Introduction

Professionalism is a rhetoric widely used across many academic disciplines and occupational environments. Within healthcare, regulatory bodies such as the General Dental Council (GDC) and General Medical Council (GMC) have placed an increased emphasis on professionalism, particularly in light of healthcare scandals and resultant public enquiries, such as the Francis Enquiry.1 This has also impacted upon the educational and training requirements of such professionals, with regulators making the teaching and assessment of professionalism far more explicit in their requirements. In 2011, the GDC published Preparing for practice: Dental team learning outcomes for registration, which was subsequently updated in 2015.2 This document sets out the learning outcomes that all dental care professional undergraduate students must achieve to be eligible to be placed on a GDC register. The outcomes are centred around four domains: Clinical; management and leadership; communication; and professionalism. The dental student learning outcomes within the professionalism domain are further divided into: patients and the public; teamwork; ethical and legal; and development of self and others.2

'The GDC expects professionalism to be embedded throughout dental education and training. All students must have knowledge of Standards for the Dental Team and its associated guidance.'2 The document further states that 'It is essential that students recognise the importance of professionalism and are able to demonstrate the attributes of professional attitudes and behaviour at all times from the beginning of their training.'2

This explicitly highlights that the teaching and assessment of professionalism is a clear requirement for those responsible for dental education. The GDC, however, does not provide prescriptive guidance as to how this should be achieved. It is therefore important that educators have a clear understanding of professionalism, as how it is conceptualised will affect the design and delivery of the relevant curriculum. This paper aims to provide an overview of some of the wider perspectives that have been used to frame professionalism in the literature.

At its most literal level, professionalism can be defined as 'the conduct, aims, or qualities that characterise or mark a profession.'3 This definition alludes to certain shared personal characteristics and behaviours which reflect social norms that one is expected to adhere to within that role, without explicitly defining what these might be. The term 'profession' has been recognised for centuries. Traditionally, it implied a well-defined group of individuals who had undergone formal training to gain a body of specialised knowledge in order to carry out a particular form of work, over which they had monopoly and self-regulation, in return for placing the interests of others before themselves.4 Nowadays, an ever increasing number of occupations now consider themselves professions, and this has tended to blur such a definition with, for example, 'self-regulation' becoming less important. This in turn has complicated perceptions of professionalism. Professionalism, from a business perspective for example, may look very different to that considered in healthcare. Professionalism in managerial and business discourses has been used to market companies as providing superior services and to motivate employees.5 This is clearly at odds with concepts of professionalism in healthcare settings and has been highlighted by Cruess et al., who argue that the widespread use of the term 'professional' in ordinary speech means that academic usage should specifically refer to medical professionalism.6 Although the vast majority of professionalism literature in healthcare relates to medicine, such a term fails to acknowledge the numerous other healthcare professions for which professionalism is equally important.

Within healthcare (primarily medicine) different academic disciplines have studied professionalism, led by sociologists for whom it has long been an object of study, often from a critical perspective focusing upon the benefits that physicians derive from their professional status.7,8 More recently, the increased focus on professionalism by healthcare regulatory bodies has led to an increased interest in professionalism by healthcare professionals, regulators, academics and educationalists involved in training future members of such professions. This expansion of interest in a concept which is so difficult to clearly define has unsurprisingly resulted in several ways of viewing professionalism depending on the underlying intention and background of the authors. Sociological literature tends to focus on societal contract, public service, roles, identity and power, whereas educational literature highlights behaviours, attitudes and traits.

Societal contract

Considering the traditional role and definition of a profession, one method of conceptualising professionalism is that of a contract with society. Historically, society granted self-regulation to the professions in return for altruistic public service. Healthcare scandals and perceptions of the abuse of such trust has resulted in society exerting greater control over the professions.6 This has manifested in several ways, including increased legislation such as the Statutory Duty of Candour, giving healthcare organisations an explicit duty to report any mistakes or problems resulting in patient harm, more explicit guidance and codes of conduct from regulatory governing bodies and increasing numbers of lay members within such organisations, thus reducing the ability to self-regulate.9,10,11,12 Thus, concepts of professionalism in this discourse have changed over time as society has demanded greater transparency, control and accountability of the professions.6 It has also been suggested that financial challenges have resulted in governmental organisations attempting to redefine professionalism to encompass managerial agendas to deal with a scarcity of resources and rationalisation of care within budgets.5 Teaching professionalism from this perspective might focus upon adherence to regulatory codes and a focus on transparency and accountability.

Occupational control

Some sociologists have viewed the discourse of professionalism as relating to occupational control.5 This can be either from 'within', by its members aiming to maintain a monopoly over their work with resultant high status and power, or from 'above' as a means of occupational discipline and accountability to external bodies.5,13,14 In both instances, a societal contract is implied. In the case of the maintenance of monopoly and internal control of the members of a profession, this contract allowed professionals considerable licence, in return for behaviour which put the interests of patients and the public first. More recently, following healthcare scandals, control has shifted, with professionals now required to account for their performance to external bodies, who act on behalf of society to maintain standards.

Social construction

As the role of professions in society has changed over time, so too have perceptions of professionalism. This has been ascribed to changes in the provision of healthcare, such as managed care, care provision by other healthcare professionals, increased use of technology, greater patient knowledge and expectations, in addition to the influence of political forces and policies.15 Geographical location and culture has also been discussed, with reported differences in perceptions of professionalism in various parts of the world. A recent article by Cruess and Cruess reviewed the literature regarding concepts of professionalism in medicine in different nations and cultures.16 They concluded that being a doctor involves being a healer and a professional. While the first component has relatively universal features, the second aspect will depend upon the culture and location that the individual is practising in, which will determine how their services are organised.16 In medicine, changes in the structure of care delivery and the increasing prominence of managers in the healthcare system has resulted in significant changes to the professional role.17 This has been compounded by increasing standardisation of care, utilisation of checklists and adherence to clinical guidelines, with it being increasingly deemed unprofessional not to adhere to such guidance.18 Historically, doctors were the centre of care provision in medicine, with all other healthcare professions assuming a secondary role. Friedson17 argued that medicine was undergoing a 'deprofessionalisation', with consumers now assuming the dominant role as opposed to doctors. He also suggested that doctors took a secondary role to their managers and employers, now becoming just another salaried healthcare worker, thus losing their autonomy and possibly the high social status traditionally associated with the profession. In addition to this, it has been suggested that such managerial control results in loss of internalised and embodied professionalism by the healthcare professional, with a negative impact upon patient empathy and trust.19

As this sociological work tended to focus on the medical profession, direct comparisons between medicine and dentistry may be difficult, due to some notable differences in the delivery of care. In the UK, a significant proportion of medical care is provided in a hospital setting, with doctors being salaried employees. Conversely, most dental care is delivered in independent dental practices that contract work from the NHS or provide it on a privately funded basis. However, it could be argued that the autonomy and social status of both professions has been affected by the increase in allied healthcare professionals who now perform many of the tasks traditionally only carried out by doctors or dentists. This could further reduce the dominant role of the dentist in the clinical care environment, which would echo Marxist perspectives about the proletarianisation of doctors in the medical profession.17 Although managers were identified as having a significant role in the shift of professional dominance in medicine, they have played less of a role in dentistry.20 Traditionally, however, only registered dentists could own a dental practice. Changes in regulation now mean that many practices are owned by corporate organisations, nurses, hygienists and dental technicians. This has resulted in dentists losing their autonomy by becoming another employee of the organisation rather than assuming the central role, which parallels the changing role of doctors in hospitals. Furthermore, it could be argued that doctors work for an ethical organisation, with core principles and values centred on providing excellence in patient care. Conversely, dental practices owned by corporate entities that employ dentists may not have such grounding in ethical principles, which may further de-professionalise individual clinicians.

Overall, conceptualising professionalism as being socially constructed tends to lead to a focus on issues of power and control, with commentators interpreting changes in professional practice through a lens which asks questions about the degree of control exercised by professionals in different contexts. Such an approach also lends itself to the notion of new members of the profession being 'socialised' into that profession, allowing them to develop a professional identity within an organisational context.21 Such a view would therefore suggest that education should focus upon socialisation within an occupational setting rather than setting out to teach professionalism explicitly.

Values, traits and attributes

Most of the literature which takes this approach comes from medical professionals and educators, particularly in North America. It suggests that professionalism stems from internal values and traits, such that professionals are inherently 'good' people.22 Conceptualising professionalism in such a way could lend itself to the concept of embodiment of professionalism by the individual, generating empathy, caring and patient trust.19 This concept has been condensed further by Brody and Doukas.23 They argue that it should be conceptualised as being made up of two components; 'professionalism as a trust generating promise' and 'professionalism as application of virtue.'23 This implies that any observed actions and behaviours actually stem from an underlying set of values.

From an educational perspective, such a view means that selection of suitable people to enter the profession is of paramount importance, as such qualities cannot readily be taught. Despite this, attempting to select participants on the basis of their values can be challenging, as demonstrated actions or claims made may not correlate to a person's underlying beliefs and values.

Behaviours and codes of conduct

Healthcare regulators and institutions often have their own definitions of professionalism, which usually encompass expected behaviours and codes of conduct.2,24,25 Educational literature from Europe often uses such a perspective. Such definitions lend themselves to both a clear understanding of expected standards, while also supporting the policing of such standards and providing tangible reference points for educating newer members of the profession. Within dental education in the UK, the GDC document Preparing for practice: Dental team learning outcomes for registration defines professionalism as 'the knowledge, skills and attitudes/behaviours required to practise in an ethical and appropriate way, putting patients' needs first and promoting confidence in the dental team.'2

This definition is used in conjunction with the nine standards for the dental team, which provide specific behavioural expectations of registrants and students. Professionalism defined in this way has also been described as a second order competence; that is something that can only be demonstrated while performing another task.26

Interestingly, this definition also mentions ethics in the context of ethical practice. The overarching principles of biomedical ethics include respect for autonomy, beneficence, non-maleficence and justice.27 Although such principles are clearly intertwined with the notion of professionalism, Shaw28 argues that the two terms are not interchangeable, which can create problems when holding professionals to account against such definitions. He feels that a dentist can be unprofessional if they fail to meet the standards laid out by the GDC, but ethical practice and the ability to deal with ethical dilemmas transcends such guidance, such that an ethical dentist will go beyond what is expected by any regulatory demands.28

A complex construct

A literature review of professionalism in 2004 found ninety separate elements of professionalism reported.26 An individual's professionalism can be related to their personality, attitude, values, traits and competence. Although it is manifested as behaviour and actions, this can be influenced on a general level by the norms and responsibilities associated with that profession, in addition to society's expectations of them. Specific interactions are also influenced by the context of the situation and organisational culture in which it takes place, in addition to the relationship between and communication among the individuals involved.

Given this web of overlapping concepts, attributes and situations it is not surprising that professionalism has been described as a complex construct.29 To further complicate matters, the relationship between the different facets is not straightforward and is poorly understood. An individual's behaviour would be expected to reflect their underlying attitude about a certain situation; however, several systematic reviews of the subject reveal somewhat variable correlations.30,31,32 Attitudes themselves can change and are thought to be influenced by emotional responses, cognitions and behavioural intentions.33

Professionalism has also been conceptualised as consisting of multiple inter-connecting levels; the individual, institutional and societal.26,34,35 Taking all of these things together, Table 1 presents some of the different aspects of professionalism that have been highlighted in the literature, including values, traits, behaviours and actions, and seeks to locate these in the different levels at which professionalism may be manifest or required.

Table 1 Dimensions of professionalism definitions reported in the literature for medicine and dentistry when considered as a multi-level construct2,4,22,26,36,37,38,39,40,41,42,43,44,45,46,47,48,49

From an educational perspective, the lens through which professionalism is conceptualised can have important ramifications in terms of curriculum design and pedagogical outcomes. A course designed to 'teach' professionalism as a set of behaviours and adherence to rules will look very different to that designed to facilitate development and internalisation of values. The former can rely more heavily on didactic teaching to provide students with a knowledge base of the professionalism literature, encompassing behavioural expectations. Conversely, courses which aim for students to internalise the values and norms of the profession will require an educational framework of authentic situated learning, intentional role modelling of positive behaviours, collaborative learning and reflection on experience in a positive learning environment.50

Other authors have suggested that professionalism is a competence, implying that it is a skill which can be mastered in a similar fashion to carrying out a clinical procedure.51,52 Such an example can be found in the Association of Dental Education in Europe document, Profile and competencies for the European Dentist, in which the first domain of competency outcomes relate purely to professionalism.25 From an educational perspective this could be counter-productive, as if students feel they have become competent in professionalism, they may not devote any further learning and reflection toward it. Conversely, if professionalism is viewed as a set of values and traits then one could argue that striving for self-improvement and learning continues throughout one's career.

This brief overview of the relevant literature has highlighted the multiple different ways in which professionalism may be conceptualised, and the potential implications that this may have for education and curriculum design. As regulatory bodies continue to increase the emphasis on this aspect of dental student education, it is important that educators should be aware of these issues. Collective reflection and debate about what professionalism really means and how it might best be taught would be of value in ensuring that dental education meets the needs of both society and the profession.