Paramedic practice, like many areas of health care, has moved forward dramatically since the early 1970s when the first training scheme for paramedics was established in Brighton. The 1980’s saw a national training scheme adopted and in 2000, paramedics became registered with the Council for Professions Supplementary to Medicine (CPSM), soon followed by the transfer to statutory regulation with the Health Professions Council.
The new generation of paramedics coming through education and training programmes across the country receive far more integrated theory, practice and professionalism in their development than perhaps their predecessors did in the early days of paramedic training. This shift is in line with the professional body, the College of Paramedics (CoP), Curriculum Framework 2008 (Furber, 2008). This acts as an educational guide for future paramedic education and development, influenced by the Quality Assurance Agency (QAA) Benchmarking Statements (QAA, 2004). It reflects the wider changes across all the health and care professions in terms of training and practice. As knowledge and technology changes, so must educational input, and as public expectations of professionals change, so must the emphasis on professional skills in training and practice.
The Health Professions Council (HPC) has also been undergoing growth and change since it was established in 2001 and subsequently changed its name recently to reflect the wider range of professions we regulate—in August this year, 88000 social workers in England joined the register and from that date we became the Health and Care Professions Council (HCPC). Over the last five years we have increased our emphasis on researching the work that we do. For example, we know from analysis over the last eight years the majority of complaints about HPC registered health professionals concerned conduct, not competence. Last year, fitness to practise data analysis showed that only 8 % of HPC cases were exclusively competence related. The remainder of concerns were either about conduct alone or conduct and competence of the practitioner. (HPC, 2011). We have therefore embarked on a programme of research to look more closely at conduct and professionalism.
‘We know from analysis over the last eight years the majority of complaints about HPC registered health professionals concerned conduct, not competence...’
One of the questions we sought to explore was: what do professionals themselves think ‘professionalism’ means? We commissioned researchers at Durham University to look at perceptions of ‘professionalism’ (Morrow et al, 2011). Specifically, we asked them to explore what the concept meant to students and educators in three professions— occupational therapy, paramedic and podiatry, 115 students and educators in 20 focus groups took part.
What emerged from the study was that ‘professionalism’ was seen not so much as a discrete competency but a situational judgement, a set of behaviours influenced by context, rather than a fixed, defined characteristic. These behaviours were strongly influenced by the particular care group, peer group, and knowledge and skills of an individual. How peers behaved, for example, could strongly influence how an individual viewed ‘professional’ behaviour and what was appropriate in one context might not be in another. The use of humour and calling a patient by their first name, were examples of behaviours that needed to be adapted depending on the context, and the skill of professionalism was in knowing what to do and when to do it. The report gives illuminating examples of unprofessional behaviour and why it was judged to be so.
Parallels can be drawn with that of the medical sociologist Freidson (2004), and his work around the notion of professionalism. Here, Freidson suggests, professionalism cannot exist unless it is believed that the particular tasks performed are different from those of other workers. The notion that the knowledge of professionalism requires a foundation in abstract concepts or theories that must be learned in an educational setting is a familiar one, suggesting a body of knowledge is required of professionals.
In addition to the work currently being undertaken by Durham University a study exploring the acculturation of student paramedics as they embark upon the workplace is underway (Donaghy, 2011). Here, university paramedic students who attend placements are observed within the working environment for a number of shifts, whilst working with their more experienced paramedic colleagues. Although this piece of work is on-going and results are still preliminary, the initial findings appear to suggest that students are socialised into what Wenger (1998), believes to be a community of practice. Lave and Wenger propose that newcomers (students) may be influenced by colleagues, who were established ‘legitimate participant’ (Lave and Wenger, 1991) members, of the workforce. What does appear from the observations are that students find difficulty in challenging a number of traditions and practices which appear endemic within the practice setting and which often have synergy to the notion of professionalism. Students may value the sense of community within the work placement, providing that each student can integrate within that community. How this may influence professional behaviour is as yet unclear. However, early observations support Lave and Wenger (1991) notion.
‘There are different ways in which ‘old-timers’ and newcomers establish and maintain identities conflict and generate competing viewpoints on the practice and its development. Newcomers are caught in a dilemma. On the one hand they need to engage in the existing practice, which has devolved over time, to understand it, to participate in it, and to become full members of the community in which it exists. On the other hand, they have a stake in its development as they begin to establish their own identity in its future’.
This may illustrate the potential impact upon the perceptions and understanding of student paramedics as they embark upon practice, in addition to the views and perceptions of the experienced members of the team, which Lave and Wenger refer to as, ‘old-timers’, as their traditional understanding and values may be challenged.
The second phase of the research at Durham University however, is exploring ways of measuring professionalism, and whether there are behavioural indicators which might be identified and disseminated more widely (McLachlan et al, 2009).
‘For example, what would you do if you observed behaviour in a colleague that you judge as ‘unprofessional’? How do you talk about it, if at all?’
This work is looking specifically at paramedic practice in the first instance, and builds on research undertaken in medicine, which shows a link between behaviours demonstrated at the pre-registration stage and complaints about conduct later on (Papadakis et al, 2008).
In addition to commissioning research, HCPC has been working with the UK Health Department as well as with professional bodies and educators to generate debate on professionalism amongst HCPC registered professionals. For example, in Scotland, a report on professionalism in nursing, midwifery and AHPs has been published by the Scottish Government, with recommendations on facilitating and developing professionalism.
In England, the Chief Health Professions Officer has coordinated a country wide initiative aimed at stimulating debate and discussion on professionalism, in collaboration with the professional bodies and clinical leads. This has focused initially on posing questions for clinicians. For example, what would you do if you observed behaviour in a colleague that you judge as ‘unprofessional’? How do you talk about it, if at all? Is it unacceptable within your peer group to do so? Is it more acceptable to discuss issues of competence than conduct? To date, there appears to have been a positive response to this amongst professional networks, with many establishing virtual conversations as well as face to face discussions, using the HCPC research.
We are aware that the recommendations from the mid-Staffordshire Enquiry will be published in early 2013. It is possible these may refer to the importance of professionalism in practice and how is it maintained. Professional bodies, as well as employers and regulators will have a key role to play in this over the coming months and years. These conversations may be easier within a profession than between different disciplines, but as we move into more inter-disciplinary working, it may be that this initiative could be developed through clinical commissioning groups, or existing discussions among paramedics and their colleagues. What is clear is that we need more, not less talk about professionalism and values in the rapidly changing landscape of health and social care.
‘Regulation should act as a driver to quality improvement, as well as taking action against those who do not meet accepted standards...’
Finally, a word about regulation and in particular the HCPC approach to regulation. We are committed to working with the professions on an on-going basis, on education and training as well as practice and professionalism. We are very aware of the huge changes across health and social care, and the impact they are having on services. We must maintain our conversations with the professions we regulate during these times of change. Robust and credible regulation is based upon a network of mutual trust—trust in the individual paramedic to regulate her/ himself, trust in the regulatory system to operate transparent, consistent, proportionate and targeted processes for ensuring that standards are maintained. Regulation should act as a driver to quality improvement, as well as taking action against those who do not meet accepted standards. This is the litmus test—are we as regulators concerned with quality—our own and those regulated by us—or not? Regulatory bodies must be constantly self-critical, reflective, emulating the high standards of professionalism of those they regulate.