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Developing professionalism inphysiotherapy and dietetics students inprofessional entry coursesSandra Grace a & Franziska Trede ba School of Health and Human Sciences , Southern CrossUniversity , PO Box 157, Lismore , NSW , 2480 , Australiab The Education for Practice Institute, Charles Sturt University ,Locked Bag 450, Silverwater , NSW , 2128 , AustraliaPublished online: 04 Oct 2011.

To cite this article: Sandra Grace & Franziska Trede (2013) Developing professionalism inphysiotherapy and dietetics students in professional entry courses, Studies in Higher Education,38:6, 793-806, DOI: 10.1080/03075079.2011.603410

To link to this article: http://dx.doi.org/10.1080/03075079.2011.603410

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Developing professionalism in physiotherapy and dieteticsstudents in professional entry courses

Sandra Gracea∗ and Franziska Tredeb

aSchool of Health and Human Sciences, Southern Cross University, PO Box 157, Lismore,NSW 2480, Australia; bThe Education for Practice Institute, Charles Sturt University,Locked Bag 450, Silverwater, NSW 2128, Australia

In a context of education focused on skill mastery and graduate-level competence inpreparation for professional practice, the notion of professionalism could be reducedto measurable and rules-based concepts, and the values, ethical decision making andprofessional autonomy that underpin it could be overlooked. Using a blend ofhermeneutic phenomenology and discourse analysis, this article explores howprofessionalism is understood, talked about and experienced by lecturers andstudents in physiotherapy and dietetics courses at an Australian university. Thefindings of the study highlight the complex and evolving nature of professionalism.Understandings of professionalism appeared to be influenced by opportunities tothink about and discuss values that inform them. Moreover, issues like culturalcompetence and environmental sustainability were not part of participants’understandings of professionalism, suggesting a need to rethink philosophicalapproaches and pedagogical strategies to develop a notion of professionalism thatadequately prepares students for the demands of contemporary professional practice.

Keywords: professionalism; professional values; professional identity; healtheducation; physiotherapy

Introduction

Professionalism in health care is a complex and evolving concept. Professionalism hasexpanded from narrow constructs of professional competence based on specialistknowledge and skills, and a code of ethical and professional conduct, to include astrong focus on professional autonomy, reflective practice, communication, pro-fessional relationships, commitment to continuing professional development, andaccountability to society and the profession (Eraut 1994; Mahony 2003). Professionalbehaviours described as part of competency frameworks have been promoted in theUnited States in particular. For instance, the Accreditation Council of GraduateMedical Education (2011) defines professionalism competency as behaviours ‘demon-strating a commitment to carrying out professional responsibilities and an adherence toethical principles’. Other examples include Brehm et al. (2006, 1), who highlight theimportance of building ‘appropriate relationships with clients and colleagues’, andFornari’s (2004) model for professionalism that identifies honesty and integrity, respon-sibility and accountability, self-improvement, self-awareness and knowledge limits,collaboration, respect for others, compassion and empathy as professional behaviours.

# 2013 Society for Research into Higher Education

∗Corresponding author. Email: sandra.grace@scu.edu.au

Studies in Higher Education, 2013Vol. 38, No. 6, 793–806, http://dx.doi.org/10.1080/03075079.2011.603410

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This list of professional behaviours illustrates a focus on competence and perform-ance, without discussing underlying philosophical principles and dispositions. Within atechnically and rationally driven practice model the practice of honesty, integrity andcommitment to self-improvement, for example, can be interpreted operationally in anobjective, detached manner as manifestations of professional codes of conduct,whereas, within a practical and patient-empowered practice model, these very sameprofessional behaviours are understood to be products of personal qualities mediatinga focus on interpersonal relationships (Trede and Higgs, 2008). Without a declaration ofthe philosophical stance that underpins professional competencies they remain open tointerpretation.

Fish and de Cossart (2006) developed a practice model that links professionalism toprofessional values and professional identity as key forces that guide decision makingand professional judgement. They argued that the competence framework, togetherwith standards and performativity which make professional practice seem ‘masterable’,are ‘at the heart of the erosion of professionalism’ (403). Higgs, McAllister, and White-ford (2009) pointed to the importance of students and professionals developing thecapacity to make good judgements and decisions in uncertain and diverse situations.Health professionals, not just students, need to refer to frameworks of ethical principlesto inform their decisions and actions, to ensure the continued integrity of their pro-fessions and to maintain the trust of their communities (Kass 2001). Professionalismhas also been associated with taking responsibility for one’s actions. This meansmaking consistent professional judgements based on overarching professional values,rather than automatically applying predetermined rules of conduct in every casesimply as a matter of procedure. There can be an uneasy relationship, however,between accountability and responsibility. Accountability requires health professionalsto justify their actions against rules and regulations. Accountability can absolve prac-titioners from taking responsibility for their actions, whereas responsibility requiresthem to justify their actions, their professional reasoning and ethical framework(Schuck, Gordon, and Buchanan 2008).

The role of university education in developing a sense of professionalism and pro-fessional identity in students remains under-researched (Trede, Macklin, and Bridges2011). Universities are currently struggling with framing practice and the teachingand learning of it. The rising prominence of evidence-based practice, pressures ofaccountability, performativity and risk management have implications for how profes-sionalism is understood, taught and assessed. The teaching of professionalism mightderive more from externally prescribed and procedural concerns, rather than internallyconceived, personal and self-reflective ones (Schwandt 2005; Green 2009). A lack ofclarity and of conceptual underpinnings of what constitutes professionalism persistsas the landscape of professionalism continues to evolve. Teachers themselves needto address issues of agency and professional identity, and redefine professionalism as‘rooted in both intellectual enfranchisement and actual experience’ (Daly, Pachler,and Pickering 2003, 2905). A study by MacFarlane (2002) on ethical practice amonglecturers found that there is a marked difference between novice and experienced lec-turers. Novices adopted a more rule-bound and absolutist stance, whereas experiencedstaff took a more contextually-derived and responsible perspective on professionalism.MacFarlane concluded from his findings that ‘it is important that the ethical responsi-bilities and challenges of practice are more fully conceptualised and debated’ (178).Professionalism is complex and multifaceted, and evolves with ongoing learning.We believe values cannot be simply assimilated, but will mature with practice

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experiences accompanied by collective discussion and debate. Stark et al. (2006)suggest that self-reflective learning is a practical and necessary method of learningprofessionalism:

Some aspects of professionalism (e.g. communication skills, ethics and confidentiality)may be taught didactically. However, students need opportunities to participate in appro-priate activities from which they may analyze what they see and do, consider the impactthat those activities have on them and devise a learning plan to develop their own profes-sionalism. Reflection helps students to integrate theory and their understandings gainedfrom experience, whilst developing future practice. (25)

Given the highly contextual, relational and social nature of contemporary profes-sionalism, the key issues that need to be discussed in relation to its development in stu-dents are what is taught and learned, and how these processes occur. From thediscussion of professionalism it appears that it is learned not only in the classroombut in the world of work through active participation and reflection on experiences.Theoretical perspectives on education for professionalism can be found in constructi-vism, which advocates meaning making, learning through practice, reflecting on auth-entic workplace experiences, and active participation of students (Mezirow 1990;Brookfield 2005). The roles of experience, participation, lifelong learning, and selfand collective reflection on professional practice experiences appear to be core strat-egies in the process of becoming professional (Trede 2009). Brehm et al. (2006, 1)argue that ‘students must develop a wide range of characteristics, attitudes, and beha-viours as well as a lifelong commitment to professionalism’. When professional beha-viours are taught out of context their relevance to practice is questionable; they need tobe learned and challenged within practice contexts.

The specific aims of the project were to: (i) explore ways in which professionalismis talked about and experienced by lecturers and students in their first and final year ofstudy, (ii) identify and compare the ways professionalism is conceived and expressedamong participant groups, and (iii) contribute to concepts of education for practicethat enhance professionalism.

Methods

This qualitative study is informed by hermeneutic phenomenology (Van Manen 1997)and discourse analysis (Wodak and Meyer 2001). Hermeneutic phenomenology is aneffective methodology for revealing people’s experiences of professionalism in phy-siotherapy and dietetics courses. Phenomenological research examines the nature ofhuman phenomena and the experiences of those who live through them, taking intoaccount the contexts and subjective meanings participants give to particular situations.In hermeneutic phenomenology the emphasis is placed on interpretations of phenom-ena that offer deep layers of meaning.

Discourse analysis is concerned with the socio-cultural context within which formaland informal talk and written materials affect the understanding and practising of thephenomenon under study (Habermas 1987). This approach focuses on the relationshipbetween speaker (our participants), social context (the university, curriculum and indus-try partnerships) and the phenomenon (professionalism). Discourse analysis is based onthe assumption that the way people talk about a phenomenon influences and is influ-enced by social structures. The way professionalism is talked about influences theway professionalism is understood and experienced. Discourse analysis was a

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particularly fitting approach for this study in its exploration of the relationship betweenworldviews, how professionalism is talked about and dominant social contexts.

Design and data collection

We conducted focus groups of between 60 and 90 minutes with a total of 28 partici-pants (first-year students, final-year students and lecturers from physiotherapy and die-tetics). We interviewed 6 first-year physiotherapy students from a total population of118; 6 final-year physiotherapy students from a total population of 36; and two lecturersout of a possible three. We interviewed 3 out of 46 first-year dietetics students; 9 out of36 final-year students; and 2 out of 3.5 full-time lecturers. Participating lecturers wereteaching in clinical subjects or subjects that included lectures on professionalism.Student focus group sessions were advertised via electronic media and verbally bycourse coordinators during class time. Eight focus groups were conducted, each con-sisting of between two and six participants. There were 4 male and 20 femalestudent participants. Students’ ages ranged from 18 to 31 years. Eighteen studentswere enrolled in their first university course. Twenty students came from rural areas,three from metropolitan areas and one from overseas. Ethics approval was obtainedfrom the university’s ethics committee. Focus group discussions were taped and tran-scribed verbatim.

Data analysis

We were interested in the discourses and lived experiences of each focus group, and inanalysing shared meta-themes, differences and contradictions across the focus groups.We developed a multilayered data analysis method that blended discourse analysis withhermeneutic phenomenology, involving three stages: description, interpretation andcritique. In the first stage, each transcript was scrutinized for information that relatedto the research topic to generate descriptive codes (Guba and Lincoln 1981). Tran-scripts were entered into the NVIVO software program for coding. These codesemerged from the data and were not preconceived. There was no attempt to generalize,but rather the aim was to present participants’ interpretations. In the second stage, thenumber of codes was reduced by comparing them across the focus groups and cluster-ing them into themes, as described by Miles and Huberman (1994). In this stage wesearched for situated, organizational and pedagogical issues that influence perceptionsof professionalism. We looked for values underpinning understandings of profession-alism as manifested in the way people talked. For example, some participants talkedabout evidence-based medicine, best practice and using research for their practice inways that suggested a factual, technical and rational-objective understanding of profes-sionalism; others talked about context, individual situations and diversity of perspec-tives, suggesting social-interpretive understandings of professionalism. In the thirdstage, we compared and contrasted themes and searched for contradictions. We particu-larly compared what participants talked about (rhetoric) with examples they volun-teered from their experiences, and searched for a match or mismatch. Further, wesought to illuminate relationships between personal and professional discourses. Find-ings from the two disciplines were compared and ways to enhance development of pro-fessionalism discussed. The following analytical questions were posed to the text: whatdoes the data say about professionalism and contemporary practice? Are intervieweesaware of personal, cultural, gender and other aspects that influence their perceptions of

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professionalism? Is there evidence of self-criticality? What do the interviews say aboutengagement and support from universities?

Context

The setting for the study was a multi-campus inland university in Australia that isknown as the university for the professions. The majority of courses are professionalentry courses, and its learning and teaching approaches have a strong focus on prac-tice-based education. Physiotherapy and dietetics disciplines were chosen for theirsimilarity: both were four-year professional entry courses for allied health practitioners,and both offered clinical placements for students with industry partners. Choosing twosimilar courses enabled us to detect similarities and/or differences in students’ under-standings of professionalism, and the influences that education could have on theseunderstandings.

Findings

The findings of the study highlight the complex and multifaceted nature of profession-alism. The study found that both formal education in the classroom and in clinical pla-cements and observed professional behaviours play equally important roles indeveloping a sense of professionalism. The concept of professionalism appeared toevolve with participants’ experiences in different professional contexts. However, con-temporary issues of professional practice in Australia, such as cultural competence,environmental sustainability, leadership, preventive health care and working in multi-disciplinary teams, did not appear to form part of participants’ understandings of pro-fessionalism. Ways in which professionalism was conceived tended to differ betweendisciplines: participants from dietetics often expressed their conception of profession-alism in terms of performance competencies; participants from physiotherapy, on theother hand, tended to express their conceptions of professionalism in terms of their per-sonal values.

The results are presented in three sections which correspond to our three researchaims. In the first section we summarize key characteristics of professionalism thatemerged from participants’ discussions about professionalism. Next, we compare theways in which different participant groups expressed their conceptions of professional-ism. In the third section we present participants’ understandings of the role of educationin developing professionalism.

Ways in which professionalism was talked about and experienced

For many student participants characteristics of professionalism were difficult to articu-late. Their initial descriptions of professionalism included personal characteristics andbehaviours like neat physical appearance, punctuality and communication style. Theyneeded prompting to elicit other perspectives of professionalism. When studentsdescribed examples of professionalism they focused on interpersonal relationshipsdrawn both from clinical placements and from experiences with lecturers and other stu-dents. Professional relationships were described as polite and respectful, and those withpatients were described as patient-centred and using appropriate communication styles:

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The use of language in a conversation would be different in a professional relationship to apersonal relationship. Being professional in terms of appearance as well. (First-year die-tetics student)

Being able to communicate with health professionals and different types of patients.Getting informed consent and treating people with dignity. (First-year physiotherapystudent)

According to student participants, professionalism was also manifest in the ability tohandle difficult situations in a rational and reasoned way:

I see a lot of physiotherapists who just seem very calm. They are very proactive but calm at thesame time which allows them to make good decisions. (Final-year physiotherapy student)

She wasn’t alarmed or panicked, and I think that is a huge part of professionalism, taking thingsin your stride, being able to handle anything that is given to you. (First-year dietetics student)

Other characteristics of professionalism included technical expertise and knowing thelimits of one’s knowledge:

Knowing your boundaries, knowing when to refer on to other people, your limitations. Sorather than just trying to do it all yourself, it’s probably best to give the case to someoneelse. (Final-year dietetics student)

Notions of professionalism were strongly influenced by students’ experiences ofrole models of good professional behaviour, through observing instances of whatwas seen as unprofessional behaviour and through their own experiences of practiceas university students and student practitioners.

Role models

Role models were reported to be powerful influences on developing a sense of profes-sionalism. For student participants characteristics of professionalism transcended disci-pline boundaries. They learned about professionalism in many ways, includingobserving interactions between lecturers, clinical supervisors and students:

I remember one of my lecturers who was just the epitome [of professionalism]. I used tolook at her and think, ‘That’s what I want to be like’. She was just so calm and nothingrattled her. She was very warm, empathic. I thought, ‘I want to be her’. (Final-year die-tetics student)

My clinical educator on my clinical placement was a good role model for me, and it wasjust how he interacted with people at work and with me as a student, especially if I wastreating a patient. And also using current knowledge and things like that, and how he pre-sented that to a patient to make them feel more accepting of what he was doing. (Final-year physiotherapy student)

Unprofessional behaviour

Students gave examples of what they considered to be unprofessional behaviour.Invariably these examples involved disrespect within personal relationships. In onecase a student observed a conflict between two practitioners who disagreed aboutpatient management:

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I had a patient who had an NG [nasogastric] tube and they were planning for him to go to anursing home that doesn’t like taking patients with an NG tube. So the medical staffwanted to take it out before the patient left so that they could get rid of him prettymuch as soon as possible. I find it’s a common thing in public hospitals at the momentbecause of budgets and just a lack of beds. She had to confront the medical team andsaid, ‘No, you can’t just take him off NG. He needs to be meeting his nutritional require-ments before he goes to the nursing home, or they need to find a nursing home that willtake someone with an NG tube’. If they truly believe that it’s best for the patient then Ithink that’s fine, but if it’s to get him out because they don’t have enough beds that’sjust ridiculous. (Final-year dietetics student)

In another example, practitioners were observed making derogatory remarks aboutpatients to other health practitioners:

On my last placement we sat in on some board meetings with the nurses, physios, dieti-tians and some of the doctors, and some of them were not very professional in the waythey spoke about patients. Some of the patients had been there for a while, probablysocial rather than medical issues stopping them from going home, and just the way every-body talked about those patients was not very professional. They weren’t very kind aboutsome of them and they were saying things that they probably shouldn’t have been saying.(Final-year physiotherapy student)

Some students described experiences of the health system hierarchy during theirclinical placements, and regarded being spoken to disrespectfully as unprofessional:

I’ve had one little experience where a doctor talked to me in a very condescending wayand I thought it was very unprofessional. (Final-year dietetics student)

Some students also identified behaviours they considered unprofessional among their peers:

We had a project with a couple of sporting teams. Each pair was given a specific sportingteam and was asked to examine the relationship between their diet and the sport. We hadto present the findings to the teams and coaches. One member of our class said that someof the female rowers were quite overweight. She used inappropriate language, and thiswas in front of the whole team and the coach. We knew instantly that what she wassaying was very unprofessional. (Final-year dietetics student)

I have seen unprofessional behaviour in other students on placement – things like speak-ing about their personal lives in the middle of the ward or using mobile phones while theyare on duty. (Final-year physiotherapy student)

Participants’ discussions and experiences of professionalism did not include suchdimensions of professionalism as cultural competence, commitment to practices thatpromote environmental sustainability, promoting preventive health care, practising inmultidisciplinary health teams and being able to adapt readily to changes in pro-fessional practice. When prompted, some students recalled classes where such issueshad been discussed or instances on placements of multidisciplinary team management,but the dimensions referred to above did not generally form part of their understandingsof professionalism. For example, when asked about whether they had discussedenvironmental sustainability in relation to professionalism, two students responded:

Not really. I suppose resource management has come up, mostly in public hospitals wherethey have limited resources, but it is not so much about environmental sustainability. It ismore about money. (Final-year physiotherapy student)

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I don’t think we talked about environmental sustainability enough at all. There’s a lot ofliterature on the topic and it’s up to us to encourage people to have greater awareness.(Final-year dietetics student)

Comparisons between participant groups

Differences were identified between the ways in which physiotherapy and dietetics par-ticipants conceived and described professionalism. Participants from physiotherapytended to emphasize the influence of emerging professional values on their understand-ing of professionalism, whereas participants from dietetics tended to talk more aboutprofessional competencies in operational terms, such as knowing the limits of theirknowledge, using current research findings in practice and establishing patient-centred relationships purely in performance terms without reference to underlyingvalues.

It appears that first-year dietetics students did not take any clear concept of profes-sionalism to their first practice experience. For some students professionalism wascouched in terms of practice environment and behaviour:

Personally I wasn’t thinking about aspects of professionalism [on practice]. (First-yeardietetics student)

I guess I touched on [professionalism] a little bit, looking at the professionalism of the spacethat was provided, and how the dietitian conducted herself. (First-year dietetics student)

First-year physiotherapy students, on the other hand, had been explicitly encouraged torelate their personal values to the professional arena and, having already studied onesubject which included their discipline’s code of ethics, could discuss professionalismin terms of ethical principles. In the following example, the student was not simplyreporting on behaviours but more generally about ‘doing the right thing’, whichrequires interpreting behaviours through a personal value system:

Everything comes down to doing the right thing. If you do that in practice, then I think youare being professional. (First-year physiotherapy student)

Final-year students in both disciplines were nearing completion of their clinicalplacements, and had discussed professionalism in their formal education. The tendencyto interpret professional behaviours in terms of their underlying values was evident inthe responses of some final-year physiotherapy students:

Our values influence how we actually present ourselves in the workplace, so if we canunderstand what bias we have based on our values, and how we have been raised thenit is something that we can be mindful of when we are trying to be professional.(Final-year physiotherapy student)

In response to questions about their understandings of professionalism, final-year die-tetics students tended to focus on achievement of competencies, such as practising froma sound evidence-base and keeping abreast of current research:

My last supervisor on my prac constantly practised evidence-based medicine anddrummed that into me – how the department kept doing research and always kept up

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with the latest research. It makes us better practitioners as well, because we have to pullout that research paper then and there and think about it. (Final-year dietetics student)

Students did not discuss whether the type of research they were referring to was quan-titative or qualitative, although the reference to evidence-based medicine impliesempirico-analytical approaches to knowledge and practice. Whether professionalismis taught from an empirico-analytical, evidence-based perspective or from a hermeneu-tic-humanist perspective makes a difference to how professional identity is understoodand ultimately embodied (Fish and de Cossart, 2006). The former is based on a tech-nical, detached, objective stance, whereas the latter is based on a situated, interpersonaland interpretive stance. Quantitative research in health focuses on propositional techni-cal knowledge, whereas qualitative research focuses on complexity, uncertainty anddiversity that generates practical knowledge.

Differences in the capacity to articulate aspects of professionalism, and in whetherparticipants viewed professionalism as either a fixed or evolving concept, were alsoevident and appeared to be associated with clinical experience. Professionalism fromthe perspective of lecturers was a process that involved continually weighing up theconsequences of behaviours, evaluating contexts and making decisions. They recog-nized that their professional judgements called on years of learning from practiceexperience, and required self-reflection and autonomy. For the physiotherapy lecturersin the study professionalism was underpinned by the interpretive paradigm. Thisinterpretation accepts that knowledge, decision making and practice cannot be ascribedto notions of best practice, but align with notions of particularized and situated practice.Professional behaviours cannot be prescribed but are values-based and context-dependent:

When I was a practitioner I might have thought about professionalism as the way youlooked. I thought that you had to be neat, clean and tidy, hair short, tied back, uniformneatly pressed, and I still think that’s important and I still tell students that they need tohave that presentation. And I would also probably have thought about doing the rightthing but not putting a great deal of thought into it . . . we’ve had Della Fish here doingsome in-services and I think that really changes the way you think about things. I’vealso read some of Stephen Kemmis’s work on professionalism and praxis so I nowthink that professionalism is underpinned by your own values and thoughts and beliefs.So it’s going to be a bit different for everybody. But it still has to be guided by thecode of conduct. So there are guidelines for professionalism – you would look to yourprofession’s code of conduct, and then consider what Stephen Kemmis says aboutpraxis being moral. But moral to whom? (Physiotherapy lecturer)

The dietetics lecturers in the study, like their students, tended to emphasize achieve-ment of competencies like taking responsibility for one’s actions, advocating for theprofession and practicing evidence-based health care. However, dietetics lecturerswere able to draw on years of clinical experience to assess the relevance and usefulnessof evidence for individual cases. It appears that dietetic lecturers’ implicit understand-ing of professionalism was informed by an interpretive paradigm without explicitlyteaching this to students.

If I was working with a patient I would be basing what I do on evidence and good evi-dence, not just what I read in the literature but also what I know from my own previouspractice. I would also recognize the limitations of my competence. I’ve thought about thatand I’ve thought about where I’m comfortable to practise and where I would perhaps stop.It’s the same with learning and teaching. There are situations where I’m confident I know

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how to behave, how to manage a situation professionally and then there are times where Ithink, ‘Well, I’m not sure about that’. So I go and talk to someone else. I see that as part ofbeing professional, that you recognize where your limits are and you’re able to identifyhow to move forward. It’s a continual process of learning about how to behave [profes-sionally]. (Dietetics lecturer)

Pedagogical approaches to developing professionalism

Although there was no scope in this study for an in-depth review of curriculum designin relation to professionalism, it is noteworthy that the physiotherapy course formallyaddresses professionalism in Year 1, and provides seven clinical placements, whereasthe dietetics course addresses professionalism only in Years 3 and 4, and provides sixclinical placements. Clinical placements and dedicated subjects provided formal spacesin the curriculum for developing professionalism.

According to students and lecturers, professionalism can be developed both throughformal curricular activities and informally through observation and incidental learning:

I would like to think that implicit in the other subjects is that sense of professionalism. Theclinical subjects are very heavily focused on how to manage a patient. I think there are a lotof hidden messages that come across in other subjects. If you’re teaching skills or communi-cation and patient education, in those subjects you’re role modelling aspects of profession-alism. There’s also a clinical subject I teach in fourth year. There are definitely discussionsabout critically appraising evidence but we also discuss legal responsibilities and ethicaldecision making, and those sorts of issues around professionalism. (Dietetics lecturer)

It came indirectly through lecturers and looking at how they dress, how they act towardstheir students and just how they interact with each other. I think you just pick up things.(Final-year dietetics student)

In our teaching clinic, we had one session when we talked about the best way to approachdifferent situations in terms of ethics and professionalism, but not a formal class to say this ishow you be professional. It all came over indirectly in the teaching method and styles, and Ithink going on site visits, just watching our lecturers and seeing how they act. There was alot of watching and learning by examples. (Final-year physiotherapy student)

Assessment played a key role in determining what students perceived as beingimportant to learn. Both final-year physiotherapy and dietetics students were familiarwith their disciplines’ codes of practice, and had undertaken assignments that presentedthem with ethical dilemmas to ponder. Physiotherapy students were also given a writtenassignment which required consideration of the values underpinning their own decisionmaking and behaviours. Marks were awarded for how well students defined the values,deconstructed them and were able to identify their influence on their professionalpractice. This assignment was set by academics and encouraged students to thinkabout professionalism. It did not assess performance or competence, and was separatefrom clinical supervisors’ assessments of developing professionalism on placements:

For our first assessment we had to hand in a PowerPoint presentation about our values andhow they related to our professional behaviour in practice. We had to provide detailedexamples of our values. (Final-year physiotherapy student)

Students in both disciplines could fail a practical examination if their professional-ism was deemed unacceptable. This was a strong reminder of how highly profession-alism was regarded by lecturers:

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I remember a guy a couple of years above us who failed a prac exam because he referred tosomeone’s bottom as their butt . . . which is probably a bit rough, but that is one example.(Final-year physiotherapy student)

I know some students who have been at risk of failing because of professional behaviour– discussing personal issues in their social life with patients and their mates at inappropri-ate times and in inappropriate areas in the hospital. And also inappropriately associatingwith other hospital employees. (Final-year physiotherapy student)

Clinical supervisors were responsible for assessing students on clinical placements.Competency-based checklists were used to assess such professional behaviours ascommunication skills, maintaining confidentiality, knowing one’s strengths and weak-nesses, and management skills. Checklists were convenient and time-efficient tools forassessing students on clinical placements. However, clinical supervisors may struggleto reduce complex attitudes and behaviours to checklists of competencies that cansimply be ticked off. One of the physiotherapy lecturers observed that clinical supervi-sors were comfortable assessing students on technical skills, but were reluctant to failthem on professional behaviours:

In my experience clinical supervisors are very reluctant to complain about students’ pro-fessional behaviour. I think it is because those things are tacit, hard to pin down. And itwill often be when you’ve rung to ask how a student is going and they say, ‘Oh, they’regoing well’. And just when you’re about to hang up they’ll say, ‘Oh, there’s just onething’, and they’ll blurt out some hideous professional misconduct. (Physiotherapy lecturer)

Discussion

This study suggests that academic educators and clinical placement supervisors play acrucial role in shaping the development of professionalism in undergraduate students.Findings from this study have implications for educational strategies to develop astrong sense of professionalism, and these are:

(1) Students look to their lecturers and clinical educators as role models ofprofessionalism.

(2) There is a need for reflective spaces to learn and make sense of professionalismin the workplace and at university (especially after workplace experiences) tocritically reflect and make meaning of them.

(3) Lecturers need to create capacity in students to question and discuss profession-alism from philosophical perspectives and as active participants.

(4) Students learn from talking about professionalism.(5) Discussions about professionalism need to include contemporary social and

cultural issues as they relate to professional practice.

Students’ interpretations of professionalism included a range of characteristics andbehaviours that they had encountered in classroom education and clinical experiences.They could identify role models of good professional behaviour and examples ofbehaviours they considered unprofessional. Student participants were familiar withtheir discipline’s codes of ethics. However, using these codes as guidelines to beinterpreted in different situations requires students to actively engage in judgements,responsibility and decision making. Knowing a code of ethics is not the same asunderstanding the philosophical perspective that underpins such a code. Further,

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knowing something and applying it in practice are two different matters. There is a needto include a dedicated space in the curriculum to stop, reflect, debate and make sense ofprofessionalism. This will enable students to conceptualize more fully the complexcontextual nature of professionalism in clinical practice.

Dietetics students’ first formal lectures in professionalism occurred in their thirdyear of study. Physiotherapy students who encountered formal education in profession-alism in their first year were more readily able to articulate their interpretations ofprofessionalism and draw on their early practice experiences. Physiotherapy studentshad been encouraged to reflect on the values underpinning their interpretations ofprofessionalism and could articulate dimensions of professionalism, professionalvalues and hidden assumptions. However, whether this educational focus translatesto differences in professional behaviour in graduates remains to be seen and futurestudies could examine the implications of a values-based education for professionalismbeyond university education.

The findings of this study highlight the potential for a pedagogy that sets students ona journey to develop their sense of professionalism:

(1) Students compare what they have been taught and have experienced on prac-tice, but require opportunities to explore their ideas in depth for meaningmaking, and to share and integrate their knowledge and insights to continuouslyshape their sense of professionalism. Moderated sessions to talk and thinkdeeply about professionalism could help students make sense of differencesbetween theoretical notions of professionalism and professionalism as embo-died practice. One of the physiotherapy lecturers remarked on the effect ofone of the focus groups in this study on students’ thinking about professional-ism: ‘The students that I had this year certainly, having been in the focus groupwith you, had thought about professionalism more after that and were able torecognize behaviours that were professional and some that were not so pro-fessional’ (Physiotherapy lecturer). Providing opportunities to talk togetherand articulate ideas is one strategy to enhance the development of profession-alism. Other strategies could include reflective writing about workplace learn-ing experiences to probe what students have learned, and how it has changedtheir practices. A shift from isolated subjects that deal with issues of profession-alism to a course approach that overtly integrated the meaning of professional-ism at all levels could enable professionalism to pervade a university course.

(2) Professionalism needs to be problematised and critiqued so that current con-cepts of professionalism are challenged, reaffirmed or transformed to new con-texts. Our student participants appeared to unconditionally accept their lecturersand clinical supervisors as role models. Students could learn more from theirexperiences if they were more explicitly guided to look out for certainaspects of professionalism and given further opportunities to discuss and cri-tique their observations and experiences. By the end of their course, theyappeared to have been socialized to the workings of professional hierarchies,including unquestioning acceptance of the professional behaviours of their lec-turers and clinical educators. There was little evidence to suggest that studentswere motivated to critique their profession’s standard of professionalism.

(3) Students learn a great deal about professionalism from their clinical supervisors.Academic educators should collaborate more closely with them so that all stake-holders recognize professionalism as an important aspect of university courses.

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Eraut’s research (1994) confirms that students are more influenced by clinical supervi-sors than academic educators when it comes to the development of professionalism.Further research will be required to explore the impact of an explicit pedagogy forprofessionalism on graduates beyond their university course.

Conclusion

Students learned about professionalism through their classroom and workplace learningexperiences. The influence of classroom education was evident in the different waysparticipants from physiotherapy and dietetics talked about and experienced profession-alism. The focus on values underpinning professional behaviour was introduced in thefirst semester of the physiotherapy course and cultivated throughout it. Student partici-pants from physiotherapy tended to articulate their understandings of the complexrelationship between values, decision making and practice knowledge as their profes-sionalism developed. Students from both disciplines observed, articulated and emulatedthe professional behaviours of their role models, who were lecturers, clinical supervi-sors and clinicians. Although the explicit teaching of philosophical stances that under-pin various perspectives of professionalism had an impact on students’ discourses onprofessionalism, becoming professional is a process where learning by observingshould not be underestimated.

According to our participants, professionalism was understood to be a multifacetedconcept, ranging from personal characteristics and behaviours, such as attendance todress code, punctuality and effective communication skills, to being able to establisheffective interpersonal relationships, handle difficult situations calmly and reasonably,keep abreast of the impacts of current research on practice, and provide patient-centred care. However, professionalism did not appear to encompass cultural compe-tence, environmental sustainability, leadership, preventive health care or working inmultidisciplinary teams. Given the pressures on current health care systems to findmore efficient ways of managing clients (including diversifying job roles and multidis-ciplinary teams), universities should provide much-needed opportunities in the curricu-lum to enhance those aspects of professionalism that encourage adaptability andreadiness for emerging trends in professional practice.

University courses may require a more explicit pedagogical approach in developing asense of professionalism in students. Most of the explicit responsibility for developingprofessionalism lies currently with academics. However, stronger partnerships withindustry could engage clinical supervisors to share ownership of the responsibility todevelop students’ sense of professionalism, and to better prepare them for the uncertain,complex and diverse dimensions of practice. Students who develop self-awareness, andwho can articulate and apply their values in practice, may lay the foundations for a flour-ishing future practice. These values include sustainability, cultural diversity, leadershipand creativity. Developing professionalism is a lifelong process which requires thecapability to learn from practice, to question the status quo and to reflect, critique andtransform both individually and collectively. The capacity for such capabilities is vitalto prepare students for work in the uncharted realms of future professional practice.

AcknowledgementWe would like to acknowledge funding from the Research Institute for Professional Practice,Learning and Education, Charles Sturt University for this research.

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