An exploration of how well final-year pharmacy students understand professionalism

Introduction

In healthcare education it is recognised that there is a need to ensure undergraduate students possess the traits and attributes appropriate to professional practice. However, a universally accepted definition of professionalism remains elusive. Many authors have tried to describe what constitutes professionalism and the healthcare literature abounds with disparate definitions from different healthcare fields.^{[1],[2],[3],[4],[5],[6]}
 

To help educators understand the expectations of professional bodies or other organisations in the field a number of guidelines have been produced on what constitutes professionalism and how this can be conveyed to students.^{[7],[8],[9],[10]}

In response, many medical and pharmacy schools in the US have developed strategies to incorporate the teaching of professionalism,^{[11],[12],[13],[14],[15],[16]} but few have reported attempts to measure student attainment of professionalism.^{[17],[18],[19],[20]}
 This is not surprising, given that these respective groups have yet to agree on definitive definitions of professionalism.

Notwithstanding this, US pharmacy educators have advanced the ways in which professionalism can be taught and assessed.^[21]
 By contrast, in the UK there is little published work on pharmacy professionalism, whether from the professional body, the regulator or pharmacy educators. One notable exception is the introduction of student codes of conduct and fitness to practice procedures in all UK pharmacy schools from September 2010 at the behest of the Royal Pharmaceutical Society.^[22]

The growing acceptance, on the UK pharmacy regulator’s behalf, that aspects of professionalism in the UK are not all they should be has led the pharmacy department at the University of Wolverhampton to review how professionalism is conveyed to students. Before making any changes to the curriculum we thought it important to determine student views on professionalism. This study is the first to report on UK pharmacy student views and their perception of professionalism.

Methods

All final-year (year 4, n=31) pharmacy students at the University of Wolverhampton were invited, via email, to participate in a focus group. The email invitation consisted of a letter introducing the study, background information sheets and a consent form. Those students who expressed an interest in taking part were recruited. In total 11 students participated in one of two focus groups. Each student was reminded that participation meant agreeing to the recording of the discussion, and dissemination of the data. Participants were told that they were free to withdraw at any time, and students were given the opportunity to ask questions before the focus group took place. Signed consent forms were obtained from all participants before the start of each focus group.

The focus group agenda consisted of a number of open questions with prompts to gain information from participants who did not disclose it initially. The question schedule was based on previous research reported in the pharmacy literature on professionalism and undergraduate pharmacy student behaviour.^[21]

Both focus groups were conducted at the university by one of us (SK). Notes were made during focus groups to supplement understanding of transcripts. The focus group discussions were taped and transcribed verbatim. Transcripts did not identify participants. Data were collected and analysed in iterative cycles and coded manually by the authors of this paper. SK did not have a role in teaching or assessing professionalism for any of the participants. This avoided the possibility of relationships having power and influence over the data collected.^[23]

As researchers, it is important to acknowledge our own definitions and comprehension of professional behaviour because these shaped the questions we asked students in the focus groups. Therefore, this research adopts a social constructionist approach: it does not aim to discover scientific facts, but seeks to explore students’ views and experiences of professionalism.

Ethical approval for the study was granted by the behavioural sciences ethics committee at Wolverhampton University.

Results

Four major themes — appearance, personal characteristics, responsibility and knowledge — were identified that students thought demonstrated professional behaviour and professionalism. Each is highlighted, although the order in which they are described does not signify any level of importance ascribed to the themes by participants.

Appearance

Comments made in the focus groups indicated that students did equate personal appearance with professionalism.

It is mainly about the way you look. I feel appearance has a big impact on whether someone is regarded as professional. Appearance plays an important role as well, the way you look. (FG2P6)

In both focus groups lengthy discussion took place over what constituted acceptable dress code, including clothing worn on religious grounds.

Would you want to take advice from a pharmacist who is dressed in a Hawaiian T-shirt and shorts? (FG2P1)

I think your appearance can impact on your career. For example, Muslim women who wear the veil … I do not think that it is professional. I understand that everyone has their own religious views, but there is a limit. (FG1P4)

I don’t have anything against religion, but to cover your face, I don’t think that comes across as professional … wearing a veil is forming a barrier. (FG1P5)

…a headscarf is OK, but covering the face is not good, it’s a barrier (FG2P5)

Appearance was a prominent theme, but some students understood that wearing “a uniform” did not necessarily mean a person was demonstrating professionalism. It might simply be dictated by social norms:

The patient will always go to the pharmacist who is dressed well, but I don’t think the way someone dresses should have an impact… . It shouldn’t be such an issue, but I guess it is. (FG2P3)

[A] person off the street would think different [about women wearing a veil]… . They would think oh my God…. I think it would cloud their perception of her professional character. (FG1P5)

I think you can be scruffy and have excellent knowledge. (FG2P3)

You can, but will a patient want to approach you if you look scruffy? (FG2P2)

Personal characteristics

Students believed that certain character traits showed they demonstrated professionalism. They thought a person should be of good character and exhibit the right sort of attitude:

Attitude: I think that is part of professionalism … because, at the end of the day, even if you are following guidelines and doing the right thing you could still not be professional in terms of attitude towards the person … you cannot be rude; you have to have good manners. (FG2P2)

Character must incorporate good attitude. (FG1P3)

They also believed people should possess qualities such as honesty and trustworthiness:

Honesty should be a clear link to professionalism … an honest personality is a key attribute. (FG2P1)

I think you have to be trustworthy,. If you haven’t got trust with your patients then you are not professional. (FG1P2)

You have to be someone they can confide in. (FG2P2)

Responsibility

Students were aware that their own behaviour and the way they conduct themselves is not just confined to the classroom but affects the way they interact socially. They were also aware that those actions might have repercussions on their professional lives.

… not just inside the university, but outside as well. (FG1P5)

If someone wanted to drink alcohol, being a professional shouldn’t stop them, but there is a line to draw. (FG1P4)

Anything you do in your personal time can affect your working life as well. (FG2P4)

Think twice about doing anything … think about the implications it will have … think about the consequences … you’re never going to drive stupidly. (FG1P6)

Additionally, students appreciated that their actions would not only be a reflection on themselves but also the profession:

You have to remember we are representing pharmacy, so we have to be careful with our actions all the time. (FG1P4)

You have to be a responsible pharmacist. You cannot bring your profession into disrepute. (FG2P3)

Interestingly, more than one student said they foresaw problems in modelling expected behaviours in social settings:

It is going to be hard, because you have to control your behaviour outside when you are in the social network; that’s going to be the hardest thing ever. My manners in terms of being in a professional environment are completely different to how I am at home. It’s a bit like Jekyll and Hyde. I will have to have two personalities. (FG1P1)

I think it is going to be hard, because to a certain extent I think you have to change your personality to become a person who is professional 24/7. (FG2P4)

Knowledge

A recurring theme mentioned by both groups was the need to possess appropriate knowledge:

You have to be on the ball. (FG1P5)

You obviously need to be competent at what you do. (FG2P3)

One of the key attributes (of professionalism) is the pharmacists’ knowledge. (FG2P4)

As well as the themes described above, students, primarily from the first focus group, expressed concern over perceived pressure they will face as pharmacists if they worked in the community sector. They feared that commercial targets and interference from managers could compromise patient care:

You get all this pressure from the top, people ringing you up saying do (medicine use reviews), deadlines etc. (FG1P4)

I think community pharmacists are too focused on how many items they do a day, as opposed to dealing with patient issues and care… . It’s all business driven and you never get to use your knowledge, you’ve got so much pressure to hit targets that you forget your main role: caring for patients. (FG1P1)

 The code of ethics says that the patient should always be put first… . They [unnamed multiple] make you do 10 MURs first even if they haven’t completed all the dispensing. (FG1P2)

How is that being a professional pharmacist [manager interference] if you are not putting the patient first — that’s definitely unethical. (FG1P5)

The problem you have with being a professional in pharmacy is the fact that, especially in community pharmacy, there is pressure from the manager. (FG2P2)

The final question of the focus group schedule asked students how they had developed their own sense of professional identity while at university. Students spoke of the influence academic staff and practising pharmacists had on them:

We have had this professionalism thing drilled into us since day one. It may have taken a while to grasp the idea, but we have now got it. (FG1P4)

The lecturers themselves … all dress very professionally and behave professionally … we are in the mind set of acting like professionals … when we go to placements, we think when we look at some of the pharmacists that that’s how we need to be in the future. (FG1P2)

You learn it on placement as well … the pharmacists you see are not always professional, it really does depend. (FG2P2)

Discussion

Students identified appearance, personal characteristics, responsibility and knowledge as components that constitute professionalism. When considered against proposed definitions of professionalism, such as the most recent American College of Clinical Pharmacy (ACCP) paper on defining student professionalism, overlap exists between student perception and the key traits of professionalism noted in the paper, namely responsibility and honesty and integrity (recorded under personal characteristics).^[10] However, other traits, such as respect for others, care and compassion and a commitment to excellence were rarely, if at all, cited as qualities they needed to possess to exhibit professionalism.

Appearance featured heavily in the discussions of both groups and was obviously something that they saw as important. The fact that most students equated professionalism with socially acceptable norms in relation to outward appearance suggests that they have a somewhat superficial understanding of what professionalism really is. This is supported by students not having a deep appreciation of knowledge; they knew that knowledge was a prerequisite for personal competency but did not relate this to lifelong learning or talk about how striving for excellence goes beyond personal need and affects the profession as a whole.

More worrying was the lack of discussion about the need for care and compassion toward the patient. Patient care was mentioned only when it might be compromised due to excessive commercial pressures and the inability to comply with the profession’s code of ethics.

The general failure to make the patient the central focus of their actions could call into question whether these students have the ability to develop meaningful relationships with patients based on trust, although both groups did acknowledge that trustworthiness was a necessary personal character trait.

The trait that seemed most developed was that of responsibility. Students saw that they were responsible for their own actions regardless of time and place and had a duty to their peers and profession. However, students did not extend this notion of responsibility to include responsibility to individual patients or society in general. This suggests a somewhat superficial understanding of professionalism, and has been noted by others.^[24]

The course at Wolverhampton University relies on student visits to practice settings and providing positive role models to instil professionalism, as these have been highlighted as important factors in professional socialisation.^{[24],[25],[26]}
 This approach is reflected in student comments on how they have developed a sense of professionalism.

However, students did not seem to grasp fully what it means to be a professional. That begs the question as to whether the Wolverhampton approach to professionalism is appropriate. In many US schools a more formal approach is taken, often using the pharmacy professionalism toolkit,^[9]
 although there are no published studies reporting on whether these approaches enhance student understanding of professionalism.

Much has been written about the inculcation of professionalism and the notion of a hidden curriculum, whereby students are influenced by the organisational structure and culture. Findings from this study do not support this notion. Perhaps more importantly, Hilton uses the term “proto-professionalism” to describe the lengthy transition from student to professional.^[27]
 The transition requires not only knowledge and skills but experience and reflection.

In current UK pharmacy programmes students get limited opportunities to gain meaningful experience before graduation and their ability to be competent, reflective practitioners has also been questioned.^[28]
 Therefore, it might be unreasonable to expect that final-year pharmacy students have a full understanding of professionalism and its implications for them in practice, given the current status of undergraduate pharmacy education in the UK. Indeed, some students spoke of anxiety in making the transition from student to professional, with the need to switch between personalities, known as identity mobility strategy.^[29]

Since pharmacy students are required to undertake one full year in practice after graduation before they can register it would be worth examining their views to see if this additional experience has any effect.

Limitations

Although this study reports on an area of professionalism thus far neglected — pharmacy students’ views — the findings have to be taken in context. This study reports on the views of one cohort of final-year students from one UK university. Therefore the findings are specific to this institution and should not be generalised to other UK institutions. Additionally, unlike in the US no formal guidance or instruction has been given to UK pharmacy schools and thus differences in US and UK pharmacy student views on professionalism may be stark.

Conclusion

Students had a sense of professional identity and professionalism, but this mainly centred on how this would affect them as individuals. Deeper understanding on the relationship with patients and others was mostly lacking.