FG2, paramedic student)

Organisational culture could also be importantin creating or reinforcing professionalism,or allowing unprofessional behaviour togo unstopped.

“There's still this real culture against whistleblowing… if you were to report somebody,no one on your station would ever talk toyou ever again, you would have to moveand live somewhere else… you know, if he’sa good bloke, how could you saysomething against him even if he is aterrible practitioner?”(FG18, paramedic classroom educator)

3.4 Experience androle modelling

The areas of situational awareness andcontextual influence discussed above wereoften related to experiences during training.These included direct experience gained inpractice, and from role models encounteredat work.

“There’s a lot of people come into theservice... and they can’t talk to differentgroups, old people. They find it very hardactually to talk to old people and that’ssomething that you learn on the road... it’ssomething that you’ll never learn out of atextbook.” (FG4, paramedic student)

“You have different people you work with aswell, so professionalism is going to changeday to day with people you work with aswell.” (FG1, paramedic student)

Role models could be positive or negative, andparticipants spoke of developing their ideas ofprofessionalism and good practice by drawingon different elements observed in different rolemodels. Some students also spoke of learningfrom their peers, while some tutors referred totheir responsibility to act professionally anddisplay a professional approach in theirteaching. Students felt they could identify thebits from good and bad role models theywould like to adopt and to avoid, indicatingthey felt their judgement to identify the goodand bad examples was good enough to do so.The possibility of adopting unprofessionalhabits through complying with others’behaviour was also raised.

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“Taking bits from all the different people thatyou meet… you’ll see something and thinkthat’s really good, and then it’s taking thebest bits from everyone, saying they’rereally good at talking to the client andgetting their attention, and then... they’rereally good at putting equipment togetherand this is the best way to do that… andI’ve learned a lot from other people in theteam as well and I think that’s reallyimportant.”(FG19, occupational therapist student)

“We’ve all been shifted around to differentpeople, most of us have, and you kind ofget... to see the good people and the badpeople and you can kind of like pick andchoose all the little bits that you want totake from different people’s practice, so it’squite nice.” (FG11, paramedic student)

Educators recognised that this modellingoccurred, and were aware of the risks ofinappropriate modelling. The vast majority ofeducators have been in practice or are stillactive practitioners and they were often awareof their own potential as role models.

“There will be a demonstration ofprofessional practice just by the way weconduct ourselves.” (FG6, occupationaltherapist classroom educator)

“If you treat somebody right they tend totreat you right as well, and I think it’s thesame with the students. If you areprofessional, you are on time, you haveeverything prepared, you can answer theirquestions and things, it looks professionaland they want to learn, and it’s the sameout there on the road.”(FG5, paramedic classroom educator)

The enthusiasm of some educators wasidentified as a positive example bysome students.

“We’re quite lucky because we get put withpractice placement educators whovolunteer to do that job to teach… becausethey’ve volunteered for that you know theyare really quite good at their job and quiteprofessional because they want to advancethe profession by teaching others... youlearn a lot about... your bedside mannerand definitely how to be professional.”(FG11, paramedic student)

“I remember going on placement and I hada fantastic educator and just a brilliant OTand I remember thinking that’s kind of howI’d like to be and to kind of conduct myselfreally, so I think I could see how theyworked with the client... I thought yeahthat’s good practice, that’s how I’d like tobe as an OT.” (FG13, occupational therapistplacement educator)

Role models were not limited to the students’own profession. Good examples could befound in other professions.

“I think looking at other professions, not justpodiatrists, but GPs, nurses, doctors,physios, dentists, how do they conductthemselves in a professional manner, what’stheir understanding of professionalism?Looking at how other people presentthemselves professionally, not justmedically but in business as well and justthroughout general life.”(FG15, chiropody / podiatry student)

Peer learning, with students modellingbehaviour from each other and establishingtheir own norms of professional behaviour wasalso identified as important.

“It’s surprising what peer pressure can dowith a student because the students will letanother student know if they’re unhappywith their [...] behaviour.” (FG7, chiropody /podiatry classroom educator)

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“They’re quite sort of practice affirming witheach other, they’re quite nurturing. I think itdepends on the group obviously, everygroup’s different, but I think they’re quick tosay that’s not right, but equally ifsomebody’s done something really goodthey would aspire to be like that.” (FG7,chiropody / podiatry classroom educator)

3.5 Achieving professionalism

Student participants were asked whether they‘felt like a professional’. The intention of thisquestion was to elicit opinions on whenprofessionalism or professional identity may‘begin’ or be adopted, and whether it is relatedto the regulatory status of being a registeredprofessional. Interestingly, there was a range ofopinions, illustrating different perspectives onwhat professionalism means, and how itrelates to ‘being a professional’. Some statedthat professionalism is distinct from being ‘aprofessional’, and that the use of ‘professional’as an adjective (‘being professional’) or as anoun (‘being a professional’) carries verydifferent meanings.

“I think being a professional as a sort ofprofessional body if you like, beingregulated, then yes that's different fromactually being [professional].”(FG18, paramedic classroom educator)

The majority of students felt thatprofessionalism began as soon as they begantheir training – for example, even if they didn’tfeel like a ‘professional paramedic’, they feltlike a ‘professional trainee paramedic’, that is,professionalism to them was centred onpractice, not status. In the sense thatprofessionalism may be ‘part of the self’ asdescribed in an earlier section, and somethingthat is essentially inherent to the individual, itmay be brought by students to their training intheir underlying values, and carried throughwith them into practice.

It may therefore be possible (and desirable) to‘be professional’ and act in a professionalmanner before acquiring all the necessaryknowledge and skills and becoming aregistered professional. Indeed it may not bepossible to qualify without being professional.

“I think [feeling professional] is an absolutelyindividual thing. I think I’m a professionalsince the day I started this course andalways given it everything, always done mybest.” (FG15, chiropody / podiatry student)

“I definitely feel like a professional [but] Idon’t feel like a paramedic, and I think that’spurely down to my lack of confidence aboutmy knowledge.” (FG11, paramedic student)

“When you first start training as an OT youdon’t have all the knowledge that it takes tobe an OT but you should still beprofessional.” (FG13, occupational therapistplacement educator)

At the same time, professionalism was stillseen by both educators and students todevelop over time through education andlearning on the job, and some reportedchanges in their attitudes and behaviour. Someeducators felt that professionalism was therefrom selection and admission to the course,others that it developed, or in some casesremained a concern. Some students describedfeeling like a professional once they went outon the road or into practice, and some saidthat this feeling emerged or was strengthenedwhen they returned to their place of trainingand reflected on their experience.

“There are others at the early stage that youthink you have got concerns about and youthink, ‘Oh my God, I don’t know whatwe’ve got here’, but actually you veryquickly notice that they are learning, theyare changing the way that they approach.”(FG18, paramedic classroom educator)

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“I think there is a point leading up to[registration] at which a student decidesthey are going to accept the obligationsplaced upon them, they take responsibilityfor their own actions, and at that point theythemselves become an occupationaltherapist... and for some students that willhappen before they arrive on the programme,for some it will happen somewhere near theend of year three... and I don’t think we canpush it upon the students and theirexpectations of placement, but I don’t thinkthey ever take that on until it becomesinnate.” (FG6, occupational therapyclassroom educator)

“A lot of them don’t change betweenlevel one and level three so I think it is apersonality issue and it’s difficult to change.Not saying you can’t change, but it seemsquite difficult for a lot of people to change.”(FG7, chiropody / podiatry classroomeducator)

Some thought they would feel like aprofessional chiropodist / podiatrist,occupational therapist or paramedic whenregistered with the HPC, or when they werepractising independently; others thought itwould not be until they had a few yearsexperience and were teaching others. At thesame time, it was noted that being registeredwas not synonymous with being professional.Some educators referred to professionalismas ‘evolving’ or as a ‘journey’ and one thatcontinued as a ‘lifelong journey’throughout practice.

“You can be a professional to the standardwhere you’re talking to patients with respectand things like that... but the fact of havingthe underpinning knowledge andexperience to have the confidence to makethe decisions – it’s years, isn’t it.”(FG4, paramedic student)

For some students, their own developingprofessionalism raised issues about how farthey could, or should, challenge what theyconsidered to be unprofessional behaviourin others.

3.6 Differences betweenprofessions

While the main themes definingprofessionalism were similar for the threeprofessional groups, there were some inherentdifferences between professions relating totheir different organisational contexts, and thedifferent clinical environments leading todifferent professional demands andpatient relationships.

Paramedics see patients in the most acutecircumstances, and are effectively at thebeginning of any episode of healthcare (theymay be responding to a referral, but even then,they are the first patient contact on the way toa hospital). Chiropodists / podiatrists andoccupational therapists on the other handreceive patients through referrals, and will oftensee patients over a period of time in which thegradual development of a relationship canoccur, allowing the professional a longer periodin which to establish an appropriate level andform of communication. The acute nature ofparamedic care also has implications for thephysical environment of the job, and the riskanalysis regarding their own safety. Theemergency nature of the paramedic role alsomeant that they had dealings with, andcompared themselves to (and feltthemselves compared to by others), the fireand police services as well as otherhealthcare professionals.

“You’ve had all three of us lined up and Ithink the public straight away would say thepolice are probably the most professional,then fire and we’d be last.”(FG3, paramedic student)

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“Also I think we do as a body, I think weoften, and we get sympathy from thepublic, we hide behind the guise of oh it’stheir stress relief, they're not racist, that'sjust the way they, there’s no stress, there’sstresses like getting off on time and things.”(FG18, paramedic classroom educator)

By contrast, while any health or social carecontact contains risk, and chiropodists /podiatrists and occupational therapists mayenter community or domiciliary settings whererisks are not controlled (and prison settingswhere risks may be controlled but heightened),visits are likely to be planned, and any riskanalysis conducted in advance. The differentenvironments in which chiropodists /podiatrists and occupational therapists workmay influence service users’ expectations, forexample they may be more comfortable to trythings in their own home than in a morepublic environment.

“When you’re working with a client within adepartment when there are other peoplearound there are certain things that you dothat might embarrass that individualbecause of the more public nature of whatyou are doing... which, with the individualin their own home you would be able todo.” (FG6, occupational therapyclassroom educator)

All professions have different time constraintsto their practice, but the circumstances aredifferent. Chiropodists / podiatrists andoccupational therapists will tend to havescheduled appointments, some of whichwill be in clinics, but others will be in thecommunity, in people’s homes, with differentexpectations. Paramedics have less definedschedules, being responsive to calls, but onceon a job there are time constraints, such astarget response times, and limits to how longcan be spent on handover at a hospital.

“Even simple things like once you’vehanded your patient over at hospital andyou come back to the ambulance, usuallyyou green up straight away once you’vefinished... we might be at hospital fiveminutes and then we’d go onto the nextjob, but if we were with an old hand, theyjust stay at hospital for like an hour becausethey want to relax, read their paper, thingslike that, because that’s how they wouldhave done it 20 years ago and if you satthere and greened up after five minutesthey’d [not be happy] and then for the restof the year you’d be known as the personon the station who greens up really quicklyso you’ve got to be careful.”(FG11, paramedic student)

Of the three groups, the chiropodists /podiatrists differed in that many of their cohortexpected to go into private practice as amatter of course. While there may beopportunities for private practice in the otherprofessions, they were training with theexpectation of working in the NHS.

The professions differ in their history asprofessions, and some responses highlighteda contrast between the professionalisation of arole, meaning its formal status and regulation,and the emergence of professionalism in itsculture. Paramedics are a relatively youngprofession, and the majority of the currentworkforce trained in the pre-graduate system.It also still has the legacy of the IHCD shortcourse route to registration, meaning that newparamedics are entering the workforce withvery different training experiences to thosealready there, including senior management.

It was suggested that because of this, theremay be a mismatch between the aspirationsof training programmes and the consequentprofessionalism of graduates emerging fromprogrammes, and the culture of theorganisations in which they are then employed.Individual professionalism may be developing

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at a very different rate to that of the employingorganisation. This may be the seed of longer-term change, or may lead to frustration, andattrition of those individual attitudes.

“Our very own… [Trust] Chief Executivecame here and told the students thatstudied for [a degree] that they will be nodifferent… they’ll be paramedics and so willeveryone else that trains in his service… onan in-service training course. Which wasless than helpful.”(FG18, paramedic classroom educator)

Paramedics were also particularly aware of therole of the media – drama and ‘reality’television programmes – in constructing publicperceptions, although as the educatorspointed out, this also affected the perceptionsof potential applicants.

“It seems like a lot of the things in themedia, the paramedics get blamed forsomething, possibly quite minor, [and] getreally taken to the dogs kind of thing. Andyet a lot of the perceptions of the public arelike, well, that we shouldn’t be doing thatanyway, that we’re just taxis to hospital, sowhat are we doing that kind of thing [for]anyway?” (FG11, paramedic student)

“That’s where people get the wrong imageof us – if people don’t watch Casualty theythink we are just taxi drivers, people who dowatch Casualty think we save everyone’slife and everything they go to is lifethreatening, and so everyone gets thewrong idea.” (FG11, paramedic student)

There were also a small number of referencesto identifying role models in mediarepresentations, with the dramaticrepresentation of a paramedic emphasisingpositive qualities of the job. Educators pointedout that those who came for interview withsuch expectations were often not felt to besuitable for the job as their expectations werelikely to be unrealistic.

3.7 Implications for selectionand education

The belief that the qualities required to be ‘agood professional’ are pre-existing, if notinnate, may have implications for the ways inwhich health or social care professionals areselected. Some educators commented that abelief in the profession itself could be a keyaspect of professionalism and this could bedisplayed during, or before, training as well asafter qualification.

“You couldn’t come into a healthcaresetting if you didn’t have some values andbeliefs about, you know, helping people...I think for me as well to come into OT it’sabout having the values and beliefs of theprofession before you come into it almost,because you need to believe in theprofession to be a professional OT.” (FG14,occupational therapy placement educator)

“We find it time and time again, don’t we,that, not always but in a lot of the cases,the students that do really well onplacement and are perhaps middle of theroad or even struggling academically, buton their placements they do very wellbecause they have the belief and the rightpersonal attributes to be able to do reallywell on placement.” (FG14, occupationaltherapy placement educator)

Similarly, if professionalism is a reflection of aset of core beliefs or attitudes, rather thanknowledge-based competency, there areimplications for how professionalism is taughtor developed in training. The part played bymorals and values raises questions regardingthe teaching of professionalism, for examplehow deep-rooted values are and howamenable they are to change. Is it the holdingof values or the ability to put one’s own valuesto one side if they are dissonant with thevalues of the profession that is theimportant quality?

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“Things like empathy can be learned andimproved upon within their learningperhaps, whereas other aspects are justthere or they’re not.” (FG7, chiropody /podiatry classroom educator)

“They can’t change their values, they can’tchange their perceptions.”(FG18, paramedic classroom educator)

“To try and get an attitude change, I meanhow do you get an attitude change? Youcan’t.” (FG7, chiropody / podiatryclassroom educator)

“If students don’t have those inbuilt valuesas soon as they leave, you know, they’llvirtually forget everything they’ve learned.”(FG7, chiropody / podiatryclassroom educator)

While the majority of educators saw theinherent, pre-existing qualities as important,the need to develop and bring out the best ofstudents was important in their ownprofessional role. Educators’ roles mean theymust engage with ‘professionalism’ assomething that can be taught or improved inan educational setting. Educators’ views alsovaried with their relationship with the students.Those who were responsible for progressionwithin the educational programme (‘classroomeducators’) saw the educational role asdifferent to those who saw the students onlyin a practice environment.

“We have to hand over that responsibility toeducators in practice and in the past theyhaven’t always been clear as to whether toexpect the student to follow what’sexpected in the workplace or allow them tobe a student with quite sloppy habits…they were saying things like, well, you know,I’ve passed so and so but I wouldn’temploy them, and we’re having to say wellactually you’re the gate keeper to theprofession and there’s an expectation, why

are you passing that person, we would likeyou to fail them if you are saying they areunprofessional.” (FG6, occupational therapyclassroom educator)

The complexity of professionalism also raisesthe issue of how easy it may be to measure.This question is being addressed in part byStudy 2 of the current project.

“It comes from so many different places andit’s so many different things… I think that’swhat makes it hard to measure.” (FG13,occupational therapy placement educator)

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4 Discussion

Focus groups were conducted with educatorsand students drawn from chiropodist /podiatrist, occupational therapist andparamedic populations to exploreprofessionalism. The study had four objectives– to explore what constitutes professionalismas perceived by students and educators in thethree professions, to identify how professionalidentity and an understanding ofprofessionalism develop, to identify examplesof professional and unprofessional behaviour,and to inform the development of thequantitative data collection in Study 2. The lastof these will be dealt with in the interim reporton Study 2. The others are discussed below.

With regard to objectives one and two, theanalysis illuminated the complexity of theconcept of professionalism, echoing findings inthe earlier literature, but also increasing ourunderstanding of the factors which influenceit and how they inter-relate. The results havealso identified pertinent issues for thedevelopment of professionalism in education,training and practice.

The analysis has identified dual perspectiveson professionalism – as an holistic concept, andas a multidimensional, multi-faceted constructconsisting of professional identity, professionalattitudes, and professional behaviour. Earlierwork on professionalism in clinical contextshas often focused on the last of these,identifying professionalism as a competencywhich can be taught and assessed.5, 6, 7

However, it has been acknowledged in theliterature that such decomposition ofprofessionalism may be problematic, and thatit may be more usefully considered as an holisticconstruct.20 The holistic construct was oftenlinked by respondents to good clinical practice– professionalism is ‘doing the job well’.

Discussion of where people felt their views ofprofessionalism came from identified two mainsources of influence: the first, the respondents’personal qualities and the second, the contextof the immediate situation. Many respondentsfelt that professionalism was a consequence ofqualities that the individual brought to theprofession – perhaps not actually innate, butcertainly pre-existing. A consequence of thiswas that many felt that professionalism wassomething which was an essential part ofthemselves, and that as a professional theyshould always be ‘on duty’; any lapses wouldnot only let themselves down but also diminishthe profession in the eyes of the public.

A common theme was that ‘the right sort ofperson’ will be attracted to a profession (forexample, a caring person will be attracted toa caring profession), and that if they have theright qualities, they will succeed. If people of acertain ‘type’ are suitable for a profession, oneimplication is that some form of personality-based aptitude testing may be appropriate forselection, although with the risk that theprofession would be more limited as a result.Chamberlain and colleagues21 found someevidence that students who had similarpersonality profiles to qualified dentists (on the‘big five’ personality dimensions ofextroversion, conscientiousness, neuroticism,openness to experience and agreeableness)did better in first year coursework, suggestingpersonality may be linked to aptitude.However, the use of such methods wouldrequire a great deal of development to ensuretheir high-stakes usage was valid and reliable.

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4 Discussion

When viewed as a product of individualqualities, professionalism was thereforesubstantially focused on values and beliefs thatinfluenced practice. However, it was also felt tobe significantly determined by the context ofpractice. This included the immediate clinicalcontext, with the needs, demands andexpectations of patients varying case-by-case,and the organisational context, includingmanagement support and the expectations ofother professionals. Organisational andmanagement structures may encourage orinhibit the emergence of professionalism, theimplication being that if professions are treatedwith respect, and with the expectation ofprofessional behaviour, then that behaviour willfollow. Organisational influences involved beingvalued and supported, having realistic targetsand expectations from the profession, and notexpecting people to work in poor conditionsand with unreasonable workloads or deadlines.Working under pressure with poor resourcesincreased the pressure on the profession tocut corners and risk practice that wasunprofessional or close to it.

There were also issues around the perceptionof the status and expertise of theseprofessions compared to other healthprofessionals and (for paramedics) emergencyservice workers. Feeling that expertise wasundervalued or unrecognised in comparison toother professions could also have anundermining effect.

Morale was therefore an important contextualelement for the development ofprofessionalism. This could stem from practicalaspects such as resources and facilities, toless tangible elements such as a culture ofprofessionalism as a positive, rather thanpunitive, concept. Considering the extent andhistory of an occupation or organisation’sprofessionalisation may provide a wayof engaging with their attitudestowards professionalism.

It may be that attempts to address concernsabout professionalism need to look beyond theeducational setting, and the behaviour oftrainees, to also seriously consider how theworking environments and organisationalcultures those trainees enter can bedeveloped, to ensure that professionalism ismaintained post-registration and does notdeteriorate in practice.

The need to see the appropriateness ofbehaviours as being determined by clinicalcontext is not a new observation10, althoughmuch of the literature does not take account ofthis, perhaps because it is not expedient toassessment where standardised tools andclear metrics are the primary aims. The role ofmanagement and organisational influences indetermining professionalism was not identifiedin the literature reviewed to date. Increasedawareness of their responsibility to supportprofessional behaviour may set new challengesfor both educators and regulators. The tensionbetween the influences of individual andcontext would also appear to be of concern toeducators and regulators. Teaching andassessment (or revalidation) of somethingwhich is dynamic, and bound to specificindividuals and environments, is difficult. WhileObjective Structured Clinical Examinations(OSCEs) or similar simulated patient exercisesmay provide some insight into the appropriatejudgement, they may not explicitly examineprofessionalism, and where they do, havebeen found to have questionable reliability.10

The adoption of professional identity, that is thecategorisation of oneself or another person asa member of the professional group, is anotherway in which the development ofprofessionalism may be viewed. One indicationof this was the feeling that professionalism wassomething that reflected on the profession as awhole, with a driver of professional behaviourbeing the desire to represent the professionwell. The perceived attitudes of others –patients and professionals – to the professionalgroup as a whole reinforced this identity.

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4 Discussion

The importance of identification as aprofessional was also apparent in students’discussions of when they felt they became, orwould become, a professional practitioner.While rooted in personal values and beliefs,becoming a fully-fledged professional wasseen as a work in progress, to be influencedby the professionals around them. Rolemodels both within the profession and thewider clinical team were important for studentsto identify what type of professional theywanted to become.

The emergence of professional identitytherefore also appears to be a result of aninteraction between the individual andexperience, with some respondents basing iton their perceived qualities, some onexperience, and some on the statutoryachievement of professional registration.Theoretically, these different elements mayindicate different dimensions of theprofessional identity which individuals mayattend to, and against which they may judgethe ‘fit’ of the professional identity to theircurrent role.22 One study with medical studentsfound a number of factors influenced theiridentification as doctors, including experienceof practice, apprehension about being adoctor, and interpersonal problems.23 If theadoption or experience of professional identityis related to professionalism, it is clear thatagain personal as well as contextual factorsshould be addressed. Educators, in describingthe sort of person who would make a goodprofessional, also invoked identity, as what aprofessional is rather than qualities they have.This may be a risk for recruitment, as it maylead to a confirmation bias (recruiting peoplewho fit a stereotype rather than who have theright qualities). Consideration of identity mayalso be useful for formative assessmentthough, as it may be a means of establishingthe extent to which individuals are assimilatingthemselves into the culture of their professionand are ready to take the step into practice.23, 24

The third objective of the study was to identifyexamples of professional and unprofessionalbehaviour. The examples discussed in thefocus groups reflect those identified in theliterature where review papers haveconsistently identified core themes of ethicalattitudes, good communication, andcompetence, all of which were raised in thedata presented here. Appearance wasimportant, both on a symbolic, social level(‘being smart’) but also pragmatically in termsof hygiene. This went beyond personalappearance into professional spaces such asvehicles and equipment. Professionalbehaviour was recognised and involvedmaintaining good standards of practice andkeeping up to date as well as showing theappropriate respect for patients, colleaguesand the profession. Unprofessional behaviourwas the inverse of these, and poor attitudesidentified as those which might lead to theemergence of unprofessional behaviours.

However, the complexity of professionalism,and its dual nature and dual origin, means thatwhile it is relatively easy to define, it is notsimple, and it is not easy to recognise inabsolute terms whether behaviour isprofessional or unprofessional. Many exampleswere coded as ‘ambiguous’, because evenwhile describing them, participants wereexpressing the specific contextualised natureof their appropriateness.

‘Professionalism’ therefore may be defined inthe interaction of practitioner, patient or serviceuser, and context. The professional bringsrelatively stable beliefs, traits and attitudes, butthey must respond to the demands of thepatient, personally as well as clinically, and theorganisational and physical environment mustallow professionalism to flourish. It is solocalised in specific interactions therefore thatany absolute approach to defining what is or isnot professional will be problematic.

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4 Discussion

However, perhaps this is not a problem.A more constructive approach toprofessionalism, for educational institutionsand regulators alike, may be to recode‘professional behaviour’ simply as ‘appropriatebehaviour’ in relevant communication andtechnical skills, and so to be dealt with in therelevant existing areas of a curriculum. At leastsome of the participating organisations in thisstudy already integrate professionalismthroughout the curriculum, so this is notnecessarily a change in practice. Questions of‘professionalism’ may then be refocused onthe ‘meta skills’ of situational judgement andcontextual awareness which enable individualsto identify what is appropriate, and adaptelements of their available skill-set (includingcommunication skills, practical skills andclinical skills) to the given context.The literature provides an example of asituational judgement test addressingprofessionalism which may indicate anapproach to this,25 although no data areprovided on its use.

Reframing professionalism as a capacity forjudgement, rather than discrete skills, maybenefit those who must develop it, and thosewho must monitor it. This capacity has beenpresented as a form of practical knowledge,which must be developed in practice.26 Thatthis area of professional judgement is worthy ofattention was implied by many students in thisstudy. Whether through qualities they bring tothe profession or teaching they had received,many seemed confident that they were able todistinguish between professional andunprofessional behaviour, could identifyunprofessional practice if faced with it, andwould identify and resist negative role models.Potential problems for their laterprofessionalism would be a risk if thisjudgement was not as true as they suggest.

Finally, the representation of the threeprofessional groups in fitness to practise casesvaries, with paramedics being over-represented and OTs under-represented. Thefindings here do not suggest that this is due toany particular difference in the conception ofprofessionalism or its determinants. Theprofessions did not appear to have differentapproaches to professionalism, and identifiedthe same values, influences and good and badexamples. Rather there were differences in thework of the two groups which meant that theircontextual influences may be very different,both in terms of clinical work andorganisational processes. Further workinvestigating professional lapses may needto look in more detail at how specificproblems emerge.

4.1 Limitations

All research operates within limitations, andthis study is no different. The focus groupmethod cannot be sure of comprehensivelyuncovering every viewpoint, although thenumber of groups and participants here issubstantial for this method. The use of Post-itnotes to record all members’ views beforebeginning discussion helps to ensure thatpotential minority views are taken into account.

The exclusion of Institute of Health and CareDevelopment (IHCD) students was a deliberatechoice, and may mean that certainperspectives were lost. However, one of theparamedic sites did include a similarpopulation in terms of experience in theambulance service, with in-service training,and so substantial difference is not anticipated.

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Professionalism in healthcare professionals 39

4 Discussion

4.2 Questions arising and futureresearch directions

This study has identified professionalism as anholistic construct which is linked to a range ofattitudes and behaviours, including meta-skillsof situational awareness. The on-goingquantitative study is developing aquestionnaire to establish the relationshipbetween these elements, and relate them to anobjective measure of conscientiousness.The questionnaire development has beeninformed by the analysis presented here.

This study has identified a possible model ofprofessionalism as a meta-skill of situationaljudgement, allowing professionals to selectappropriate behaviour from a toolkit orrepertoire. The development of the repertoiremay be different from the development of thatjudgement. Professional judgement may betherefore seen as analogous to clinicaljudgement, and that analogy may bearfurther examination.

The study did not identify any particulardifferences between the views of students ofdifferent years, and educators. While theoverall understanding of professionalism maynot differ substantially, there may bedifferences in their experience ofprofessionalism. These differences may notjust be between professionals, but also thedifferent training routes and relationshipsbetween students and educators. Educatorsemployed by higher education institutes andby the NHS implied different perspectives ontheir roles. Further work may examine how theinteraction of personal qualities, context androle is dealt with in educational and practicesettings.

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5 Conclusion

This study has identified key themes in relationto professionalism, from a sample ofchiropodists / podiatrists, occupationaltherapists and paramedics. The participantsperceived ‘professionalism’ both as an holisticconcept, and as a set of specific appropriatebehaviours. This was related to a professional’ssense of self, to pre-existing values, andidentification with a profession, but was alsofirmly rooted in the context of practice. What isseen as professional in a specific instance willvary with the expectations of the patient orservice user, the demands of practice, andthe environment.

‘Professionalism’ then is not perceived as anabsolute, but constructed in the interaction ofindividual and context. Identification of‘unprofessional’ behaviour in the workplacemay therefore be inferred to be subject to thesame judgements. Beyond basic minimumstandards, which may be set by regulationsand codes of conduct, identification of thesebehaviours cannot therefore be assumed tobe clear-cut.

Questions of professionalism (and lack ofprofessionalism) may be better framed more interms of the ability to identify when behaviouris appropriate rather than always in terms ofabsolute behaviours. It is suggested thatprofessionalism may be better regarded as ameta-skill of situational awareness andcontextual judgement, allowing individuals todraw on a range of communication, technicaland practical skills, and apply the appropriateskills for a given professional scenario. The trueskill of professionalism may be not so much inknowing what to do, but when to do it.

The role of organisational context inencouraging and facilitating professionalismwas also an important observation. This couldbe in the form of management and resources,or the structure of work and the perceptions ofother professional groups.

These key points, of professionalism as ajudgement rather than a skill, and of the role oforganisational support, may be developed toexplore new ways of encouragingprofessionalism in trainees and existing staff.Implications for education, assessment, as wellas revalidation, should be explored.

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Professionalism in healthcare professionals 41

References

1 M.A. Papadakis, C.S. Hodgson,A. Teherani , N.D. Kohatsu, ‘Unprofessionalbehaviour in medical school is associatedwith subsequent disciplinary action by astate medical board’, AcademicMedicine, 79 (2004), 244–249.

2 M.A. Papadakis, G.K. Arnold, L.L. Blank,et al, ‘Performance during internalmedicine residency training andsubsequent disciplinary action by statelicensing boards’, Annals of InternalMedicine, 148 (2008), 869–876.

3 A. Reid, Editorial: ‘Identifying medicalstudents at risk of subsequentmisconduct’, BMJ, 340 (2010),1041–1042.

4 J. Thistlethwaite, J. Spencer,Professionalism in Medicine (Oxford:Radcliffe, 2008).

5 L. Arnold, ‘Assessing professionalbehavior: yesterday, today, andtomorrow’, Academic Medicine,77 (2002), 502–515.

6 R.L. Cruess, S.R. Cruess, ‘Teachingprofessionalism: general principles’,Medical Teacher, 28 (2006), 205–208.

7 Measuring Medical Professionalism, ed.by D.T. Stern. (Oxford: Oxford UniversityPress, 2006).

8 T. Wilkinson, W.B. Wade, L.D. Knock, ‘ABlueprint to Assess Professionalism:Results of a Systematic Review’,Academic Medicine, 84 (2009),551–558.

9 W.E. Brown, G. Margolis, R. RogerLevine, ‘Peer evaluation of theprofessional behaviors of emergencymedical technicians’, Prehospital andDisaster Medicine, 20 (2005) 107–114.

10 S. Ginsburg, G. Regehr, R. Hatala,N. Mcnaughton, A. Frohna, B. Hodges,L. Lingard, D. Stern, ‘Context, Conflict,and Resolution: A New ConceptualFramework for EvaluatingProfessionalism’, Academic Medicine,75 (2000); s6–s11.

11 Ginsburg et al, ‘Basing the Evaluation ofProfessionalism on ObservableBehaviors: A Cautionary Tale’, AcademicMedicine, 79 (2004), s1–s4.

12 L.V. Monrouxe ‘Identity, identification andmedical education: why should we care?’,Medical Education, 44 (2010), 40–49

13 L.J. Stockhausen, ‘Learning to becomea nurse: students’ reflections on theirclinical experiences’, Australian Journalof Advanced Nursing, 22 (2005), 8–14.

14 H.M. Swick, ‘Toward a normativedefinition of medical professionalism’,Academic Medicine, 75 (2000),612–616.

15 C.M. Joyce, J. Wainer, L. Piterman,A. Wyatt, F. Archer, ‘Trends in theparamedic workforce: a profession intransition’, Australian Health Review, 33(2009), 533–540.

16 www.hpc-uk.org/aboutregistration/theregister/oldstat

17 Health Professions Council. Fitness toPractise annual report 2010(www.hpcuk.org/publications/reports/index.asp?id =403 downloaded 20 March2011).

18 NVivo, Using NVivo in qualitativeresearch (Melbourne: QSR International,2002).

19 J. Ritchie, L. Spencer, ‘Qualitative dataanalysis for applied policy research’, inA. Bryman, R.G. Burgess (eds),Analysing Qualitative Data (London:Routledge, 1994)

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20 V. Jha, H.L. Bekker, S.R. Duffy, T.E. Roberts,‘A systematic review of studiesassessing and facilitating attitudestowards professionalism in medicine’,Medical Education, 41 (2007), 822–829.

21 T.C. Chamberlain, V.M. Catano,D.P. Cunningham, ‘Personality as aPredictor of Professional Behavior inDental School: Comparisons with DentalPractitioners’, Journal of DentalEducation, 69 (2005), 1222–1237.

22 P.J. Oakes, ‘The salience of socialcategories’, in JC Turner, MA Hogg, PJOakes, SD Reicher, MS Wetherell (eds),Rediscovering the social group (Oxford:Blackwell,1987), pp. 117–141.

23 T. Gude, P. Vaglum, R. Tyssen, Ø. Ekeberg,E. Hem, J.O. Røvik, K. Finset andN.T. Grønvold, ‘Identification with the roleof doctor at the end of medical school: anationwide longitudinal study’, MedicalEducation, 39 (2005), 66–74.

24 J. Crossley, P. Vivekananda-Schmidt,‘The development and evaluation of aProfessional Self Identity Questionnaireto measure evolving professional self-identity in health and social carestudents’, Medical Teacher, 31 (2009),e603–607.

25 S. Schubert, H. Ortwein, A. Dumitsch,U. Schwantes, O. Wilhelm, C. Kiessling,‘A situational judgement test ofprofessional behaviour: developmentand validation’, Medical Teacher, 30(2008), 528–33.

26 S.R. Hilton, H.B. Slotnick, ‘Proto-professionalism: how professionalisationoccurs across the continuum of medicaleducation’, Medical Education, 39(2005), 58–65.

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Appendix A – Letter of invitation toprospective participants

4 October 2010

Dear Student

Invitation to attend a focus group

This letter is to invite you to take part in a research project looking at the developmentof professionalism.

The study has been commissioned by the Health Professions Council (HPC, please see enclosedletter of support), and will be carried out by the Medical Education Research Group at DurhamUniversity. The HPC will have no access to data - they will only receive summaries of results.

We are interested in your views on professionalism, and you are invited to take part in a focusgroup on Wednesday 10 November 2010, at 1pm. All trainees in your programme are beinginvited. There is no obligation to take part, but your contribution may help us understand moreabout professionalism.

An information sheet on the project is enclosed. Please read it carefully and feel free to contactus with any questions.

If you would like to take part in a focus group, please return the enclosed reply slip on thefollowing page.

Yours sincerely

Jan IllingPrincipal Investigator

School of Medicine and Health

Shaped by the past, creating the future

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Appendix B – HPC letter of supportsent to prospective participants

Professionalism in healthcare professionals44

Park House184 Kennington Park RoadLondon SE11 4BU

tel +44 (0)20 7582 0866fax +44 (0)20 7820 9684www.hpc-uk.org

Chair: Dr Anna van der Gaag

Chief Executive and Registrar: Marc Seale

September 2010

To whom it may concern,

Research Project: The professionalism and conscientiousness of trainee healthprofessionals

I would like to invite you to take part in the above research project which is beingundertaken by Durham University. The research, which the Health ProfessionsCouncil has funded, will involve two studies, one looking at how professionalism andprofessional behaviour are defined and experienced, the other aiming to investigateissues related to the measurement of professionalism.

Attached is an information sheet from the research team explaining more about thestudy and what your participation would involve.

Individual data will remain wholly confidential to the independent research team andwill not be shared with anyone else, including the HPC.

We thank you in anticipation of your contribution to the research.

Yours sincerely

Dr Anna van der GaagPresident of the Health Professions Council

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Appendix C – Focus groupinformation sheet

Professionalism andconscientiousness inhealthcare professionals

Focus Group ParticipantInformation Sheet

We would like to invite you to take part in afocus group as part of our research study.Before you decide, we would like you tounderstand why the research is being doneand what it would involve for you.

Please read this sheet carefully. If you have anyquestions, there are contact details at the endof this sheet. Talk to others about the study ifyou wish.

What is the purpose of the study?

Many problems faced by health professionalsare identified with ‘professionalism’ rather thanclinical proficiency. This study is looking atwhat trainees and trainers in differentprofessions mean by ‘professionalism’, howperceptions of professionalism develop, andhow professionalism may be measured.

Why have I been invited?

All students in the first and final years of the xprogrammes at x University are being invited totake part in focus groups. Trainers are alsobeing invited to take part in separate focusgroups – we are interested in how the views oftrainees and trainers compare. Otherprofessions are also involved in the study.

Do I have to take part?

Participation is entirely voluntary. If you agreeto take part now, you can change your mind atany point.

What am I being asked to do?

You are being asked to take part in a focusgroup at x to discuss your views of whatprofessionalism is, and how unprofessionalbehaviour may be identified.

The focus group will involve 10-12 othertrainees and will take up to two hours. Beforethe group starts you will be asked if you arehappy for the discussion to be recorded andtranscribed, and to sign a consent formagreeing to the recording being made.

The recording will be confidentially transcribed,and will be erased following transcription.

What are the possible disadvantagesand risks of taking part?

It is possible that the discussion may addressissues of professionalism you areuncomfortable with. Remember you do nothave to say anything you may beuncomfortable with. If there are any issuesraised that you would like to speak tosomeone about, there are contact details atthe end of this form.

If anything is said which clearly identifiescriminal behaviour likely to be damaging topatient safety, it will not be possible to maintainconfidentiality. If you are aware of any suchbehaviour, you are encouraged to discuss itwith a tutor or supervisor. If you describe anysuch behaviour so that individuals cannot beidentified, confidentiality will be maintained.

What are the possible benefits oftaking part?

In finding out more about professionalism, thisresearch aims to improve the experience ofhealth professionals, and patients. It may helpensure that any assessment of professionalismis appropriate, and inform the developmentof training in professionalism. It may bethat through taking part you feel more ableto reflect on and explore yourown professionalism.

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Appendix C – Focus group information sheet

Will my taking part in this study be keptconfidential?

Yes. We will follow ethical and legal practiceand all information about you will be handled inconfidence.

The recording of the focus group will beanonymised during transcription, and thetranscript will not include your name. Alltranscripts will be stored securely on DurhamUniversity’s secure network, to which onlymembers of the Medical Education ResearchGroup will have access.

Quotes from the focus groups and interviewsmay be used in reports and papers, but willnot include any details which could identifyanyone personally.

What will happen if I don’t want to carryon with the study or am unable to?

Once the focus group is completed, you willnot be expected to have anything more to dowith the study. You may be separately invitedto complete a questionnaire.

If you decide you have said something youwould prefer not to be used as data, forexample quoted in results, let us know withintwo weeks of the focus group, and we willsend you the anonymised transcript for you toidentify the statements and remove them.

Who is organising and funding theresearch?

The research is being funded by the HealthProfessions Council, which regulates yourprofession. However, they will have no accessto data and will only receive summary reportsfrom the researchers, in which no individualswill be identifiable.

The research is being organised and managedby the Medical Education Research Group atDurham University (seehttp://www.durham.ac.uk/school.health).

Who has reviewed the study?

All research in the NHS is looked at by anindependent group of people, called aResearch Ethics Committee, to protect yourinterests. This study has been reviewed andgiven favourable opinion by Leeds (West)Research Ethics Committee. It has also beenreviewed within the Durham University Schoolof Medicine and Health. It has been registeredwith the x NHS Trust.

Further information and contact details

If you have any questions or concerns aboutany aspect of this study, please feel free tocontact the Principal Investigator who will try toanswer your questions:

Dr Jan IllingMedical Education Research GroupDurham UniversityBurdon HouseLeazes RoadDurhamDH1 1TA

email. [email protected]

If you would like to talk to someone not directlylinked with the study, you can contact theDurham University School of Medicine andHealth:

Professor James MasonSchool of Medicine and HealthWolfson Research InstituteDurham University Queen's CampusThornabyStockton on TeesTS17 6BH

If the project has raised any other concerns,you may contact x

The Health Professions Council may alsoprovide information about professionalism andprofessional regulation – their website iswww.hpc-uk.org

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Appendix D – Consent form

Consent form

Title of Project: Professionalism and conscientiousness in healthcare professionals

Name of Researchers conducting focus groups:

Please initial each box

Name of participant: .......................................................................................................................

Date: ...............................................................................................................................................

Signature: ........................................................................................................................................

Name of Person taking consent: .....................................................................................................

Date: ..............................................................................................................................................

Signature: .......................................................................................................................................

PLEASE SIGN ONE COPY OF THIS FORM AND RETURN IT TO A RESEARCHER.KEEP ONE COPY FOR YOURSELF.

1. I confirm that I have read and understand the informationsheet dated 27 September 2010 (version 5) for the abovestudy. I have had the opportunity to consider theinformation, ask questions and have had theseanswered satisfactorily.

2. I understand that my participation is voluntary and that Iam free to withdraw at any time without giving any reason.

3. I understand the focus group will be audio-recorded andconfidentially transcribed. I agree that anonymised quotesmay be used in reports and publications.

4. I understand that in the event of any informationregarding criminal activity which may be detrimental topatient safety being raised, the information may be passedto x University.

5. I understand that relevant data collected during the studymay be looked at by individuals from regulatory authoritiesor from the NHS Trust in order to monitor the quality of theresearch. I give permission for these individuals to haveaccess to my anonymised data.

6. I agree to take part in the above study.

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Appendix E – Codes and definitionsused in framework analysis

Professionalism in healthcare professionals48

Code Definition

Definition of professionalism

Adherence to codes /regulations / protocols

Any references which explicitly mention codes of conduct /regulations / protocols.

Appearance Anything referring to what they look like to patients / otherprofessionals; uniform, tidiness, personal hygiene, obesity,tattoos, hair.

Appropriate behaviour /attitudes / communication

Generic code for any descriptive level of professionalism –doesn’t need to be specific, but specific examples should alsobe coded under ‘behaviours’.

Context Contextual awareness and situational judgement. Anyreference to professionalism varying with physical context,including the people worked with (patients and colleagues).

Development over time Anything relating to how professionalism changes over time.Will include responses to Q4 around when people feel like /become a professional.

External perceptions Anything relating to how the profession / professionalism isseen by others – patients and other professions. Includeelements of social responsibility and role of profession in healthpromotion and education, anything relating to obligation to seta good example, practice what they preach.

Also public image as presented in media, and perceived imageamongst other professionals.

Good clinical care Explicit mentions of clinical workplace or clinical work –competence, safe practice, knowing limitations, criticalself-reflection.

Holistic construct Won’t / can’t break down ‘professionalism’ into specific areas.‘It’s a bit of everything’.

Other definition Anything else which is probably a definition, but which doesn’tclearly fit into any other codes. To avoid creation of ad hoccodes when we’re independently coding.

Part of self ‘It’s what you are’. Definitions which focus on quality of selfrather than behaviour. May overlap with holistic in analysis.Also personal qualities, beliefs.

Role boundaries Personal / professional boundary and not overstepping it.Related to situational awareness, knowing what the limits ofprofessionalism are and when those limits should / can beextended or drawn in. When does behaviour becomeappropriate / inappropriate.

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Appendix E – Codes and definitions used in framework analysis heading

Code Definition

Source of professionalism

Education / training References only to tertiary and professional education inthis code.

Learning on the job References to workplaces in this profession only.

Media Perceptions of profession as portrayed in media.

Organisational environment References to what the organisation context allows orencourages. Include pragmatism (eg ‘You can’t work like thatin the real world’); how the organisation treats the professionalgroup; constraints in practice; management andservice demands.

Other source As ‘Other definition’; anything which doesn’t fit, to avoid adhoc coding.

Personal background References to family, childhood, upbringing, primary andsecondary education. Cultural background. References toinnate / learned values and morals. Implicit and assumedvalues, unwritten rules.

Previous employment (paid /voluntary)

References to any employment before starting in thisprofession.

Regulations as source Codes, regulations, policy documents, standards.

Role models References to individual or groups who are explicitly describedas providing models (whether positive or negative). Caninclude peers – other students. Include references to normsetting within peer groups.

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Appendix E – Codes and definitions used in framework analysis heading

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Code Definition

Examples of Professional / Unprofessional / Ambiguous behaviour

Appearance References to specifics of appearance.

Clinical practice References to clinical skills in the workplace.

Communication Anything referring to verbal or non-verbal communication,language. Some references may be vaguer than others (eg‘politeness’), so judge whether definition or example. Includeinstances with patients and colleagues in clinical andeducational contexts.

Conscientiousness References to the sort of thing which may link toConscientiousness Index (but not as restrictive). Timeliness,assignments, diligence.

Other example Any specific behaviour which doesn’t clearly fit into above

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Appendix F – Raw data giving examplesof professional, unprofessional and‘ambiguous’ behaviours

These quotes give further illustration of howparticipants described professional andunprofessional behaviour, as well as exampleswhich were ambiguous or which illustrate thecontextual dependency of professionalism.They expand upon the boxes included in theresults section, and the headings reflect thecodes used in the initial analysis.

Demonstrating clinicalknowledge and competence

Professional behaviours

“I think sort of honesty and recognising yourown limitations as well so if you’re strugglingwith something it’s about going I’m finding canI get some help from someone rather than justburying your head in the sand”(FG13, occupational therapy placementeducator)

“Throughout the whole thing, just workingwhen you’re supposed to work and ask for thehelp when you need it and clarification if youneeded that, it’s very easy, you know, there’sthe other side of it, slack off on the other page,it’s very easy to do that and not do the learningthat you should be doing and blame everybodyelse when you fail”(FG5, paramedic classroom educator)

“Yeah documenting notes is definitely a skillthat you learn on placement that does makeyou part of being a professional OT” (FG19,occupational therapy student)

“I think that’s going to be the same standard,that’s going to be a professional standard youcan have the same standards of hygieneregardless of where you are just as an youknow it wouldn’t be any different betweenclinic and someone’s home would it...”(FG16, chiropody / podiatry student)

“I think it is important because if you are notauditing the right information or like drawingout the right information from assessments,that’s important to share, then wouldn’t bevery professional would it if you weren’t sharingthe right information”(FG19, occupational therapy student)

Unprofessional behaviours

“Poor standard of care, someone I knowworked with somebody who refused to give adrug because it was a rectal drug so that’spoor standard of care”(FG11, paramedic student)

“...I followed him [chiropodist / podiatrist] onvisits in and out of houses it was get in, getout, finish as early as I can, not checking if thepatient’s medication had changed or anythinglike that down to really poor infection controlwith instruments [...] the whole time I was therehe never changed his instruments, apart fromthe actual blade itself, he never changed hisblade handles he used the same scissors forevery patient...”(FG15, chiropody / podiatry student)

“Well a patient being dropped, not reportingthings that should have been reported, youknow, failing to disclose” (FG6, occupationaltherapy classroom educator)

“Not getting consent properly. Yeah, explaininglike the side effects of a drug, you know, littlethings like that” (FG11, paramedic student)

“Not being aware of risks perhaps, you know,in a kitchen with a client without realising theconsequences of leaving that client with asharp knife or with a boiling kettle and thembeing quite frail and those sorts of things,that’s just about naivety” (FG6, occupationaltherapy classroom educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“I used to do a clinic where I followed this girlwho was on the day before and the unit andthe material it was just absolutely filthy andgrubby, bits of all sorts in drawers...nothinggetting tidy, it was all her values, no valueset [...] So then you go in a bit early to tidyeverything up and clean it because you knewthat every time you went in the clinic it wasgoing to be a mess, the young ones had leftfrom the time before” (FG7, chiropody /podiatry classroom educator)

[when a neighbour or friend asks you fortreatment] “Again from that professional pointof view, you’d say no, come see me onMonday [...] even in your own homeenvironment you’ve still got to show that kindof professionalism where no sorry, there is aline that you can’t cross sort of thing but I’msure there is professionals out there who dothat” (FG15, chiropody / podiatry student)

“Leaving the doors open on the back of theambulance I hate that [...] it is a clinical errorisn’t it you’ve got to be shut away, anyone canwalk past [...] I don’t say it to them but I thinkthat’s really unprofessional because it’s, you’retreating a patient there’s certain things youmight have to do that might have to exposethem and it’s just not fair on them”(FG9, paramedic student)

“Yeah, there was one story that was told byone of our lecturers who actually witnessedunprofessionalism amongst one of her workcolleagues and it was somebody had beenbrought in drunk on an ambulance to A and Eand what the paramedic had done was she’dcovered the person and the girl wascompletely drunk and motionless so fromanyone looking, would think that that was adead body being brought in and that is a formof negligence and unprofessionalism and thatperson was reported as a result of that”(FG10, paramedic student)

Ambiguous behaviours

“Well like a couple of shifts ago we’d bothfinished me and my crew mate this was abouttwenty five to seven and we finished at 6.30and they gave us a job and we asked themanager, you know we’ve just finished andthey said, oh it’s just round the corner... Weended up being two and half hours later off butI think it’s kind of going out of your way to helppatients because technically we could havesaid no” (FG9, paramedic student)

“I don’t think you should be treatedunprofessional if you want to get off on timebecause it is a twelve hour shift andsometimes I don’t get a lot of breaks...”(FG9, paramedic student)

“You can be over meticulous and you can be,not over professional but over kind of thoroughand a lot of people like that they can spendtwo hours on a scene and I think there’s again,there’s got to be a point where you’ve got tosay we are actually just here to treat what weseen and take to hospital or leave at home butsome people do spend a lot of time onscenes...” (FG9, paramedic student)

Keeping up-to-date

Professional behaviour

“... if you see someone actually reading currentresearch and saying to you, did you know thatthey are thinking about introducing narcanintra-nasally or something and you’d be like,oh that’s very professional, they’re keeping upto with current evidence, that’s a reallyimportant part of it” (FG11, paramedic student)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“I did a couple of shifts where I spent a coupleof weeks with an emergency care practitioner,he was always reading bits of research andthings like that and then my practiceplacement educator, if there is something he’snot quite sure on, you know, he’ll go back tothe station, look it up and print it off and thenread it and seeing people do that, you know,they want their knowledge to be as high aspossible to make their patient care as currentas possible and relevant and seeing that isreally good” (FG11, paramedic student)

“I think if they are keeping on top of theirsubject, you know, their clinical sort ofexcellence and they’ve read a paper andthey’re bang up to date and they know thatabsolutely new sort of thinking of things... theyare bang up to date and you think wow, he’son top form, he knows what he is talkingabout, you know he’s keeping up to date andthat’s what I would say as being professional”(FG2, paramedic student)

“Some of them, who make it their businessand do access stuff and do look at journalsand do keep up to date”(FG18, paramedic classroom educator)

Attitudes and behaviours

Professional behaviours

“...I think where you say, you know, if you sayyou are going to do something, then you do it,you don’t just not do it”(FG19, occupational therapy student)

“...putting in the extra work when you are notgetting paid for it, just from my experiencefrom my parents, the way they act is quiteprofessional because they are always puttingin extra work...” (FG10, paramedic student)

“Yeah, it’s also from a student perspective,although there’s so much studying that wehave to do and there’s lots of reading itsremembering to have a break yourself... butagain it kind of links into it even though as aparamedic, a professional, you’re looking at itdifferently but yeah, it’s how you manage yourtime” (FG12, paramedic student)

“I was thinking you know sometimes like ourstudents, some students will kind of wait at theclinic door, they are told they can’t go into aclinic unless a member of staff is present sothey will have the uniform on, get themselvesready and they wait at the clinic door to kind ofgo in... and others are always late but the onesthat are late are always late” (FG7, chiropody /podiatry classroom educator)

Unprofessional behaviours

“...you find some people will just cruise alongand not do a lot within the station whichdoesn’t help the environment within thestation” (FG1, paramedic student)

“If people are turning up late for work what arethey going to be like going on a home visit orseeing someone in their home that it’s notconveying a good image to other people goingto meetings and case conferences, it needs tobe on time” (FG13, occupational therapyplacement educator)

“Coming in late, you know habitually beinglate, not just the one occasion where it’s beendifficult [...] and it’s the taking responsibility forthat lateness so it’s ok somebody being late,really sorry I’m late, well you don’t even getsorry you were late, ‘I’m late’, ‘why were youlate?’, ‘Oh it was because of somebody else’,it’s that sort of thing, it’s everybody else’s fault,it’s never me” (FG6, occupational therapyclassroom educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“Sitting yawning or not taking interest, notasking questions or reading up on things, notbeing prepared, not showing any enthusiasm,those sorts of things come through regularlyand sometimes that’s because a student hasgone thinking that they are going to beeducated and not that they need to participatein their education by doing so...”(FG6, occupational therapy classroomeducator)

“Talking in class when, and quite clearly it’sinappropriate to be talking about whatever it isthey are talking about you know, whispery,jokey, messing around, not talking about whatwe are supposed to be talking about, youknow, not showing the insight that they’rethere for a reason, that’s one thing”(FG6, occupational therapy classroomeducator)

“County basics like time keeping and one ofthe huge things that we have at the moment islike with mobile phones and things, isn’t it,you know, using them at inappropriatetimes” (FG13, occupational therapyplacement educator)

“You get a lot of them who will sit there and belike another job and you just think well yes,that you are at work or you walk in and thinkoh they’ve said the vehicle is ok so I’m notgoing to check it, you know, just in case, youknow, straight when you think they can’t bebothered” (FG3, paramedic student)

Ambiguous behaviours

“We’ve all got different ideas about what’sacceptable where mobile phones areconcerned... I like to be at work and focus atwork and so for me I prefer to have textmessages to look at when I come home if Iknow something’s happening then atlunchtime but I realise that people havedifferent situations, ill children might need toget hold of them or someone’s ill and that’sdifferent” (FG13, occupational therapyplacement educator)

“...I think you can feel that you haven’t beenprofessional because you haven’t had the timeto be professional so you know you shouldhave seen, I don’t know, ten people in the lastweek but you’ve only seen four of thembecause you’ve had to do other things as welland you feel unprofessional and you know thatthat’s what you should be doing but youhaven’t got the time to do it, it’s not like you’vepurposely gone out of your way to beunprofessional but you just can’t” (FG13,occupational therapy placement educator)

Overall communication

Professional behaviours

“Communication, that’s one of my key things,behaviour and communication in whatdifferentiates a professional and somebodywho is behaving unprofessional and I think thatgoes through everything they do, not just theirwork, it’s their communication”(FG18, paramedic classroom educator)

Unprofessional behaviours

“...You know having a student who was unableto communicate effectively with a patient andwas quite patronising and derogatory in hermanner towards the client...” (FG14,occupational therapy placement educator)

“Their attitude generally, you know, you canpick on, if you are a caring person, whichobviously we are because we’re in thisprofession, you know straight away whensomebody is talking harshly to an elderly ladyor gentleman, they may have learningdifficulties, they may have dementia, things likethat, it still doesn’t give them the right to talkdown to them and things like that andgenerally if you are with an attendant orcolleague, you pick up on it straight awayand it’s a case of pulling them to one sideand having a word, you know” (FG1,paramedic student)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“...two students I’ve had issues with it’s beencommunication and that lack of being able tocommunicate with patients or have any ideaabout what’s going on around them. I had onestudent that just used to sit in groups and afterthe group would discuss how the group hadbeen and she just couldn’t tell me anythingabout how the patients have been. I tried tosee whether it was me that was intimidatingher, trying to get her to work with assistantsbut she was just [not engaged]”(FG14, occupational therapy placementeducator)

“Flirting with patients, it does happen, becausethey’re in your trust and it would be like if youhave an inappropriate relationship with apatient, obviously it’s a massive breach of thattrust” (FG17, chiropody / podiatry student)

“I mean sometimes it’s just an MDT meetingbecause we have big personal meetings butthe patients aren’t there... because thepatients aren’t there I think sometimes theprofessionals forget and sometimes it’sterminology, how they described patients andthey think it’s safe because it’s a team that theyknow quite well but then they forget that theymight have students in and new people whohave come in, you know and sometimes aftera meeting we have to say, oh that’s just howthey are when actually they shouldn’t besaying it in the first place... you know it’s asentence about a patient which is quitederogatory like about their size or somethingwhich isn’t really relevant to anything and thatcan be a quite public meeting sometimes aswell”(FG8, occupational therapy placement educator)

Ambiguous behaviours

“...regarding speaking to patients and thingslike that, someone’s standards might beslightly different to your standards so as youmentioned, there’s a grey area then so thatmay fall from your eyes as being slightlyunprofessional, in their eyes, they’re not”(FG2, paramedic student)

“...you’ve got to be careful about imposingyour standards upon other people, you can’tlive in a place like this, it’s scruffy, it’s dirty, it’sthis, if they’re happy and that’s their choicethen making them feel comfortable withthat... somebody who actually says no I’mgoing to put a call in to a social workerbecause this place is substandard for living, isthat then being unprofessional even thoughthey are doing it in their patients’ bestinterest?, it could be argued that it is and,equally the same, if that person walked outand said no, they’re happy with it, it’s theirchoice they’ve got capacity to make thatchoice and you walk away, somebody elsemight come in and think you’re actually beingunprofessional by actually not taking anyfurther action with it so it is subjective”(FG2, paramedic student)

Communication

Professional behaviours

“Yeah, being clear and concise with telling thepatient clearly what you like think their need tolike would be their weakness and asking themdo they agree with it and then coming to likean agreement and negotiating goals and stuffand being clear about them”(FG19, occupational therapy student)

“I think it’s learning to speak, personally I thinkit’s learning to speak to them at their level, Imean if you go into little auntie Mary, it’s nogood spouting off all clinical terms andconditions, if she’s got a bad chest, tell hershe’s got a bad chest, you know, not that shecould have possible pneumonia or something,speak to them in a language that they canunderstand” (FG3, paramedic student)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“…listening to them as well because if you’renot like paying attention you might misssomething that they are saying, it could besomething really important about like someonehas had a fall in the morning and maybe it’snot a good idea to do that walking sessionwith them today because they are a bit shookup so it’s like listening and like being constantlyaware of what’s going on like around youbecause obviously things change on a minuteto minute basis sometimes”(FG19, occupational therapy student)

“…you have to write your notes so that anyonecan understand them but even the patientbecause the patient is allowed access to thenotes…” (FG19, occupational therapy student)

“It’s your body language as well, like the wayyou come across and be interested in theperson and not like looking off over the otherside of the room, you know, it’s making sureyou are paying attention to the patient with allthe communication, not just what you say,but obviously what you say is also importantbecause obviously there’s the basic stuff likenot swearing and things like that that couldoffend people” (FG19, occupationaltherapy student)

Unprofessional behaviours

“Not giving people time, some people justneed time to explain and just, if I want to beshowing respect... if I’ve had an interactionand I’ve just thrown a lot of information at themI just want to take a step back and say right sohow’s that been for you or have you got anyquestions on that and just give people achance to take control again and say rightactually this is what I want because it’s so easyfor us as professionals to think right this iswhat we need to do rather than thinking aboutwhat do they want from us”(FG13, occupational therapy placementeducator)

“...You know having a student who was unableto communicate effectively with a patient andwas quite patronising and derogatory in hermanner towards the client...”(FG14, occupational therapy placementeducator)

“I’ll tell you one of the things I think, you see,I might sound really old fashioned now which isgoing to be quite funny but I don’t even know ifit happens any more but when I was a student,our first contact with our educator was we hadto write a letter, we had to write them aletter… to our educator saying this is who Iam… and you know there’s nothing worsethan receiving an unprofessional letter fromsomebody written on a scrap of paper thatthey’ve pulled out of a notebook somewhere,you know, that’s really, you know, that’s reallyunprofessional” (FG13, occupational therapyplacement educator)

“it [written communication] needs to be politeand respectful and appropriate in any situation,to me, when I get the students that email me,all in small letters and it’s got like kisses at theend and things like that, to me that’s reallyunprofessional [...] I always give them a talk atthe beginning of every year that I don’t wantthem to do that because if they have to bedisciplined or anything, that’s me that’s goingto have to do that and I don’t want them to putkisses on their emails and it’s not appropriateand they still do it and so the ones that don’ttake that on and still behave in, you know, thatcommunication really makes a difference to meto whether I view them as being professionalor not...” (FG18, paramedicclassroom educator)

“I was on a placement when a new studentfaxed in something and they’d done it in textspeak, see you later, and that to me didn’tcome across as professional, somebody givinga bad impression before you even saw them”(FG13, occupational therapyplacement educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“I started getting them [letters of introduction]all by email rather than through the post andnow and some of them became so informalthey were, it was almost like ‘Hi [first name]and oh I’m coming on placement and can youtell me a bit about it [...] I’m sorry but I’m of anage where I don’t like to be called by my firstname by somebody that I’ve never met. Iwouldn’t call a consultant or a senior managerin this hospital by their first name if I didn’talready know them...” (FG8, occupationaltherapy placement educator)

Ambiguous behaviours

“it’s a difficult one because you want toobviously have a lot of information and youread up about conditions etc and at the end ofthe day it’s about seeing the person and usingyour, utilising your knowledge, you know, avery individual way by getting to know aperson for being a person and it’s quite hardsometimes to get that right and you thinkabout, oh I know I might come across as quitepatronising or using the right terminology andhow you use everything you non-verbalcommunication and your verbalcommunication as well” (FG13, occupationaltherapy placement educator)

“...should we write [in a report for example]... they [patients] use expletives or inappropriatelanguage in the situation or should you just bereally quite clear cut about the language that’sused and it all comes back down to risk andhow specific you should be about thesituations and let other professionals knowwhat’s going on” (FG13 occupational therapyplacement educator)

Respect for patients andcolleagues

Professional behaviours

“…he’d never come back and talk aboutpatients or anything, I don’t think that’sbecause he was quiet, I think that’sbecause he was professional”(FG11, paramedic students)

“Obviously not sort of talking about the peopleso that the people can hear and making suredoors are shut and just simple things like that”(FG13, occupational therapy placementeducator)

“A. I think the biggest thing really is when youactually see somebody show respect for thepatient because that kind of stands out…

“B. Yeah, has the time of day for them, nottrying to rush them in, rush them out, next onekind of thing.

“A. And it’s not just around the actual clinicalcare, it’s just respecting them as a person, kindof sits very head and shoulders above otherthings” (FG17, chiropody / podiatry students)

“I think it’s just the way they interacted with theclients, the rapport they had but how they hadthe respect of the team and how theyintegrated in the team and just the passion forthe job and enthusiasm really and just, youknow, you could tell they loved doing whatthey did really” (FG13, occupational therapyplacement educator)

“I was kind of thinking of relating to colleaguesin meetings and things I think you know givingeveryone a chance to speak and valuingeveryone’s opinion because I think in ourteam… they do value everyone’s opinion but Iknow I’ve been in situations before where itwas the OT who we listened to what they’vegot to say, oh it’s just the physio and you knowthat’s not important kind of thing, so you knowrespecting everyone’s opinion” (FG13,occupational therapy placement educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“Well you know my team leader, he alwaysasks your opinion of everything and he alwaysappreciates anything you do for him, anything.He always thanks you for it and he alwaysvalues your opinion and if he thinks your idea isbetter than his he’ll use your idea”(FG4, paramedic student)

Treating people equally

Professional behaviours

“...you’ve got to treat everyone equally, I meansay even if you go to someone who has justmurdered someone else, you’ve still just got totreat them just as a person and don’t worryabout any of the other things in their life”(FG10, paramedic student)

Unprofessional behaviours

“I mean I’ve had, when I’ve been driving I’vehad my crew mate that has just had enough ofthe patient in the back has come and sat in thefront with me on route to hospital... like if apatient stinks or something they’ll just comeand sit in the front” (FG9, paramedic student)

“I get so embarrassed when I’m driving andyou’ve got the attender and they’re notspeaking and you’ve got to, I don’t understandif people don’t speak to patients, how do youfind out anything if you don’t speak to them,it’s literally that is all we’re doing”(FG9, paramedic student)

Ambiguous behaviours

“But it is quite hard when you’ve done a jobwhere you’ve had a real abusive, you know,maybe kicked out and then you go to yournext job and it’s the same and you go and youget the same again, it doesn’t happen all thetime but it does happen where you’ve beenSaturday night, Friday night, whatever, you’vehad a load of abuse and then you go to thenext one and because you’ve had it 20minutes, you go in with a professional [attitude]but then everybody does it, you do get a bitagitated” (FG3, paramedic student)

Appearance

Professional behaviours

“And its jewellery as well, we were talkingabout wearing jewellery like crosses and stuff,fair enough if that’s your faith but if you aremeeting other clients, you’ve got to push yourown judgements and morals aside and bemore aware that that might offend someone ofa different culture” (FG19, occupationaltherapy student)

“I tend to keep very plain what I do wear, justplain colours if I’m dressing in my own clothesand I don’t wear jewellery”(FG19, occupational therapy student)

“...being appropriately dressed, you can’tnecessarily say smartly dressed because it’snot really appropriate to go to a sports sessionin your best finery or your heels or whatever,but yeah, you dress appropriate to what youare doing and where you are working”(FG19, occupational therapy student)

Unprofessional behaviours

“Dressing appropriate to context, you know, ifwe are going to be doing certain activities in aclassroom situation, moving and handling,things like that and people are, you know...wearing heels and false nails... low tops” (FG6occupational therapy classroom educator)

“...you know when they [students] haveslipped or they think they can get away withthat bracelet in clinic or with hair coming roundover the shoulder or any one of us would sayno that’s not professional go and sort it out”(FG7, chiropody / podiatry classroomeducator)

“There’s lots of rude things etc on those typesof t-shirts and tops. Then I wouldn’t think thatwould be a professional thing to do eventhough it’s outside of your nine to five, Mondayto Friday life” (FG6, occupational therapyclassroom educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“...they’ve [students] got the knowledge but it’swhen they do turn up in their jeans and their,you know, love bites on their necks which wejust had fairly recently that you just think whydo I have to start and explain to somebodywhy a love bite is not appropriate”(FG8, occupational therapy placement educator)

“If you walk in there [to a patient’s house] andyou’re unshaven and your shirt’s hanging [out],your shirt looks like you’ve slept in it for aweek... hands in pockets”(FG5, paramedic classroom educator)

Ambiguous behaviours

“I suppose it’s the same about make-up, youknow, should you have a little bit of make-upon but, you know, sort of being really heavilyoverdone and the kind of messages that gives”(FG13, occupational therapyplacement educator)

Uniform

Professional behaviours

“I think like the old school ones seem to more,like better with the uniform… they always havethe boots polished” (FG3, paramedic student)

“...I wouldn’t dream of now going into the NHSand turning up in a pair of jeans and a t-shirtand treat somebody, it’s just not somethingyou would think of, even if I was stuck out inthe wilds in the middle of nowhere, I would stillturn up in a uniform because I would wantpeople to see me as a professional”(FG15, chiropody / podiatry student)

“...uniform has to be clean, pressed, youknow, hair tied back, no big chunky jewellery”(FG15, chiropody / podiatry student)

Unprofessional behaviours

“I’ll give you an example, you know, we havethis uniform now which we’ve had for two orthree years, [there are] people on the road withthe uniform they [have] had [for] five years,totally different... so I blame the managementfor letting that person wear the uniform, that’san old uniform, they should be wearing this”(FG3, paramedic student)

“...you get people switching them [epaulettes].I mean there is a person in management at astation who will wear the wrong epaulettes andthey’re a manager, someone you looktoward... she’s like not doing her job by notwearing her epaulettes because you can’t goto her as such because you think she is thesame level as me, there’s no point talking toher... I think that’s wrong”(FG9, paramedic student)

Ambiguous behaviours

“When you’re in your own time, it’s your owntime, you know, you’re a different person then,you should set like when you go out to work,you should be, you know the professionalparamedic that you are and that’s expected ofyou but when you’re not, you know, back intoyour what you feel [your private time] I don’tthink you should go around in your uniformcommitting crime, that’s not what I’m onabout” (FG10, paramedic student)

“If I was the type of person who didn’t shaveand wore my shirt hanging out and slouchedaround all the time, I would have a differentview, I would think that somebody who comesin with their polo shirt pressed and his trouserspressed and his shoes polished I would think abit square, you know, but that’s, you know,whereas he might think that I wasunprofessional so it’s very much whereyou start from really”(FG5, paramedic classroom educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

Public health

Unprofessional behaviours

“Well I think grossly overweight don’t you.Paramedics especially. I think that’s extremelyunprofessional because we are kind ofpromoting, well I think as self careprofessionals we are promoting healthy lifestyleand we turn up and they’re horrendouslyobese, you now, and the patient is just goingto look at you and just go oh what on earth isthat” (FG9, paramedic student)

“Well there’s people I work with and you knowyou do get terrible jobs like what we would callone under where someone’s trappedunderneath a train and you do physically haveto get under the train to treat them to find outwhat their problems are, to see if they’reconscious or to see if they’ve diedalready... they [overweight colleagues] wouldn’tphysically fit down there who then you’recompromising the patient’s health in a way”(FG9, paramedic student)

Communication in context

Ambiguous behaviours

“what I sort of struggled with is who makesthat judgement because what’s inappropriatefor one person is not inappropriate to anotherand an example of that, I’ve been to a patient’shouse where someone has said to us I don’tlike being called that… I don’t like beingcalled darling and stuff like that so is thatinappropriate behaviour or might someone,you know not mind being called that and intheir age group they might think that is totallyappropriate or in someone else’s age group it’sthe patient that makes that decision for you”(FG2, paramedic student)

“[A] level 2 student introduced the patient tome by the patient’s first name, you know. NowI imagine it probably wasn’t, well I don’t know,but l but it may not have been the patientsaying to the student call me Jane or youknow, or call me Willie. It may have been thestudent saying to the patient do you mind if Icall you Jane or Willie, you know and Ipersonally don’t think that’s appropriate. If apatient says to the student, please call meJane or Willie then that’s fine but I don’t thinkits right for the student to say to the patient doyou mind if I call you such and such. But that’swhat happens nowadays” (FG7, chiropody /podiatry classroom educator)

When you go to the GP’s surgery, you know,and you maybe see the practice nurse, youknow, very often they’ll call you by your firstname even though they haven’t asked. Now Iknow they probably see it as trying to befriendly and, you know, but it’s what youconsider professional isn’t it whether youconsider it acceptable or not” (FG7, chiropody/ podiatry classroom educator)

“Sometimes you go into some patient’s houseand you call them by their second namebecause you know if you call them by their firstname you’re being too familiar and it’sunprofessional. You learn that very quickly”(FG4, paramedic student)

“But like with unprofessionalism, you know, likewe said about joking, that is a, I’ve spoken toloads of paramedics and that is their way ofcoping, like making a really bad situation betterbecause they are probably, I don’t know, thenext day they are going to have to see thesame thing again and if they didn’t joke aboutit, then it’s just going to drag them down butthen there is times where you say it as well andwho you say it to, like to work colleagues, it’snot as bad because they are probably goingthrough the same emotion but to the family orto the patient, I think it can be quiteunprofessional” (FG10, paramedic student)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“You drop your patient off at hospital, deliveryour patient after a really bad complicated jobor harrowing job and you come out and youcrack on with the guys and chat about it evenmake jokes about it” (FG5, paramedicclassroom educator)

“We have a very black sense of humour. Youhave to though because if you didn’t you’dend up killing yourself... an outsider looking inwould think my God you’re joking. They reallywould... it’s a defence mechanism, it’s acoping strategy... if the public saw that theywould say that would be very unprofessional”(FG4, paramedic student)

“...the occasional joke within the educationsetting is fine but you couldn’t continually dothat because you would be undermining yourprofessional appearance whereas in othersituations you could be more relaxed perhaps”(FG6, occupational therapy classroomeducator)

“It is difficult for us and it’s difficult for studentsbecause it can get confusing because we’vegot again a young client who works on blackhumour and you know jokes and some of thatand it’s hard for, because sometimes you dojoke with people and if you step back from andlisten to it it’s not PC but it’s how they’redealing with their injury...” (FG8, occupationaltherapy placement educator)

Boundaries

Professional behaviours

“…I mean you have different relationships withclients to one you have with a family memberof a friend, it’s you know making sure you’renot disclosing too much, I behave differentwith my friends than I do when I’m in work soit’s setting that boundary and saying well thisis, you know, this is appropriate, this isn’t,clients don’t need to know how old mychildren are or whether they go to school, youknow, what my dog’s called” (FG8,occupational therapy placement educator)

“As a person I’m quite sort of, you know, I’mhappy to give a lot of information, you know,maybe I shouldn’t say that, you know, but I’msort of reigning in what I say and think it shouldbecome more, I think because I initially thinknobody is going to do anything bad with it,with information that they might have, but youdon’t know that so you have to protectyourself and your family, that sounds reallysinister but you know…”(FG19, occupational therapy student)

Ambiguous behaviours

“the people I was working with were seekingout communication in different ways shall I sayand just trying to find those ways to build up atherapeutic relationship with someone and youwanted to get to know people sometimes youhave to just try and see things from their pointof view and then that kind of questions youknow am I, you know, am I overstepping themark here, particularly how I use like my senseof humour” (FG13, occupational therapyplacement educator)

“I think I’ve put that about not being a friend tosomebody and that’s a difficult boundary andit’s difficult for students to learn the differencebecause you’re being friendly with somebodyand you’ve had a conversation but you’re nottheir friend as in that different level of kind ofinformation” (FG8, occupational therapyplacement educator)

“...because we work with a younger clientgroup as well and we get to know them forquite a long period of time, but I think alsoyears ago when you didn’t have mobilephones and you didn’t have email and theinternet and Facebook. I think there is theboundaries again you didn’t give out ourtelephone number to anybody, you didn’t giveout your home address but I think becausepeople see Facebook as not being yourpersonal details, but people see it as adetachment from their own... sometimes our

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

patients will give their Facebook information tostudents who then find it difficult to say I can’ttake this” (FG8, occupational therapyplacement educator)

Accepting gifts

Ambiguous behaviours

“There are rules governing things like patientsgiving you gifts but how, you know, how youdeal with that, it’s like you’re not allowed toaccept gifts from patients or you’re not allowedto do something which may be seen asleading to you treating somebody favourablythan somebody else” (FG19, occupationaltherapy student)

“Yeah because it depends on the setting, likesome you can do it where you accept it as ateam gift, a gift to the team so then it’s notsingling out anybody individually but it dependswhat it is as well to what the gift is and whatrules are in different places” (FG19,occupational therapy student)

“I think it is one thing, you know, sort of afamily giving the ward a box of chocolates orflowers whatever to say thank you and a cardbut if you are working in another setting wherepeople might be considered quite vulnerable,for them to come along and give a gift, if theygive you money or anything that you can see isputting them at a loss, it’s not a case of beingable to accept it for the team, you have, youknow, as much as they want to give it to you,they’re putting themselves in detriment to do it,you can’t accept it, you know, you just have tosay that” (FG19, occupational therapy student)

“...when it’s appropriate just if somebody offersyou, you know, a bag of boiled sweets to, ohthank you very much I’ll have one of those towhere they’re actually giving you quite apersonal gift and it’s not just like a box ofsweets for the whole team when the person isdischarged from your service. It’s how to dealwith that” (FG8, occupational therapyplacement educator)

“...there isn’t a notice up, there isn’t a clearsign in a department to say please don’t givethese things and I think when patients comeand they’ve thought about something they’vewanted to buy you then you feel it’s a personalinsult to them if you say no and it’s a reallyawkward situation and again it’s not alwaysclear in departments anyway to say you can oryou can’t isn’t it” (FG8, occupational therapyplacement educator)

“We don’t know how many take money frompatients and don’t tell. Not that we have aproblem with that if a patient was to give a, if apatient wants to give a student a tip, they can.We don’t have any rule to stop it... it’s usually acouple of quid and a hairy humbug” (FG7,chiropody / podiatry classroom educator)

Maintaining professionalism

Ambiguous behaviours

“But it is quite hard when you’ve done a jobwhere you’ve had a real abusive, you know,maybe kicked out and then you go to yournext job and it’s the same and you go and youget the same again, it doesn’t happen all thetime but it does happen where you’ve beenSaturday night, Friday night, whatever, you’vehad a load of abuse and then you go to thenext one and because you’ve had it 20minutes, you go in with a professional [attitude]but then everybody does it, you do get a bitagitated” (FG3, paramedic student)

“We’re only human, you can’t be like happyand joking 24 hours a day, I mean you’re goingto have bad days, we’re all human, we’ve allgot things going on in our lives and there’sgoing to be times when you are with a patientand you are not going to be as professional asyou would be if you were having a good daykind of thing, like you might rush a treatment oryou might be ignoring them a little bit, notbeing as engaged in conversation with them,things like that” (FG14, occupational therapyplacement educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“Twelve hours on the road and then tenminutes before you’re due to finish your mate’snot in to take you off and you get a late job. Ithink we’ve all been on a job where you cansay someone’s took a shortcut”(FG4, paramedic student)

“It’s just human nature that though isn’t it.Because we’re human after all like aren’t wewhen it comes down to it. It doesn’t matterhow professional you are we’re humans.”(FG4, paramedic student)

“We have to hand over that responsibility toeducators in practice and in the past theyhaven’t always been clear as to whether toexpect the student to follow what’s expectedin the workplace or allow them to be a studentwith quite sloppy habits and we had to speakto some people, you know, they were sayingthings like, well, you know, I’ve passed so andso but I wouldn’t employ them and we’rehaving to say well actually you’re the gatekeeper to the profession and there’s anexpectation, why are you passing that person,we would like you to fail them if you are sayingthey are unprofessional” (FG6, occupationaltherapy classroom educator)

Outside work

Ambiguous behaviours

“If you bump into one of your patients... I thinkthat might be different if you bump into apatient, you’d have to say ‘Oh hello’ and youwould have to try and look sober and but apartfrom that, you don’t think about your job whenyou are out and about do you”(FG15, chiropody / podiatry student)

“I think patients need to understand as wellthat we’re not podiatrists 24/7, we do haveother lives, I mean any professional, no matterwhat you are doing, you’re not 24/7,you’ve got a life” (FG15, chiropody /podiatry student)

“Well, physically assaulting people or thingslike that… I know that you are still bound bythings from the HPC whilst you’re not at workbut it’s I think that one’s a little bit even more ofa dilemma because somebody could complainabout you and really just have an attitudeabout you or an opinion about you and I dothink staff need to be aware of that but wheredoes it stop? If you went out to the local puband you were walking home and you couldn’twalk in a straight line, is that unprofessional oris that just you being out socialising, you know,I just think there’s a bit of wave running greyline here now of where the line is drawn butyeah, I think the exceptional rules... if you havebeen assaulting somebody and have beenaccused and done for any sort of custodialsentence, yes, we wouldn’t want those peoplebeing paramedics” (FG5, paramedicclassroom educator)

“I can understand that on social networkingsites where you’ve got you in your uniform andthen in the next photo it’s you drunk or in afight or something, that’s when I think thatdoesn’t look good but if it’s just you, obviouslynot a picture of you in your uniform, I don’t seewhy that’s, I mean like I have a [relative] in theforces and on [their] social networking site,[they’ve] got [them] in uniform and when[they’ve] gone out and yet they’re veryaccepting of that but we’re not”(FG10, paramedic student)

“When I was at university Facebook was sortof flagged up as a big no no when we were onplacements, we were told we weren’t allowedto even mention we’re on placement... therehad been some incidents in the past wherepeople had sort of mentioned educators orsaid or complained about what a horrible timethey were having and it just obviously themessage that gives for the people it comesacross as very unprofessional...” (FG13,occupational therapy placement educator)

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Appendix F – Raw data giving examples of professional, unprofessional and‘ambiguous’ behaviours

“It’s a minefield [social networking sites], it’sthere, use it at your own discretion and it’sentirely up to you and be it on your head if youdo something that you will later regret” (FG14,occupational therapy placement educator)

“I think it must be hard for them to flip thatswitch between I’m at Uni and I’m still astudent OT but I’m not at Uni, I’m kind of inthe work place and yeah my behaviour’s got tobe different but how much different...” (FG8,occupational therapy placement educator)

“We have to hand over that responsibility toeducators in practice and in the past theyhaven’t always been clear as to whether toexpect the student to follow what’s expectedin the workplace or allow them to be a studentwith quite sloppy habits and we had to speakto some people, you know, they were sayingthings like, well, you know, I’ve passed so andso but I wouldn’t employ them and we’rehaving to say well actually you’re the gatekeeper to the profession and there’s anexpectation, why are you passing that person,we would like you to fail them if you are sayingthey are unprofessional” (FG6, occupationaltherapy classroom educator)

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