PrimeResearch&DevelopmentLtd
StudentFitnesstoPractiseandStudentRegistrationAliteraturereviewAprojectfortheHealthProfessionsCouncil
GeorgeBoak,LindsayMitchellandDavidMoore
February2012
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TableofContentsChapter1:Introduction............................................................................................................ 3
1.1 Natureandscopeofthereview .................................................................................. 3
1.2 TheHPC’sprogrammeofworkonstudentfitnesstopractiseandregistration ......... 3
TheHPC’sdefinitionofstudentfitnesstopractise .......................................... 4
Theimpactassessment..................................................................................... 4
Theconsultationquestionsandpossibleoutcomes......................................... 5
1.3 Conclusion ................................................................................................................... 5
Chapter2:Methodology .......................................................................................................... 6
2.1 Searchstrategy ............................................................................................................ 6
2.2 Searchresults .............................................................................................................. 7
Chapter3:Findingsfromthepublishedliterature ................................................................. 10
Introduction.................................................................................................... 10
3.1 Perceptionsofstudentfitnesstopractiseandrelatedthemes ................................ 10
Overview......................................................................................................... 10
Professionalism............................................................................................... 11
Professionalsuitability.................................................................................... 13
Goodcharacter ............................................................................................... 16
Misconduct ..................................................................................................... 17
Healthimpairmentanddisability ................................................................... 17
Summary......................................................................................................... 18
3.2 Factorsaffectingstudentfitnesstopractise ............................................................. 18
3.3 Educationalinstitutionsandstudentfitnesstopractice ........................................... 21
Introduction.................................................................................................... 21
Fitnesstopractice:development ................................................................... 22
Fitnesstopractise:assessment ...................................................................... 25
Assessmentforselection ................................................................................ 25
Assessmentduringeducation......................................................................... 26
Fitnesstopractise:investigationanddiscipline ............................................. 28
3.4 Regulatorybodiesandstudentfitnesstopractise .................................................... 33
3.5 Conclusionsaboutthefindingsfromtheliterature .................................................. 34
Chapter4:Regulatorsandstudentfitnesstopractise ........................................................... 38
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4.1 TheUKhealthandsocialcareprofessionregulatorsandtheirapproachestoregulatingstudentfitnesstopractise................................................................................. 38
4.2 UKhealthcareprofessionregulatorswhohaveproducedguidancerelatingtostudentfitnesstopractise.................................................................................................. 40
4.3 Otherapproachestostudentfitnesstopractiseusedbythehealthandsocialcareprofessionsregulators,includingstudentregistration....................................................... 47
Nospecificguidanceorothermeasuresyetinplace–theGCC .................... 47
Theintroductionofstudentindexing–theNMC........................................... 47
Activelyengagingstudentsintheworkoftheregulatorandgivingconsiderationtostudentregistration–theGMC........................................... 48
Asystemofstudentregistrationnotlinkedtofundingorotheradministrativeduties‐theGeneralOpticalCouncil ............................................................... 50
Studentregistrationrelatedtothefundingofpracticeplacements–theGeneralSocialCareCouncilandotherUKsocialcareregulators................... 52
GSCC–suitability,fitnesstopractiseandrisk ................................................ 53
GSCC–qualityofpracticeplacements ........................................................... 55
4.4 OtherregulatedprofessionsintheUK ...................................................................... 58
4.5 Non‐UKhealthandsocialcareprofessionsregulators.............................................. 58
Australia.......................................................................................................... 59
NewZealand ................................................................................................... 61
SouthAfrica .................................................................................................... 61
Canada ............................................................................................................ 62
UnitedStatesofAmerica................................................................................ 63
RepublicofIreland.......................................................................................... 64
Internationalperspectives‐conclusion.......................................................... 64
4.6 Summaryandconclusions ......................................................................................... 65
Chapter5:Conclusionsandrecommendations...................................................................... 68
5.1 Conclusions................................................................................................................ 68
5.2 Recommendations..................................................................................................... 72
Bibliography............................................................................................................................ 73
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Chapter1:Introduction
1.1 Natureandscopeofthereview
Thisreportdescribesanindependentreviewoftheliteratureaboutstudentfitnesstopractise.TheresearchwascommissionedbytheHealthProfessionsCouncil(HPC)aspartofitspolicyworkonstudentregistration.
Thepurposeoftheresearchwastoassistinbuildinganincreasedunderstandingofthepotentialnature,scaleandimportanceofthepolicyproblemunderconsiderationandtheeffectivenessofdifferentapproachestomanagingstudentfitnesstopractise.TheHPChadundertakenapreliminarysearchofthetopicandfoundlimitedpublishedevidenceabouttheissueunderreview.
Theaimsoftheresearchwereto:
1. identifyandappraisetheavailableresearchliteratureandevidenceaboutstudentfitnesstopractise,includingstudentregistration
2. assistinbuildingaclearerpictureoftherisksassociatedwithstudentsintheprofessionsregulatedbytheHPCandinsocialwork,andtheeffectivenessofdifferentapproachestomanagingthoserisks
3. contributetowardsfuturedecisionsaboutthemosteffectiveandappropriatemeansofassuringthefitnesstopractiseofstudents,includingwhethertheexistingregisterofsocialworkstudentsinEnglandshouldcontinuetobemaintained.
ThisliteraturereviewformedonestrandofadevelopmentprogrammebeingundertakenbytheHPCinthelightoftheGovernment’sdecisiontoabolishtheGeneralSocialCareCouncil(GSCC)andtransferitsresponsibilityforregulatingsocialworkersinEnglandtotheHPC(subjecttotheparliamentaryapprovaloftheHealthandSocialCareBill2011).
1.2 TheHPC’sprogrammeofworkonstudentfitnesstopractiseandregistration
TheHPCistakingforwardanumberofpiecesofdevelopmentworkinordertoassumeresponsibilityfortheregulationofsocialworkers.AkeypieceofworkrelatestostudentfitnesstopractisebecausetheGSCCandHPChavedifferentapproaches.1TheGSCCcurrentlyregisterssocialworkstudentsbuttheHPCdoesnotregisterstudentsofanythe15professionsitcurrentlyregulates(ieartstherapists,biomedicalscientists,chiropodists/podiatrists,clinicalscientists,dietitians,hearingaiddispensers,occupationaltherapists,operatingdepartmentpractitioners,orthoptists,paramedics,physiotherapists,practitionerpsychologists,prosthetists/orthotists,radiographers,andspeechandlanguagetherapists).Itdoespublishstandardsandguidanceforeducationprovidersaboutapproachestostudentfitnesstopractise.TheHealthandSocialCareBill2011hasprovisionstoenabletheHPCtoestablishvoluntaryregistersofstudentsstudyingonprogrammesleadingtoHPCregistration,shouldtheCouncildetermineitisappropriatetodoso.
1 Further information on the current processes of the HPC and the GSCC in relation to Student Fitness to Practise is considered in section 4 of this review.
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Inordertofullyexploretheissuesrelatingtostudentregistrationinthecontextofstudentfitnesstopractise,theHPChasestablishedaprogrammeofworktogatherevidenceandtoseekviewstoinformitspolicydevelopment.Theprogrammeconsistsofthreestrands:
1. undertakingafirststageimpactassessmentfocusingonthedevelopmentofthepolicyproblemandtheoptionsavailabletoaddressit
2. consultingwithstakeholdersonthemosteffectivewayofassuringthefitnesstopractiseofstudents
3. commissioningaliteraturereviewtogainmoreevidenceaboutstudentfitnesstopractiseprocesses,therisksposedbystudents,andtheeffectivenessofdifferentapproachestomanagethoserisks–thesubjectofthisreport.
TheHPC’sdefinitionofstudentfitnesstopractiseInitsconsultationdocumentonthesubject,theHPCdefinesstudentfitnesstopractiseasrelatingto:
‘studentshave(ing)thenecessaryhealthandcharactersothattheywillbeabletopractisesafelyandeffectivelyoncetheyhavebecomeregistered.Itisalsoaboutstudents’abilitytoactappropriatelywiththosetheycomeintocontactwithwhentheyaretraining,includingserviceusers.’(HPC,2011a)
Thisdefinitionrecognisesthatuntilstudentshavecompletedtheirpre‐registrationprogrammes,theyarestillintheprocessofdevelopingtheirknowledgeandskillstopractisesafelyandeffectively.Thisisincontrasttothefitnesstopractiseofregistrantswhichisdefinedashaving‘theskills,knowledge,healthandcharacterinordertopractisetheirprofessionsafelyandeffectively’(HPC,2011a).
TheHPC’sdefinitionofstudentfitnesstopractiseisconsistentwiththeapproachesadoptedbyotherregulators(seechapter4)andhasbeenusedasthebasisforthisreviewoftheliterature.
TheimpactassessmentThefirststageimpactassessmentonstudentfitnesstopractisewaspublishedontheHPCwebsiteatthesametimeastheconsultation(ie1November2011).Thesummaryoftheimpactassessmentnotesthat:
‘TheHPCCouncilhasdeterminedthatstudentregistrationshouldbeconsideredacrosstheexistingHPCregulatedprofessions.Theissueunderconsiderationisthereforetoconsiderthemosteffectiveandappropriatemeansofassuringthefitnesstopractiseofstudents,includingwhethertheexistingregisterofsocialworkstudentsinEnglandshouldbemaintained.’(HPC,2011b)
ThisdecisionbytheHPCissetinthecontextofitbeingamulti‐professionalregulatorthatworkswithinasinglepieceoflegislationwithmanycommonstandardsandprocesses.
Theimpactassessmentsetsoutthepolicyobjectivesofdevelopingstudentfitnesstopractiseregulatoryprocessesandtheeffectstheyareintendedtoachieve.Theobjectivesapplybothtotheconsultationandtothisliteraturereviewandarereproducedbelow:
• ‘Toensurethatthepublicareadequatelyprotectedfromthepotentialriskofharmposedbystudents.
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• Toensurethatconcernsaboutstudentsareadequatelydealtwithsothatonlysomeonewhoisfittopractisecompletesaprogrammewithanawardthatleadstoeligibilityforregistration.
• Toensurethatstudentsareawareoftheduties,responsibilitiesandstandardsexpectedofthemasfutureregistrants.
• ToensureconsistencyandequityofregulatoryapproachacrosstheHPCregister,whereverpossibleandappropriate.
• Toensurethatanyvoluntaryregisterofstudentsisfeasibleonaself‐financingbasis,avoidingcross‐subsidisationfromtheHPC’sstatutoryfunctions.’(HPC,2011b)
Theimpactassessmentalsonotesthat‘furtherevidenceanddata(ifavailable)needstobegatheredabouttherelativeeffectivenessofthedifferentoptions’(page15),settingthecontextforthisliteraturereview.
TheconsultationquestionsandpossibleoutcomesTheconsultationdocumentdidnotmakespecificproposalsabouthowstudentfitnesstopractiseshouldbetakenforwardbutsoughtstakeholders’viewsonaspectsincluding:theobjectivestobeachievedinstudentfitnesstopractiseapproaches;therisksposedbystudentsandthesupervisionarrangementstoaddressthoserisks;studentengagementwithprofessionalregulatorystandards;consistencyoffitnesstopractiseprocessesacrosseducationinstitutions;thecosts,benefitsandequalityanddiversityimplicationsofthedifferentapproaches.
IntheconsultationdocumenttheHPCclarifiedthattheresponseswouldinformitsdecisionsaboutstudentfitnesstopractiseandregistration,includingwhether:
• theHPC’scurrentapproachtostudentfitnesstopractiseshouldbemaintainedacrosstheRegister;or
• theHPCshouldmaintainavoluntaryregisterofsocialworkstudentsinEngland;and/or
• theHPCshouldestablishanyvoluntaryregistersofstudentsforsomeoralloftheexistingHPCregulatedprofessions.
ThesemattersremainopenatthetimeofreportingthisliteraturereviewwhichpredatesclosureoftheconsultationinMarch2012.
1.3 Conclusion
ThischapterhasoutlinedthepurposeandaimsoftheliteraturereviewinthecontextoftheworkonstudentfitnesstopractisecurrentlybeingundertakenbytheHPC.Thenextchapteroutlinesthemethodologyadoptedtoidentifyandreviewtheliterature.Chapter3reportsthefindingsfromanevaluationofavailableliteratureaboutstudentfitnesstopractise.Chapter4extendsthefindingsbyreportingonthepoliciesadoptedbyotherhealthandsocialcareregulatorsintheUKandbywayofcomparison,alsoinaselectionofothercountries.ConclusionsandrecommendationsaresetoutinChapter5.
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Chapter2:Methodology
2.1 Searchstrategy
Theaimoftheprojectwastoreviewliteratureandevidenceaboutthenatureofmechanismstomonitorandassurestudentfitnesstopractise,includingregistration.TheidentificationandappraisalofinformationwasinformedbyreferencetoareasofparticularinteresttotheHPC:
• thenature,incidenceandimpactofrisktopatients,clients,usersandthepublicposedbystudents
• theimpactofsupervisiononstudentrisk
• theincidenceof‘programmehopping’
• studentengagementwithregulatorystandards
• theconsistencyofapproachamongeducationproviderstostudentsdeclaringconvictionsorotherinformationpotentiallyofrelevancetoanevaluationofprofessionalconduct
• therelativecostsandbenefitsofapproachestomanagingstudentfitnesstopractise,includingregistration.
PriortothecommissionedresearchtheHPChadundertakenapreliminarysearchandfoundlimitedpublishedevidenceabouttheseissues.Initialsearchingconfirmedtheabsenceofawell‐populatedornarrowlycircumscribedbodyofliteraturethatwouldlenditselftosystematicreview.Asaconsequencewehaveundertakenanintegrativereview(WhittemoreandKnafl,2005),amethodwhichincludesasynthesisofdiversesourcesandtypesofinformation(iebothprimaryandsecondary,bothempiricalandtheoretical,andbothcataloguedandgreyliterature)toprovideafullerunderstandingoftheissue.Themethodinvolvesproblemidentification(describedaboveintheopeningparagraph),literaturesearching,dataevaluationanddataanalysis(describedbelow),andpresentationoffindings(thesubstantivepartofthisreport).
Thenatureandscopeoftheproblemjustifiedasearchofmultipledatabases.TenelectronicdatabasesweresearchedduringOctober,NovemberandearlyDecember2011(table1).SearchingwaslimitedtoEnglishlanguagejournalsandtoarticlesfrom1990onwards(althoughnotallelectronicdatabasesspanthisperiodinitsentirety).Insomecasessearchinghighlightedworksofpotentialinterestpublishedpriorto1990,someofwhichwereselectedforreview.Howeverthebulkofliteratureidentifiedassufficientlyrelevanttowarrantanalysisisdrawnlargelyfromthelastfifteenyears.Themajorityofliteratureselectedforreviewwasaccessedelectronically,butsomewasavailableonlyasprintholdings,whichwerephotocopied.
Tolimitthescopeoftheproject,searchingwaslargelyconfinedtooccurrencesofkeytermsintitlesandabstractsonly.Thesearchstrategycommencedwithanumberofkeytermsusedinvariouscombinations(including‘student’,‘registration’,‘regulation’,‘education’,‘conduct’,‘misconduct’,‘fitness’,‘practise’)butevolvediterativelywiththeadditionofotherterms(suchas‘malpractice’,‘strugglingstudents’,‘professionalcompetence’,‘professionalstandards’,‘suitability’,‘risk’,‘accreditation’,termination’‘interruption’
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‘discipline’)thatweresuggestedfromacursoryreviewofinitialresults,orwereidentifiedtobetterexploitthethesauriofparticulardatabases.
Table1:Electronicdatabasessearched
Allied and Complementary Medicine Database (AMED)
Applied Social Science Index and Abstracts (ASSIA)
British Education Index (BEI)
British Nursing Index (BNI)
Cumulative Index of Nursing and Allied Health (CINAHL)
Education Resources Information Centre (ERIC)
Medline/PubMed
PsycINFO
Social Care Online
Social Service Abstracts
2.2 Searchresults
Thesearchstrategyinevitablygeneratedrecordsrunningintothethousands,mostofwhichconcernedregistered(ratherthanstudent)practitionersoraspectsofpre‐andpost‐registrationeducationandtrainingofnodirectrelevancetothisreview;butwewereunabletofindameansofconsistentlyandsatisfactorilylimitinginitialsearcheswithoutalsomissingpotentiallyrelevantmaterial.‘Advancedsearches’weresuccessfulinreducingthenumberofrecordsgeneratedbut,whenevaluatedagainst‘simplesearches’,appearedtoomitrecordswehadjudgedpotentiallyrelevant–aconclusionalsoreachedbyothers(FlemmingandBriggs,2006).Asubstantialpartoftheprojecthasthereforeinvolvedsiftingtheinitialsearchresultsrecordbyrecord,bytitleorbytitleandabstract,toidentifypotentiallyrelevantliteratureforevaluation.Siftingwasconductedwithreferencetotheissuesidentifiedintheopeningparagraphtothissection.Additionalliteraturewasalsoidentifiedfromreferencesintheworksreviewed.Arecordwasbuilt‐upofalltheitemsselectedforfullevaluation.
Frominitialreturnsrunningintothethousands,focusedsearchingandaprocessofrigoroussiftingresultedintheselectionofaround400articlespublishedinlearnedandprofessionaljournals,thevastmajorityofwhichhavebeenfullyevaluatedforthisreview.Eachitemwasreadandreviewedandashortsummarypreparedforusewithintheteam.Someitemswerereviewedblindbyallthreemembersoftheteamtocheckforanalyticalparity.Havingdiscardedliteraturejudgedirrelevant,theliteratureremainingwasfurtherexaminedandiscitedinsupportoftheanalysisthatformsthesubstantivepartofthisreport.
Government,regulatoryandprofessionalbodieswerethemainfocusofweb‐searchingforgreyliterature.Over100reports,policystatementsandguidancedocumentswerereviewed.ManyhavebeenusedtoinformananalysisofthepositionadoptedbyotherUK
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healthprofessionsregulators,andalsotoprovideanaccountofsomeinternationalcomparators.
Inidentifyingrelevantliteraturewedidnotdiscriminatebetweencategoriesonthebasisofa‘hierarchyofevidence’,forexampleasmightoccurinasystematicreviewbyspecifyingstrictinclusionandexclusioncriteria,notleastbecausethiswouldhavecompromisedtheintegrativeapproachadopted.Howeverwedidundertakeapost‐hoccategorisationofsourcestoprovideanoverviewoftherelativeproportionsofempiricalandnon‐empiricalliteraturecitedinthisreport(table2).
Thecategorisationisrelativelycrudeandisintendedtogivenomorethanageneralsenseofthetypesofstudy,commentaryandopinionuncovered.Forthepurposesofthisreviewpapersreportingempiricalstudieshavebeendifferentiatedbytheprincipal(whichisnotnecessarilytheonly)researchmethod.Inevitablythisconcealsotherdistinctionsbutfurtherdifferentiationwasconsideredunnecessaryforthepurposehere.Thesurveycategoryhasbeeninterpretedliberallytoincludeallstudiesthatcollect(quantifiable)databyquestionnaireoranotherresearchinstrumentfrom(usuallysampled)populationsofparticipants.
Forempiricalstudiesthecountryinwhichtheresearchwasconductedhasbeenidentified.Thisrevealsabroadlysimilarnumberofstudiesfromthetwolargestcontributorstothiscategory,theUSandtheUK.Thelargestcategory–ofwhatare,broadlyspeaking,non‐empiricalpieces–includesliteraturereviewsanddescriptive,discursive,analyticalandpropositionalpapers.Muchofthisliteraturewouldfalloutsidetheparametersofasystematicreviewyetprovidesilluminatingcommentaryonanumberoftheissuesunderconsideration.Nevertheless,itisnotablethatthereisadearthofinformationaboutsomeofthespecificissuesofinteresttotheHPCindentifiedintheopeningparagraph.
Table2:Literaturebytype
Case control studies Papdakis et al, 2005 (US); Teherani et al 2005 (US); Yates and James, 2010 (UK).
Cohort studies Goldie et al, 2002, (UK); Humphrey et al 2011 (UK); Papdakis et al, 2008 (US); Steggers-Jager et al 2011 (Netherlands); Stern et al, 2005 (US).
Focus (and other) group methods
Baingana et al, 2010 (Uganda); Banks, 2005 (UK); Cleland et al, 2005 (UK); Cleland et al, 2008 (UK); Furness and Gilligan, 2004 (UK); Lafrance et al, 2004 (Can); Morrow et al, 2011 (UK); Rees and Shepherd, 2005a (UK); Rees and Shepherd, 2005b (UK).
Interview based studies Basnett and Sheffield, 2010 (UK); Fontana, 2009 (US); Stanley et al, 2011 (UK).
Observational studies Burack et al, 1999 (US); Hodges et al, 2001 (US); Weissmann et al, 2006 (US).
Survey based studies Al-Dwairi and Al-Waheidi, 2004 (Jordan); Andreson and Obenshain, 1994 (US); Bailey, 2001 (US); Baldwin et al, 1998 (US); Barlow and Coleman, 2003 (Can); Brockbank et al, 2011 (UK); Brown et al, 2011 (US); Daniel et al, 1994 (US); Dillon, 2007 (UK); Dyrbye et al 2010 (US); Elzubier and Rizk, 2003 (UAE); Geddes et al, 2004 (Can); Hilbert, 1985 (US); Hilbert, 1987
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(US); Jette and Portney, 2003 (US); Korszun, 2005 (UK); Kovach et al, 2009 (US); Lown et al, 2009 (UK); Manthorpe et al, 2010 (UK); McGrugen et al 2010 (Aus); Rennie and Crosby, 2002 (UK); Rennie and Rudland, 2003 (UK); Rizk and Elzubier, 2004 (UAE); Roff et al, 2011 (UK); Self and Baldwin, 1998 (US); Stockhausen, 2005 (Aus); Stone et al, 2009 (US); Tam and Coleman, 2009 (Can); Unsworth, 2011 (UK).
Literature reviews and works of a descriptive,
discursive, analytical or propositional nature
Aldridge et al, 2009 (UK); Arnold, 2002; Banks 2010; Boon and Tuner, 2004; Bradshaw and Lowenstein, 1990; Brainard and Brislen, 2007; Butters and Strope, 1996; Carr et al, 2010; Chaffer. 1998; Clark, 2006: Cleary and Horsfall, 2010; Cruess and Cruess, 2006; Cruess et al 2010; Currer and Atherton 2008; Currer, 2009; David and Ellison, 2010; Dean 2011; Duffy and Hardicre, 2007a; Duffy and Hardicre, 2007b; Elliott et al, 2009; Fiesta, 1998; Fowler, 2008; Fox et al, 1995; Gaberson 1997; Ginsburg 2000; Goldie, 2008; Hall, 2004; Hickson et al, 2007; Hilton and Slotnick, 2005; Holmstrom and Taylor, 2008; Howe 2002; Howe et al, 2010; Hughes et al, 2009; Jha et al, 2007; Karnieli-Miller et al, 2010; Kasar and Muscari, 2000; Kenny, 2007; Kolanko et al, 2005; Lucey and Souba, 2010; Lynch et al, 2004; Martimianakis et al 2009; McGregor and Brown, 1998; McLaughlin, 2010; Papadakis et al, 1999; Parker et al, 2008; Postle 2009; Price, 2006; Reid, 2010; Sin and Fong, 2008; Sin and Fong, 2009; Sellman, 2007; Semple et al, 2004; Smith et al, 2007; Snelling and Lipscombe 2004; Tee and Jowett, 2009; van Mook et al, 2009a; van Mook et al 2009b; van Mook et al, 2009c; van Mook 2009d; Watkinson and Chalmers, 2008; Wagner, 1993; Wear and Castellani, 2000; Whiting, 2007; Wilkinson et al, 2009.
Inconclusion,analysingtheliteratureinvolvedidentifyingandexaminingsourcesofinformationrelevanttotheissuessetoutintheopeningparagraphofthischapter.Inevaluatingtheliteraturewesearchedforpatternsacrossmultiplesources–comparing,contrastingandclusteringtheopinions,assertions,findingsandconclusionsreported–inanefforttoencapsulatecontemporarythinkingonthesematters.
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Chapter3:Findingsfromthepublishedliterature
IntroductionAprincipalaimoftheresearchwastoidentifyandappraisetheavailableresearchliteratureandevidenceaboutstudentfitnesstopractise,includingstudentregistration.
Broadkeythemesemergingfromtheliteratureconcerned:
1. perceptionsofstudentfitnesstopractise,andrelatedtermssuchasprofessionalism,suitabilityandgoodcharacter
2. factorsbelievedtoaffectstudentfitnesstopractise
3. approachesbyeducationalinstitutionstomanagingstudentfitnesstopractise
4. approachesbyregulatorstomanagingstudentfitnesstopractise.
3.1 Perceptionsofstudentfitnesstopractiseandrelatedthemes
OverviewThedevelopmentandassessmentofastudent'sfitnesstopractiseinhealthandsocialcareisachievedthroughamixtureofacademicandpracticalactivities.Thereisalargeliteratureonthedevelopmentandassessmentofknowledgeandskills,buttheresearchliteraturewehavereviewedforthisreport,concerningfitnesstopractise,ismuchlessconcernedwithissuesofassessmentofacademicability–theunderstandingofrelevantfactsandtheory–thanwithotherabilitiesthatcontributetofitnesstopractise.Publicationsidentifiedbysearchesforarticlescontainingtheexpression'fitnesstopractise'generallyaddressedissuesofbehavioursofqualifiedpractitionersallegedtohavebeeninbreachofprofessionalstandards,orproceduresforhandlingstudentmisconduct.Inthecontextofstudentlearningandassessment,fitnesstopractiseiscloselyrelatedintheliteraturetothreeotherhighlevelthemes:
• professionalism,particularlyinrelationtomedicaltraining
• professionalsuitability,orsuitabilitytopractise,usedinthecontextofstudentstrainingforsocialwork
• goodcharacter,inrelationtotrainingfornursing.
Eachofthesethemes,intheirownprofessionalareas,arepresentedinthepublicationswereviewedasbeingcentraltoanindividual'sabilitytopractisetheprofessiontoasuitablestandard.Inthesectionsthatfollow,therefore,wewillfocusontheseelements,ascentralcomponentsoffitnesstopractise.
Ineachofthesethreeareas,writersreflectthatthereisdifficultyindefiningandassessingthetheme.Thisissometimescontrastedwiththerelativeeaseofdefiningandassessingtheacademicstandardsthatstudentsareexpectedtomeet.
WefoundlittlepublishedworkonfitnesstopractiseinrelationtoHPC‐registeredprofessionals,andhencethediscussiononthefollowingpageslargelyaddressesthesethemesastheyarepresentedinthecontextofotherprofessions.
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Theeffectofhealthimpairmentanddisability,andthedangerofunfairdiscriminationarealsopotentiallyrelevantinrelationtofitnesstopractise.Thesearediscussedseparatelybelow.
ProfessionalismProfessionalismisthetermmostfrequentlyusedinrelationtoaspectsofthebehaviourofmedicalstudents,intheUKandtheUSA,thatrelatetofitnesstopractise.
IntheUK,theGeneralMedicalCouncil'sandtheMedicalSchoolsCouncil’(2009)definitionofprofessionalismincludesprovidinggoodclinicalcare,maintaininggoodmedicalpractice,goodbehaviourstowardspatientsandcolleagues,maintainingprofessionalskills,andalso'beinghonestandtrustworthy,andactingwithintegrity'.Definedinthisway,professionalismisclearlyessentialforgoodclinicalpractice.
AnumberofarticlesintheUKandNorthAmericaputforwardalternativeunderstandingsofprofessionalismtothatoftheGMC.LiteraturereviewsbyArnold(2002),Lynchetal(2004),andJhaetal(2007)showarangeofdifferentapproachesanddefinitionshavebeentakentowardsmedicalprofessionalism.
In2002thephysiciancharter,developedincollaborationwiththeAmericanCollegeofPhysicians(ACP)FoundationandtheEuropeanFederationofInternalMedicine(Smithetal,2007)waspublishedsimultaneouslyintheAnnalsofInternalMedicineandtheLancet(ABIM,2002;Lancet,2002).Itdescribedthreeguidingprinciplesofprofessionalism:
• patientwelfare
• autonomy,and
• socialjustice
whichweretobeexhibitedincommitmentstocompetence,honesty,confidentiality,propriety,quality,access,justice,knowledge,trust,andself‐regulation.
Analternativeperspective,putforwardbyHiltonandSlotnick(2005)inareviewofmedicalprofessionalismintheUKandtheUSA,suggestedthatprofessionalismwillbeexhibitedinsixdomains:
• ethicalpractice
• reflection⁄self‐awareness
• responsibilityforactions
• respectforpatients
• teamwork
• socialresponsibility.
Thesixdomainshavebeenfoundusefulinmorerecentpublications(egRoyalCollegeofPhysicians,2005;Goldie,2008;Morrow,2011).AccordingtoHiltonandSlotnick,adefiningcharacteristicofprofessionalismis'practicalwisdom'–whichisacquiredonlyafteraprolongedperiodofexperienceandlearning.
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Professionalism,howeverdefined,isseenasofcentralimportancetogoodmedicalpractice(HiltonandSlotnick,2005;Cruessetal,2006).Afailureofprofessionalismisrelatedtopoorpractice:itissaidthatmoremedicalfitnesstopractiseanddisciplinarycasesandcomplaintsrelatetoissuesofprofessionalismthananyotherreason(egPapadakisetal,1999;Ginsburgetal,2000).
Whilstthemajorityofpublicationsonprofessionalisminthehealthandsocialcareprofessionsaresetinthefieldofmedicine,JetteandPortney(2003)reportaUSstudyresultinginthedevelopmentofamodelofprofessionalbehaviourwithphysicaltherapystudents.TheauthorstestedamodelthathadbeendevelopedonaconsensusbasisbyMayetal(1995).Surveyingphysicaltherapystudents,JetteandPortneyrefinedMay'smodelintosevenfactors,eachindicatedbyanumberofconstituentbehaviours:
• professionalism
• criticalthinking
• professionaldevelopment
• communicationmanagement
• personalbalance
• interpersonalskills
• workingrelationships.
Thefactorofprofessionalismcomprisedover30behaviours,butisdefinedbyJetteandPortney(p439)as:
a) acommitmenttoservice
b) adherencetoethicalstandards
c) ademonstrationofhumanisticvaluessuchasintegrity,honesty,respectforothers,compassionandaltruism
d) responsibilityandaccountability
e) commitmenttoprofessionaladvancement.
Inanarticleonprofessionalismforoccupationaltherapists,UScliniciansKasarandMuscari(2000)arguethatprofessionalismrequiresspecificknowledge,attitudes,andvalues–allindicatedbyprofessionalbehavioursthatinclude:dependability,professionalpresentation,initiative,empathy,cooperation,organisation,clinicalreasoning,supervisoryprocess,verbalcommunicationandwrittencommunication.
Theseexamplesshowanumberofapproachestodefiningprofessionalism,includinglistingindividualtraitsandcharacteristics,anddefiningroles,domainsandactivities(seeMartimiakisetal,2009forananalysisofdifferentperspectivesthathavebeentaken).
Individualcharacteristicssuggestedindifferentstudies,sometimesinconjunctionwithrolesandactivities,include:self‐motivation,independentlearning,interpersonalrelationships,dependability,andintegrity(Kovachetal,2009);compassion;empathy;positiveoutlook;interestinpeople;honestyandtrustworthiness(Lownetal,2009);beinghonest,actingwithintegrity(Dyrbyeetal,2010);reliability(Wilkinsonetal,2009);honesty/integrity,responsibility/reliability,compassion(Parkeretal,2008).
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AsurveyofmedicalschoolsinUSAandCanadarevealedthat54.5%(ofthe88respondents)haddefined,writtenstandardscoveringissuesotherthanacademicperformance(BoonandTurner,2004).Themostfrequentlycitedwerehonesty;professionalbehaviour;dedicationtolearning;professionalappearance;respectforlawandforothers;issuesofconfidentiality;andavoidanceofsubstanceabuse.
Takinganalternativeapproach,aUSstudybyTeheranietal(2005)foundthreedomainsofunprofessionalbehaviour,thatwereassociatedwithsubsequentdisciplinaryaction:poorreliabilityandresponsibility;lackofself‐improvementandadaptability;andpoorinitiativeandmotivation.Papadakisetal(1999)provideexamplesofunprofessionalbehaviourusedinonemedicalschooltosignaltheneedforremedialdevelopment,whichareunmetprofessionalresponsibilities;lackofefforttowardsselfimprovementandadaptability;diminishedrelationshipswithpatientsandfamilies;anddiminishedrelationshipswiththehealthcareteam.InastudybyBuracketal(1999),supervisingmedicscategorisedproblembehavioursbystudentsasshowingdisrespectforpatients,cuttingcorners,andoutrighthostilityorrudeness.
LuceyandSouba(2010)argueforamoresophisticatedviewofprofessionalismasacomplexadaptivechallenge,whichmaybeposedonaregularbasistostudentsandpractitioners.Morrowetal(2011),inastudyoftheunderstandingofprofessionalismbyalliedhealthprofessiongroups,arguethatprofessionalismcanbestbeseenintheactionsofindividualsinspecificsituations.
Therisksposedbyafailureofprofessionalismincludepoorpracticebymedicalstudentsresultinginharmtopatients–ariskpotentiallymitigatedbyclinicalsupervision(ButtersandStrope,1996),andalsotherisksofpoorpracticeaftergraduation.StudiesbyPapadakisetal(2005&2008)foundthatdisciplinaryactionbyamedicalboardwasstronglyassociatedwithpriorunprofessionalbehaviourinmedicalschool.Thestrongestassociationwaswiththosestudentswhohadbeendescribedasirresponsible,orashavingadiminishedabilitytolearntoimprovetheirbehaviour.
Mostoftheliteratureinthisareaacceptsthatthecapabilitytobehaveprofessionallydevelopsoverthecourseofastudent'seducation(egKasarandMuscari,2000;WearandCastellani,2000).HiltonandSlotnick(2005)arguethatthepracticalwisdomatthecoreofprofessionalismisonlyacquiredovertime,withexperienceandlearning,alongsideadevelopingknowledgebase.Thestatepriortoprofessionalismtheydefineas'proto‐professionalism'.
Insummary,professionalismhasbeendefined,andunderstood,indifferentways.Althoughacoreofbehavioursmaybeseenintheexamplescited(suchasbehavingwithhonestyandintegrity,workingforthebenefitofthepatient,selfimprovementandlearning)somedefinitionsappearwiderthanothers.
ProfessionalsuitabilityInsocialworktheequivalentconceptismostoftenreferredtoasprofessionalsuitability,orsuitabilitytopractise.TheGeneralSocialCareCouncil(GSCC)requirementsinclude:
‘Toawardthe[socialwork]degree,universitiesshouldbesatisfiedthatstudentshave…showntheyaresuitabletopractiseasasocialworker.’(GSCC,2002a:13)
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CurrerandAtherton(2008:281)notethatthisrequirementisstatedseparatelyfromtheotherGSCCrequirements,whichincludetherequirementthatstudentshavebeenassessedagainsttheapprovedcurriculum,havemettherelevantNationalOccupationalStandards,followedtheCodeofPractice,andhavesatisfiedchecksoncriminalrecords.'Theissueofsuitabilityisimportantenoughtobementionedinitsownright.’(p281)
YetaccordingtoCurrerandAtherton,theconceptofsuitabilityis'usedindifferentwaysinthedocumentation,andalsodifferentlyinterpretedbyindividualsinpractice'(p282).Elsewhere,Currerarguesthat'theconceptof‘professionalsuitability’isundefinedand—somewouldargue—indefinable,atleastintheabstract'(Currer,2009:1495).Notingthatthereisuncertainty,evenintheGSSC'sguidance,aboutwhetherunsuitabilityreferstoacharacteristicofcertainindividualsortobehavioursthatareorarenotacceptable,Currer(2009:1482)arguesthat’unsuitability’isbestunderstoodasajudgementtobemade'inrelationtoparticularcasesandcircumstances.'
TamandColeman(2009)reportonaCanadianstudythatdevelopedascaletoevaluateprofessionalsuitabilityforsocialworkpractice.Thescalecomprisedfivedimensions:overallsuitability;analyticalsuitability;practicesuitability;personalsuitability;andethicalsuitability.Themodelwasvalidatedwith188practisesupervisors.The33elementsofthedimensionscoveredarangeofabilitiesandattitudes,forexample:
• abletotransferlearningfromonecontexttoanother
• hasgoodinterpersonalskills
• demonstratesintegrity
• isabletocriticallyexaminepoliticalissues
• iscommittedtochangingsocialinequality
• maintainsstableemotions
• demonstrateseffectivewritingskills.
Inasmallstudyusingfocusgroupsandinterviewswithfieldinstructors,LafranceandGray(2004)foundtheconstituentsofprofessionalsuitabilitytobe:personalandemotionalmaturity;honestyandintegrityasthefoundationforethicalpractice;andcomfortwithone'sownemotionsandtheemotionsofothers.Inaddition,abilitiesandattitudesseenasimportantwere:thecapacityforselfawareness;thecapacitytoestablishrelationswithothersinthesocialworkcontext;andcongruenceofindividualvalueswiththevaluesofthesocialworksystem.
Inastudythatincludesasurveyof20undergraduateprogrammesinsocialworkacrossCanada,BarlowandColeman(2003)gaveexamplesofprofessionallysuitablebehavioursincluding:
• abeliefinthevaluesandgoalsoftheprofession
• demonstrationofcaringandsensitivityinallprofessionalrelationships
• theabilitytorespondinauthenticwayswithattitudes,beliefs,andbehavioursthataccordtheclientdignityandworth
• competenceinoralandwrittencommunication
• anabilitytoworkindependentlyaswellaspartofateam
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• acapacityforpersonalchangeandanopennesstolearning
• anacceptancethatone’sprofessionalabilities,personalintegrity,andattitudesisameasureofprofessionalconduct.
Banks(2010)arguesthatprofessionalintegrity,inthesenseofadheringtothecodeofconductforsocialwork,isoftenconstruedasequatingtoprofessionalism,butarguesthattwootherinterpretationsofprofessionalintegrityarealso,inpractice,extremelyrelevant:professionalintegrityasacommitmenttoasetofdeeplyheldvalues,andprofessionalintegrityasacapacityforreflexivesense‐makingthatenablesmoralcompetenceinsolvingethicaldilemmas.Banksarguesthateachofthesethreeunderstandingsofprofessionalintegrityisinsufficientinitself,thattheyoverlap,andthatallofthemshouldbetakenintoaccountindevelopingprofessionalisminpractitioners.
Aswithprofessionalism,someapproacheshavebeentodefinebehavioursthatindicate'unsuitability'.Inonestudy,Koerin&Miller(1995)consideredthebehavioursandsituationsaddressedbyterminationpoliciesinrelationto‘non‐academicreasons’fortermination,andfivecategoriesemerged:
1. violationsoftheCodeofEthics
2. concernsaboutmentalhealthorsubstanceabuse
3. poorperformanceinthefield
4. ‘illegalactivities’‐whichincludedmattersofdeception
5. inappropriateclassroombehaviours.
FurnessandGilligan(2004),drawingonconversationswithover70socialworkpracticeteachersandtutorscompiledalistofunprofessionalpracticesthatincluded:damagetoserviceusers;crossingprofessionalboundaries;disrespecttoserviceusers;colludingwithserviceusers;notchallengingbadpractice;takingajudgementalapproach;carryingseriousissues;and‘notusingsupervision’.BarlowandColeman(2003)alsogiveexamplesofunprofessionalbehavioursidentifiedintheirstudy.
Recentpublicationsinthesocialworkfieldaddresstheissueofprofessionalsuitabilityinthecontextoftheregistrationofsocialworkstudentsatthebeginningoftheirstudies,asituationthatdoesnotapplyinthehealthprofessions,wherestudentsapplyformembershipoftheprofessiononsuccessfulcompletionoftheircourses(Manthorpeetal,2010).Academicstaffwhomakedecisionsaboutadmittingapplicantstocoursesarethusactingas'gate‐keeperstotheprofession'(egBarlowandColeman,2003).Anumberofpapersquestiontheextenttowhichjudgementsaboutsuitabilitycanbemadeatthisstage(egHolmströmandTaylor,2008;McLaughlin,2010).Assessmentofsuitabilityatthepointofrecruitmenttoacourseoftrainingwillbediscussedinmoredetailbelow.
Aswithprofessionalisminamedicalcontext,therisksofprofessionalunsuitabilityincludepoorpracticebystudentsundersupervision,andalsotherisksofpoorpracticeaftergraduation.AsBarlowandColemannote(2003:152),'socialworkersservevulnerablepopulationswhohavetherighttoreceivecompetentandethicalpractice'thereforeitisimportanttoensuretheirprofessionalsuitability,inordertomaintainpublictrust,andtoprotectclientsfromunethicalorincompetentservice.
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Insummary,theissueofprofessionalsuitabilityinsocialworkisperceivedinsimilarwaystothatofprofessionalisminmedicaltraining,inthatitisagreedtobeanimportantcomponentofensuringfitnesstopractise,butthatitisnoteasytodefineortoassess.Attemptstodefineitbringtogetherdescriptionsofbehaviours,beliefs,valuesandotherunderlyingcharacteristics.
GoodcharacterIntheUK,theNursingandMidwiferyCouncilrequires'goodcharacter'asaconditionofentrytotheUKregisterofnurses,andalsoforentrytoandcontinuationonpre‐registrationnursingprogrammesintheUK(Sellman,2007).Chaffer(1998)saysthat'goodcharacter'isbroadanddifficulttointerpret,asdoMcGregorandBrown(1998.
Intheprevioussections,examplesofdifferentperceptionsofprofessionalismandofprofessionalsuitabilityhaveshownthatitiscommontoincludesomeunderlyingcharacteristicsinthedefinition.Inasocialworkcontext,Clark(2006:88)statesthatgoodprofessionalpracticeisinfluencedby'themoralcharacterofthepractitioner'.
GoodcharacterinnursingislinkedtotheCodeofProfessionalConduct:Sellman(2007)discussesthedifficultiesfornurseeducatorsinattestingthatstudentsreallyhave'goodcharacter'iethattheyreallyengagewithandacceptthetenetsoftheCode,ratherthansimplyensuringtheydonottransgressitintheirbehaviour(adifferencealsodiscussedinthecontextofsocialworkbyBanks,2010).SnellingandLipscombe(2004)giveexamplesofarangeofbreachesoftheCodeofProfessionalConduct,arguingplausiblythattheseexamplesarenotallequallymorallyreprehensible.
Inanexplorationofthemeaningof'goodcharacter'CHRE(2008)suggestedthattheterm'ispotentiallyproblematicbecauseitisnotwidelyusedoutsideEnglish‐speakingcountriesandhasnoequivalentinEurope',andasaresult,thetermmaynotbeeasilyunderstoodbyapplicants,refereesandregulatorsfromothercountries.TheCHREidentifiedfourcoreindicatorsthatmightcallintoquestionanindividual's'goodcharacter':wheretheindividualhasacted,orthereisreasontobelievetheyareliableinfuturetoact:
(i)insuchawaythatputsatriskthehealth,safetyorwellbeingofapatientorothermemberofthepublic
(ii)insuchawaythathis/herregistrationwouldunderminepublicconfidenceintheprofession
(iii)insuchawaythatindicatesanunwillingnesstoactinaccordancewiththestandardsoftheprofession
(iv)inadishonestmanner
(CHRE,2008;2‐3)
Thereportarguesthatthesearethekeyfactorspertainingto'goodcharacter'thatarerelevanttofitnesstopractiseissues.
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MisconductProfessionalism,professionalsuitabilityandgoodcharacteraretermsthathavedifferentinterpretations,andthereforemaybedifficulttooperationalise.Inthecontextofjudgementsaboutstudentfitnesstopractise,oneconcernistoidentifysignsoftheabsenceofthesepositiveattributes.Varioustypesofclinicaloracademicmisconduct,orfailuretomeetcertainstandards,may,inthemselves,beinbreachofcodesofconductandindicatealackofprofessionalism,suitability,orgoodcharacter.Examplesofthisapproachhavebeennotedabove(Papadakisetal,1999;Teheranietal,2005;CHRE,2008).
Anumberofpapersreportontheuseofsurveysseekingratingsof,orcommentson,behaviourthatmaybeconstruedasmisconduct(egRizkandElzubier,2004;Al‐Dwairietal,2004;Brockbanketal2011)orunethical(egHilbert,1985;RennieandCrosby,2002;RennieandRudland,2003;Roffetal,2011).Thesestudiesoftenrevealarangeofjudgementsonthedegreetowhichabehaviourindicateslackoffitnesstopractise.Thereareissuestotakeintoaccountconcerningthenatureofthemisconduct(egHicksonetal,2007;Wagner,1993),andthestageoftheindividual'seducation(egArnoldetal,2002).Certainbehavioursmaybeconsideredunacceptablefromthefirstdayofstudy,whereassomesituationsmayposeverydifficultethicaldilemmas,challengingeventoexperiencedpractitioners(LuceyandSouba,2009).Thisissuewillbediscussedfurtherbelow,inthesectionsonhowstudentfitnesstopracticemaybedevelopedandassessed.
Academicmisconductisdiscussedinanumberofarticlesinrelationtofitnesstopractice.Behavingwithalackofintegrityandhonestyinacademicmatters(suchasbyplagiarisingothers)maybeconsideredabreachofacodeofprofessionalethicsinitself,aswellaspotentiallyanindicatorofapropensitytobehaveunethicallyinothercontexts(BradshawandLowenstein,1990;Gaberson,1997).
Kenny(2007)arguesthatanursewhoplagiarisesworkmaybeinbreachoftheprofessionalcode,astheydon'thavethenecessaryunderpinningknowledgetodo(partof)theirjob,andtakingasimilarviewinrelationtoeducationfordentistry,Hughesetal(2009)arguethatplagiarismwillreducestudents'learning.Stoneetal(2009)citeasmallnumberofpaperslinkingacademicmisconductwithcheatingatworkandengagingincounter‐productiveworkbehaviours.AsmallstudyreportedbyYatesandJames(2010)suggeststhatearlyacademicdifficultiesatmedicalschool(whichotherstudieshaveshowntobeadriverofacademicmisconduct)couldbeariskfactorforsubsequentprofessionalmisconduct(althoughYatesandJamesnotethefindingsarepreliminaryandshouldbeinterpretedwithcaution).Postle(2009)arguesthatplagiarismcanindicateunsuitabilityforsocialworkpractice.
HealthimpairmentanddisabilityImpairedhealthmayproveabarriertoindividualsbeingabletosuccessfullycompletetheirprofessionaleducation,orsubsequentlytobeabletopractiseattherequiredstandard.Thisfactorisdifferentfromthedimensionsofprofessionalism,professionalsuitability,orofgoodcharacter,discussedintheprevioussections.
ApaperreportingthefindingsofaGeneralFormalInvestigationlaunchedbytheDisabilityRightsCommission(SinandFong,2008)intotheapplicationofthenursingregulator’srequirements,foundthatkeynationalstakeholderorganisations,highereducation
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institutions(HEIs)andemployersexperienceddifficultyininterpretingthe'goodhealth'requirementsconsistently.Thepaperreportsthatmethodsofimplementationvariedbetweenorganisations,andthatthisvariabilitycanleadtodiscriminationagainstdisabledpeople.
ThesocialworkregulatoryframeworkrequiresindividualstodemonstratementalandphysicalfitnessinEnglandandWales(althoughnotinScotland).Inaninquiryintofitnessrequirementsforsocialworkeducation,SinandFong(2009)foundthattheterminologyaroundfitness,andtheassessmentoffitness,inthisprofessionalareawasperceivedbyHEIstobeunclear.This,togetherwithalackofguidanceontheprocedurestobeusedtoassessfitness,hadresultedinawidevarietyofapproacheswithindifferentHEIs.Furthermore,studentswithdisabilitiesmaybeunfairlydiscriminatedagainstasHEIsconsiderissuesofmentalandphysicalfitness(SinandFong,2009).Inarelatedpieceofresearch,Stanleyetal(2011)foundthatdisabledstudents,orapplicantstocoursesofstudy,maybereluctanttodeclaretheirdisability,ormaydosoonlywithtrepidation.
Thisisadifficultarea,withHEIsrequiredtobalancetherightsofstudentswithhealthdifficultiesordisabilitieswiththerightsofthepublic,serviceusersandpatients(WatkinsonandChalmers,2008).Anumberofthehealthcareprofessionregulators,includingtheHPC,haveproducedguidanceinthisarea(HPC,2006).
SummaryFitnesstopractiseismadeupofknowledgeandskillsthatarerelevanttotheprofessionaldiscipline,plusanothercomponent,variouslydefinedasprofessionalism,suitability,goodcharacter.Thisadditionalcomponentiscomplex,difficulttodefinewithexactitude,andhasbeendescribedintermsofattributes,values,rolesandactivities.Oneapproachthathasbeentakenistodefinebehavioursthatconstitutemisconduct,andindicateadeficiencyinprofessionalism,suitabilityandgoodcharacter.Theseissuesofdefinitionandrecognitionofthiscomponentoffitnesstopractisearerelevanttoquestionsofhowitcanbeassessedanddeveloped,andtheactionsthatHEIs,regulatorsandotherbodiescantakeinrelationtothismatter,discussedbelow.
Thissectionhasalsoconsideredanotheraspectoffitnesstopractise,thatofhealthimpairmentanddisability,andthepotentialraisedintheliterature,forvariablepracticebyinstitutionsinassessingthesefactors,andthepotentialforunfairdiscriminationagainstdisabledpeopleonthesegrounds.
3.2 Factorsaffectingstudentfitnesstopractise
Studentsdeveloptheabilitiesrequiredforfitnesstopractiseinhealthandsocialcarethroughprocessesofacquiringrelevantknowledgeanddevelopingtheskillsandattitudesthatarenecessarytoenablethemtobehaveappropriatelyintheirprofessionalroles.Factorsthatenablestudentstodeveloptheseabilitiesincludethosethatprimarilyresidewithintheindividual–aptitudes,potential,beliefsandattitudes–thosethatprimarilyresidewithintheinstitutionprovidingtheeducationandtraining–suchasthecurriculum,andapproachestoteachingandlearning–andthosethatariseoutoftheinteractionofindividualandinstitutionalelements.Manyofthepapersreviewedforthisresearchfocus
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ontheactionsthatinstitutionscantaketorecruit,guide,educate,develop,assessand,wherenecessary,disciplinetraineesinordertoenablethemtobefitforprofessionalpractice.Thenextsectionofthispapersummarisesrelevantideasaboutinstitutionalactions.
Thissectionofthepaperbringstogetherrelevantpublishedideasaboutfactors,whichmayderailstudentsintheirprogresstowardsachievinganddemonstratingcompetencetopractise.Theseideasaremainlydrawnfromstudiesofunprofessionalbehaviourdemonstratedbystudents.Thereviewoftheliteratureshowedthatusing‘risk’asasearchtermgenerallydidnotrevealitemsrelatedtotheriskthatstudentsposed,moreoftenfocusingontheriskstostudentsfrom,forexample,notbeingimmunised.
Asnotedintheprevioussection,viewsaboutprofessionalism(andprofessionalsuitability)variouslyembraceboththeideathatitisacharacteristicrootedinpersonality(integrity,honesty,empathyetc)andtheideathatitmayonlybejudgedbybehaviourinspecificcasesandcircumstances(egCurrer,2009).Thisrangeofviewsnaturallyimpactsonopinionsaboutfactorsthatgiverisetounprofessionalbehaviour.
Ginsburgetal(2000)arguethatthetraditionalapproachtoevaluatingprofessionalismimpliesthatprofessionalismrepresentsasetofstabletraits,butthatthisdisregardsresearchintopersonalitypsychology,whichshowsthatthepresenceofspecifictraitsdoesnotpredictbehaviour.Thewritersarguethattherearemanygreyareasintheideaof'unprofessionalbehaviour'andthatanevaluationofprofessionalismshouldfocusonbehaviours,andtheindividual'sreasonsforbehavingincertainwaysinspecificsituations.Theyhighlightethicalchallengesthatrequireprofessionalstoreconcileequallyworthyopposingvalues,suchastheimperativetotellthetruth,andtheimperativetoprotectpatientconfidentiality:'thesevaluesmayoccasionallycomeintoconflict,andtheultimatechoicethestudentmakeswilldependonthespecificsofthesituation'(Ginsburgetal,2000:S6).
ExamplesofdilemmasofthisnaturefromLuceyandSouba(2010:1021)include:
'ShouldIleaveat12noonafterbeingupallnight,thusavoidingfatigue‐relatederrors(excellence),orshouldIstayandcontinuetocareformypatientatthiscriticaljunctureinhiscase(altruism)?'
'ShouldIdemonstratecompassionbyspendingextratimewiththispatientwhojustreceivedbadnews,orshouldIdemonstraterespectforthenextpatientbystayingonschedule?'
Anexplorationofethicaldilemmasexperiencedbysocialworkstudentsinasmallinternationalstudy,foundthatsituationsreportedasethicallydifficultwere:challengingserviceusersandcolleagues;thepowerandresponsibilityoftheworker;anddefiningtheboundariesoftheprofessionalrelationship(Banks,2005).
Inastudyofethicaldilemmasexperiencedbyphysicaltherapystudentsduringclinicalplacement,Geddesetal(2004)foundthatstudentsfrequentlyreportedethicalissuesarisingintheclinicalsetting;theissuesweremainlyrelatedtothestudents’relationshipswithclientsandco‐workersandwiththeirexplorationoftheirrolesasdevelopinghealthprofessionals.Threemainthemeswere:respectfortheuniquenessofindividuals,responsibilityandbehaviourasamemberoftheprofession,andinteractionwithand
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respectforhealthprofessionals.Moreminorthemesincluded:allocationofresources,advocacyforclient,societyand/orhealthpolicy,andinformedconsent.
Arnold(2002)buildsontheideathatunprofessionalbehaviourislikelytobesituationspecific,ratherthanarisingfromastabletraitofcharacter.Asstudentsmaybeexpectedtodeveloptheirabilitytobehaveprofessionallyindifferentsetsofcircumstancesastheyprogressthroughtraining,shesuggests:'Perhapsamatrixshouldbedevelopedtoindicatewhichlevelsofassessmentwillbeappliedtowhichelementsatwhichcareerstage[duringtraining].'(p509)
Somestudiesidentifypressureonstudentstoachievegoodgradesincourseworkasafactorthatgivesrisetoacademicmisconduct(egHilbert,1987;RennieandRudland,2003;Postle,2009).Dyrbyeetal(2010)identifystressandfearofpoorevaluationsasfactorsthatmayleadtounprofessionalacademicandclinicalbehaviours.
InastudyofcheatingandacademicmisconductamongbusinessstudiesstudentsenrolledataUSuniversity,Stoneetal(2009)foundAjzen’s(1991)theoryofplannedbehaviourprovidedausefulframeworkforunderstandingtheinfluencingprocesses.AsappliedbyStoneetal,thetheoryarguesthatthreefactorsinfluenceindividualintentions,justificationsandbehaviours,whichare:
• individualattitudestowardthebehaviour‐beliefsaboutabehaviouroritsconsequences,whichinthiscaserelatestowhetheraparticularbehaviouramountstomisconduct,and/orwhetheritisharmful.
• subjectivenorms‐theindividual'sperceptionsoftheexpectationsofotherpeopleregardingthebehaviour.Evenwhereindividualsbelieveaparticularbehaviouramountstomisconduct,theymayperceivethatitiscommonamongcolleagues‐'everyoneisdoingit'.
• perceivedbehaviouralcontrol‐theperceivedeaseordifficultyofperformingthebehaviour,whichinthiscaserelatestoopportunity,tothelikelihoodofbeingfoundout,andtotheconsequencesofbeingcaught.
Thecombinationofthesefactorsinfluenceindividualintentionsandjustifications(orrationalisations‐cfBrownetal,2011),andtheseinturninfluencebehaviours.
Thereissomesupportfromotherstudiesfortheapplicationofthisframeworktounprofessionalisminhealthandsocialcaretraining.Wherestudentsquestionthevalueofcertainbehaviours(suchasobtainingasignatureforacertainclinicalprocedure)thismayleadtodishonestbehaviour,suchasforgingsignatures(RennieandRudland,2003).AstudybyHilbert(1987)foundthatthecommonreasonforengaginginunethicalclinicalbehaviourswasthatthebehaviourdidnotseemtotheindividualtobeunethical,andthatthisperceptioncouldbeinfluenced,forgoodorill,bytheactionsofeducators.StudiesbyBainganaetal(2010)andbyAndersonandObenshain(1994)foundadeclineinattitudestowardsethicalissuesinmedicineasstudentsprogressedthroughtraining,whichBainganaetal(2010:4)suggested'mayrelatetolossofidealismandtheimpactofthehiddenand/orinformalcurriculum.'AstudybySelfandBaldwin(1998)showednodevelopmentinmoralreasoningamong598medicalsstudentsoverfouryearsofstudy,leadingtheauthorstosuggest'theremaybesomethinginthestructureofmedicaleducationthatappearstoinhibittheexpected[natural]growth'(ppS92‐93).
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Therangeofactionsthatinstitutionscantaketodevelopprofessionalbehavioursandattitudesisthesubjectofthenextsection.Afailureinanyoneoftheseactionsmaybeafactorthatatleastpartlygivesrisetounprofessionalbehaviouronthepartofstudents.
Insummary,studiesaddressingthefactorsgivingrisetounprofessionalbehaviouramongstudentstendtofavourabehavioural/situationalapproachtoevaluatingprofessionalism.Differentstudieshavefocusedonavarietyofinfluentialfactors.Behaviourthatisconsidered'unprofessional'mayariseoutofattemptstoresolveconflictsofvalues.Theabilitytotakedifficultprofessionalchoicesisacapabilitythatmaybeexpectedtodevelopovertime.Ajzen's(1991)theoryofplannedbehaviour,asmodifiedbyStoneetal(2009),appearstoprovidearelevantandusefulframework,whichincorporatesindividual,socialandinstitutionalfactorsinfluencingmisconductorunprofessionalbehaviour.
3.3 Educationalinstitutionsandstudentfitnesstopractice
IntroductionThissectionaddressesliteratureonwhateducationalinstitutionsthatprovideprofessionaltrainingandeducation(usuallyHEIs)candotodeveloptheabilitiesofstudentssothattheypractiseattherequiredlevel.Thisincludesnotonlyacademictuitionandassessment,butalsothedevelopmentandassessmentofclinicalskillsandofprofessionalism.Itisworthnotingatthispointthattheliteraturehaslittletosayabouttheroleofregulatorsinpromotingfitnesstopractiseandtendstofocusonwhateducationalinstitutionscando.Welookattheimplicationsofthefindingsforregulatorsinthenextsection.
InarecenteditorialReid(2010)callsformedicalschoolstomanagestudents'inawaythatplacesequalvalueonboththeacademicandnon‐academicaspectsoffitnesstopractise.'Anumberofstudiesaddressdifferentaspectsofthisissue.Whilstthefocusofsomestudiesreportedintheliteratureisonlearninganddevelopment,andthefocusofotherstudiesonassessmentandevaluation,thereisagreementthatbothtypesofactivityareneeded.AsBailey(2001)notes,inastudyonacademicmisconductamongstudentnurses,thereisaneedforbothproactiveandreactivemeasures,includinganethicalfocusinthecurriculum,clarityaboutthestandardstobemet,andclearpoliciesandpracticesthatareconsistentlyappliedbyallstaff.
Thissectiondiscussesthethemesintheliteratureinthreeparts–thosethatareprimarilyaboutdevelopment,thosethatareaboutassessment,andthosethatareaboutinvestigatingandmanagingdisciplinarymatters.Inpracticethereareoverlapsbetweenthethreeareas,butitisusefultoexploreeachtopiconeatatime.
Inapproachingdevelopment,assessmentanddiscipline,theliteratureemphasisesaneedforagreementbetweenstaffastowhatconstitutesacceptableandunacceptablebehaviour,asaprecursortocommunicatingclearexpectationstostudents.
Forexample,Hilbert(1985)recommendsthatstaffneedtodevelopaconsistentapproachaboutwhatisandisnotunethicalandtotakeastandwhenunethicalbehaviourisdetected.Papadakisetal(1999)andKorszunetal(2005)provideexamplestoclearlyidentifydesirableandundesirablebehaviours,andvanMooketal(2009a)foundthatstandardisedchecklists,writtencommentsandreportswerecommonlyusedtoassessprofessionalism.
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Agreementonwhatconstitutesprofessionalismisunlikelytooccurwithoutdiscussionanddialogue,andmaynotbeeasytoachieve.Forexample,Teheranietal(2005),inaUSmedicalstudy,foundthattherewasnoconsistentagreementamongstfacultyaboutwhichbehaviourswereunprofessional.BoonandTurner(2004)arguethat,inaculturethatemphasisesevidence‐basedmedicine,itmaybedifficulttoconvincestudentsand'hard‐headedcolleagues'that'ethics,professionalism,andhumanism...gototheheartofthepracticeofmedicine.'Asaprevioussectioninthisreportnoted,thereisnotuniversalagreementaboutthemeaningofkeyconceptssuchas'professionalism'or'suitability'‐orhowtheymaybeassessed.
Ontheotherhand,Goldie(2008)arguesthatthedevelopmentofamodelofprofessionalismbytheScottishDeans’MedicalCurriculumGroupdemonstratesthatitispossibletogetagreementonwhatconstitutesprofessionalbehaviour,acrossinstitutions,andevenbetweenquitedifferentstylesofcurricula.Smithetal(2007)reportonactionstakentocreateacampus‐widecultureofprofessionalisminoneUSmedicalschool:theactionsincludedcreatingacharterandmissionstatement,puttinginplaceavarietyofmeasurestodevelopanunderstandingofprofessionalism,andmechanismstointervenewhereunprofessionalbehaviourswereobserved.
TheliteratureinthisareaindicatesthattheconsequencesofnotachievingagreementwithinanHEIcanbemixedmessagestostudentsaboutthenatureof,andtheneedfor,professionalbehaviour,difficultiesinassessingfitnesstopractise,andconfusionanddifficultyininvestigatinganddealingwithallegedfailures.
Fitnesstopractice:developmentTheprocessofdevelopmentoffitnesstopractiseisemphasisedbyKasarandMuscari's(2000:43)pointthat'Professionalbehavioursmaturethroughanaturaldevelopmentalprocess;aprocessthatrequirescarefulnurturingonthepartofeducators,studentclinicalsupervisors,andcliniciansthemselves'.WearandCastellani(2000)equatethedevelopmentofelementsofprofessionalismwiththedevelopmentofclinicalskills,suchasclinicalreasoning–thatisstudentsneedtobeeducatedinthem,theyarenotunchangingandtheydonotdevelopautomatically.
Thereisbroadagreementthatanessentialpartoftheprocessofhelpingstudentstolearnthisaspectoffitnesstopractiseissettingclearexpectations,definingwhatisacceptableandunacceptable,andsettingoutresponsestounprofessionalbehaviour(egHilbert,1985,1988;AndersonandObenshain,1994;Hall,2004;SternandPapadakis,2006;CruessandCruess,2006;Howeetal,2010).
Anumberofpaperssetoutthediversemeansbywhichprofessionalismislearned.Inareviewofthehistoryofeducatingstudentsinmedicalethics,Foxetal(1995)observethatthetraditionalmodelofeducationfocusedondevelopmentofrelevantknowledgeandcognitiveskills,taughtasaseparatecourse.Overtime'awealthofdifferentmethods'emergedtopromoteethicaldevelopment,withmorefocusonemotionalandbehaviouraldimensionsofethicalbehaviour.SternandPapadakis(2006)setouttheproactivestepsthatneedtobetakentopromoteprofessionalism–byeducators,byhealthcareorganisationsandbyregulators.Theysuggestthattheteachingofcorevaluesneedstobecontemplatednotonlyastakingplacethroughlectures,smallgroupdiscussionsetc,butthroughamuch
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widerrangeofactivities,includinginformalactivities,thatoccurduringastudent'seducation.
SternandPapadakis(2006)refertotheimportanceofwhatHaffertyandFranks(1994)calledthe'hiddencurriculum',anideathathasbeenadoptedbyanumberofotherwriters(egFoxetal,1995;Masella,2006;Smithetal,2007;Goldie,2008;Bainganaetal,2010;Karnieli‐Miller,2010).Thehiddencurriculumconsistedoftutorialprocesses,experientiallearning,andlearningduringplacementactivities,andmaycontainlearningthatcontradictstheformalteachings‐inlectures‐aboutprofessionalbehaviours.BrainardandBrislen(2007),reflectingonexperiencesinmedicalschools,arguethatmanystudentsstrugglewiththecontradictionbetweentheexplicitprofessionalvaluestheyaretaughtintheformalcurriculumandtheimplicitvaluesofthehiddencurriculum.
Anumberofpapersemphasisetheimportanceofcoordinating,throughoutthewholecurriculum,teachingandlearningaboutprofessionalism(egHilbert,1988;Danieletal,1994;SternandPapdakis,2006;Smithetal,2007;Elliottetal,2009;vanMooketal,2009b)andprofessionalsuitability(HolmströmandTaylor,2008)includingonalongitudinalbasis,ensuringthat'instructionandopportunitiesforself‐reflectionappropriatetothestageoftraining'areprovidedinallelementsoftheprogramme(CruessandCruess,2006:206).Goldie(2008)callsforintegrationofmedicalprofessionalismacrosstheentirecurriculumwithsignificantinteractionbetweenformalteachingandprofessionalpractice.
Rolemodellingisseenasanimportantcomponentofconveyingprofessionalvaluesandbehaviours(egDanieletal,1994;Gaberson,1997;Korszun,2005;HiltonandSlotnick,2005;Ratanawongsaetal,2006;SternandPapadakis,2006;Weissmannetal,2006;Whiting,2007;Fowler,2008;Hughesetal,2009;Howeetal,2010;Morrowetal,2011).SternandPapadakis(2006:1797)suggestthateducatorsshoulddesignclinicalexperiencesthatwillallowstudentsobservehow'seasonedpractitioners'managedilemmasofpractice,suchasconflictsbetweentheidealtimetospendwithpatientsascomparedwiththeclinictimeavailable.Theynotethat'rolemodellingneedstobecombinedwithreflectionontheactiontotrulyteachprofessionalism'(cfalsoStockhausen,2005)andpointoutthat'facultyneedtobetrainedtopromoteakindofrolemodellingthatisessentialtoastudent’sprofessionaldevelopment'(p1796).Thepotentialfornegativerolemodels,inacademicandpractice‐basedsettings,toinfluencestudentattitudesandbehaviourisnotedbyanumberofwriters(egBrainardandBrislen,2007;vanMooketal2009b).
Theuseof'honourcodes'isdescribedbyHughesetal(2009)inthecontextofeducationfordentistry.Hughesetal(2009)advocatehonourcodesinordertodefinecheating,raiseawarenessamongstudentsoftheseriousnessofcheating,andclarifytheimplications.BarlowandColeman(2003)foundthatanumberofCanadiansocialworkschoolsuseaCodeofConducttoclarifyexpectationsandtopermitassessmentofthestudent'ssuitabilityduringtheprogramme.Theyfoundthatcodescouldincludeissuessuchasrespectingtheconfidentialityofclients;treatingcolleagues,tutors,clients,staffandsupervisorswithrespect;demonstratinghonesty,courtesy,fairnessandgoodfaith;andupholdingtheSocialWorkCodeofEthics.Thedevelopmentanduseofcodesofconduct/ethicsbyregulatorsisdiscussedinchapter4.
Valuesandattitudesarecomponentsofmostdefinitionsofprofessionalismandsuitability,andsomestudiesaddresshowthesevaluesmaybedevelopedwithinthecurriculum.Whiting(2007)explorestheethicalandpracticalissuesofseekingtochange'morally
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inappropriateattitudes'evidencedbystudents,whichmaygiverisetoquestionsoffitnesstopractise.Hearguesthatitisappropriatetodosoonaconsensualbasis,andthatinappropriateattitudesmay,firstofall,arisefromalackofunderstanding,andthatthiscanbechallenged.Wherecognitivechallengesareineffective,exposuretosituationswherepatientsareinneedofsupport,ormodellingcertainformsofbehaviour,suchasthoserelatingtocompassion,maybesuccessful.However,Whitingnotesthatchangingattitudesis'anotoriouslydifficultchallenge'(p669)andacceptsthatthismaynotbeachievableineverycase.Issuesdiscussedabove,inthesectiononthemeaningof'professionalsuitability'andthemeaningof'goodcharacter'arerelevanthere.Sellman(2007)andBanks(2010)bothdiscussed,indifferentdisciplines,thedifferencebetweenadherencetothevaluesexpressedinacodeofpractice,ontheonehand,andrealownershipofrelevantvaluesontheotherhand.Itisassumedthatethicaljudgment,andtheabilitytoactethicallycanbedevelopedduringprofessionaleducation(egBanks,2005;HiltonandSlotnick,2005;SandersandHoffman,2010).Thedevelopmentofcertainvaluesandattitudes,relevanttotheprofession(egLafranceandGray,2004),andtheabilitytoapplycriticalthinkingto'thoseassumptions,beliefsandvalueswhichhavebeenuncriticallyassimilatedandinternalizedduringchildhoodandadolescence'(Goldie,2008:521)isseenasakeypartofthedevelopmentofprofessionalism.
Activity–undertakingclinicalexperiences–isregardedasanessentialcomponentoflearningprofessionalism(egHall,2004;Price,2006;vanMooketal,2009b).CruessandCruess(2006)emphasisethatfacultyneedtoteachtheprinciplesthatunderpinprofessionalismandalsoenablereflectiveexperientiallearningthroughprovidingopportunitiestoactandreflect.
Mentoringstudentperformanceisanotherkeyactivitytosupportdevelopment.Inthiswaymentorscanenhancestudentdevelopmentbyreinforcingappropriateprofessionalbehaviour(SternandPapadakis,2006),aswellasprovidinginformedformativeassessment.
Self‐assessmentisacomponentofreflectivelearning,andanumberofstudiesadvocateitasastructuredelementwithinformativeevaluation(egHall,1994;Korszunetal,2005;Whiting,2007).InaUKstudy,however,ReesandShepherd(2005a:30)foundthatstudentshaddifficultyinaccurateself‐assessment,andfeedbackwascrucialinhelpingthemtogainthisunderstanding(foundalsoinHodgesetal,2001).
Clelandetal(2005)foundthatacohortofstudentswhohadfailedtheirfinalclinicalexaminationsshowedlowself‐awarenessinrelationtotheirpreviousperformance.Theauthorsrecommendedthat'studentswouldbenefitfromsupportindevelopingself‐reflectionskillsinsuchawaytosupportlife‐longlearning'(p504).
Insummary,literatureintheareaofactionsthatHEIscantaketodevelopfitnesstopractiseencouragesstafftohaveregardtoawiderangeofactivities,bothformalandinformal,thatconstituteteachingandlearning,andtoseektocoordinateteachingandlearningacrossalltheseactivities.Thereappearstobebroadagreementthatimportantelementsofteachingandlearninginclude:clearcommunicationofprinciplesandprocedures;rolemodellingandexplanationofdesirablebehavioursbystaff;opportunitiestopractise,andtoreflectonandreceivefeedbackonpractice;monitoringperformance,reinforcinggoodpracticeandprovidingextrasupportwherenecessary;andhelpingstudentsdeveloptheskillsofself‐reflection.
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Fitnesstopractise:assessmentTheliteratureinthisareaonthewholeadvocatestheassessmentofprofessionalismandprofessionalsuitability,bothformativelyandsummatively.Anumberofpaperssuggestarangeofmethodsshouldbeusedforassessment,andprovidespecificexamples.Thereisalsoathemeintheliteratureofthedifficultiesthatsupervisorsandotherstaffexperiencegivingcriticalfeedbacktostudents.
Assessmentofprofessionalism,orsuitability,maybeexpectedtotakeplace:a)onapplicationtoaprogrammeofprofessionaleducation,b)formatively,duringtheprogramme,toaidlearningandassessprogress,andc)summativelyatcertainpointsduringtheprogramme.
AssessmentforselectionAssessmentofthesuitabilityofapplicantstoaprogrammehasbeenaddressedatgreaterlengthinrecentyearsinstudiesofsocialworkeducationthaninotherprofessions,perhapsduetotheDepartmentofHealthrequiringHEIstoassessallshortlistedapplicantsforsocialworkdegreecoursesthroughgrouporindividualinterviewsinvolvingemployersandpeoplewhouseservicesandtheircarers(DepartmentofHealth,2002).Manthorpeetal(2010)inasurveyofEnglishHEIs,foundthatstafftaketheirresponsibilitiesinthisrespectveryseriously,andthatthetaskisresource‐intensiveandtime‐consuming.
Inareviewofliterature,LafranceandGray(2004:329)foundthatmostattentionatrecruitmentwaspaidtoacademicqualifications;andthat:'althoughthepersonalqualitiesandcharacteristicsformedpriortoarrivingattheportalsoftheprofessionareofcriticalimportanceforthepracticeofsocialwork,thesecriteriaaretheleastattendedtointheadmissionprocess.'
Dillon(2007),inastudyofrecruitmentinthecontextofapolicyofwideningparticipation,suggeststhatmorerobustselectionprocessesmayrevealmoreaboutapplicants'suitabilityforsocialworkeducation,whilstacknowledgingthatthismaynotbeenoughtoassesstheir‘emotionalandpsychologicalreadiness’forsocialwork.
ThesurveyofsocialworkprogrammesacrossCanadacarriedoutbyBarlowandColeman(2003)foundthatarangeoftoolswereusedforselection,includingacademicgrades,informationfromassessmentinterviews,references,curriculavitae,criminalrecordchecks,andscreeningquestionnaires.Theynotethatakeychallengeis'todevelopadmissionscriteriathatareequitableinorderthatdiversegroupsarenotexcluded'(p152).InEngland,FurnessandGilligan(2004)foundthattheselectionofprospectivesocialworkstudentsusuallyinvolvessomecombinationofrole‐plays,discussiongroups,writtentestsandinterviews.
Inmedicaleducation,SelfandBaldwin(2000)supportedtheuseofstandardisedtestsofmoralreasoningaspartoftheadmissionprocess,butsubjecttotheresultsoffurtherresearch.Inaretrospectivecohortstudy,Sternetal(2005)foundtherewerenoconsistent,significantcorrelationsbetweenanyinformationassessedatadmissionandanyoftheoutcomesofprofessionalbehaviourinYear3ofmedicalschooleducation.However,intheUK,asystematicreviewstudybyFergusonetal(2002)foundpreviousacademicperformancetobeareasonablepredictorofachievementinmedicaltraining,andindicatedthataparticularlearningstylewasalsoassociatedwithsuccess.
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AnextensiveliteratureanalysisofassessmentofsuitabilityforadmissiontosocialworkeducationinthecontextofchangingpolicyinEngland(HolmströmandTaylor,2008)concludesthatitisverydifficulttoassessatthispointfactorsotherthanprioreducationalattainment,andagreeswithMadden(2000:141):'withtheexceptionoftheobviouslyunsuitablestudents,thereislittleevidencethatstudentswhowillnotsucceedcanbeidentifiedinadvance.'HolmströmandTaylor(2008)arguethatadmissioncriteriashouldbeclearlydefined,butthatHEIsshouldnotrelysolelyonassessmentofsuitabilityatthisstage,andthatthereshouldberegularassessmentpointsof'non‐academic'performanceduringtheeducationprogramme.
Overall,assessmentofsuitabilityatthepointofadmissionappearstohavebeensubjecttothecompounddifficultiesofa)demonstratingtheclearlinksbetweennon‐academiccharacteristicsandsubsequentlackoffitnesstopractice,b)accuratelyassessingnon‐academicfactorsduringadmissions,andc)agreeingontheappropriatelevelofpotentialthatapplicantsshouldpossess,priortoprofessionaleducation,asathreshholdforadmission.Itisperhapsparticularlyproblematicinrelationtothesocialworkprofession,wheretherearestrongvaluesofprovidingindividualswithopportunitiestoimproveanddevelop.
AssessmentduringeducationAreviewofmethodsofassessmentofmedicalprofessionalismover20years,arguedthat'althoughassessingprofessionalismposesmanychallenges,gaugingandascertaininggrowthinprofessionalismisimpossiblewithoutmeasurement'(Lynchetal,2004:366).
VanMooketal(2009a:90)similarlyarguethatmedicalprofessionalismmustbeassessed:'assessment...isamechanismbywhichmedicalfacultiessignalthattheyvaluecertainsubjectareas.Thelackofformalassessmentmayunderminetheimpactofteaching.'TheRoyalCollegeofPhysicians(2005a:3.37)recommendedthat'eachstudent'sprofessionalvaluesshouldbeassessedthroughouttheirtrainingtoensuretheirfitnesstopractise'.
Inastudyinamedicalschool,Goldieetal(2002)foundevidencetosuggestthatalackofformalassessmentofethicsteachinginyears2and3oftheprogrammewasfelttocontributetoitslackofimpactonmedicalstudents,comparedtothoseyearswhereitwasassessed,whilstHowe(2002)concludedthatsummativeassessmentofprofessionalismisnecessary,inordertoensurecompetenceandtomotivatelearning.
Formativeassessmentmaybeusedtoidentifyatanearlystagethosestudentswhoneedextrasupport(Hilbert,1985;Clelandetal,2005;vanMooketal,2009d;Reid,2010).YatesandJames(2010:6)suggestthatwherestudentsarefoundtobeperformingpoorly,theyshouldreceiveadditionalsupportandmentoring.Lynchetal(2004:369)alsoarguethat'professionalismshouldbeformativelyassessed.Thismeansthatassessmentshouldbeginearly...beconductedfrequently,beimplementedlongterm,andprovidelearnerswithopportunitiestochange.'
Athemeinthemedicalliteratureistheadvocacyoftheuseofarangeofmethodsforassessingprofessionalism.Arnold(2002)providesareviewofmethodsofassessingprofessionalism,includingpeerorteacherassessment,surveys,criticalincidenttechniques,ObjectiveStructuredClinicalExaminations(OSCEs),methodsalsoadvocatedbyWhiting(2007).Bogoetal(2011)reportfavourablyontheuseofanadaptationofamedicalOSCE
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foruseinsocialworkeducation.Lynchetal(2004)reviewed88differentmethodsofassessmentofmedicalprofessionalism.Anumberorwritersadvocatetheuseofarangeoftoolstoassessmedicalprofessionalism,includingtheuseofaprofessionalismmini‐evaluationexercise(P‐MEX)(Cruessetal,2006;Wilkinsonetal,2009;vanMooketal,2009aand2009c).
Assessmentofprofessionalismandprofessionalsuitabilitymaybeguidedbysuchtools,butultimatelyrestsonthejudgementofexperiencedandqualifiedtutorsandsupervisors.However,anumberofstudiesnotethedifficultysupervisorscanfaceingivingcriticalfeedback(Buracketal,1999;vanMooketal,2009d;ClearyandHorsfall,2010),andthereluctanceoftutors,supervisors,practiceeducatorsormentorstofailstudents(BarlowandColeman,2003;Duffy,2003;DuffyandHardicre,2007aand2007b;Clelandetal,2008;BasnettandSheffield,2010;Carretal,2010;Dean2011),totellthemthattheirperformanceisinadequate(Clelandetal,2005),toaddressacademicdishonesty(Kolankoetal,2005;Fontana,2009),tochallengemattersofattitudeandconduct(Korszunetal,2005;BoonandTurner,2004),ortolabelastudentunprofessionalforminorlapsesinprofessionalbehaviour(Ginsburgetal,2000).Studiesthatfocusonthisdifficultyemphasisetheneedforclearpoliciesandfortraining,andsupportformentors,supervisorsandassessorstoenablethemtoundertakethisdifficulttask(egFurnessandGilligan,2004;Hicksonetal,2007;vanMooketal,2009d)'empathicallyandeffectively'(Clelandetal,2005:507).
InastudyofclinicalteachingandsupervisioninAustraliannursing,ClearyandHorsfall(2010)foundthatmanystudentswereresistanttocriticalfeedback,andwereinclinedtorespondaggressivelyratherthanconstructively.Thestudyhighlightstheneedforclearpoliciesandproceduresfortheplacementexperience(ieaboutexpectedbehaviours,andtheprocessestobefollowedifstudentsfailtomeetexpectations)andidentifiesrelevantinterpersonalskillsandapproachestogivingfeedbackthatwereneededbytheclinicaleducatorsinthissituation.
ThestrategyClearyandHorsfall(2010)suggestistodiscusstheidentifiedproblemandrepeatkeypointswiththeaimorworkingwiththestudenttoimprovethesituation;behave,speakandreiteratecalmlywithoutconveyingfrustrationoranger;havefirmevidenceanddocumentationandformalsupportfromcolleaguesandacademicbodiesresponsibleforoverseeingastudent’sfailuretomeetclinicalobjectives.
DuffyandHardicre(2007b)alsoputforwardadvicetomentorsinsuchsituations:
• highlightareasofconcernaboutperformanceasearlyaspossible
• providefeedbackintimeforstudentstoshowimprovement
• offerverbalandwrittenfeedbacksothatstudentsareneversurprisedbythedetailsofafailedfinalclinicalassessment
• donotpassastudentifthereisanydoubtthatpatientswouldbeputatrisk
• donotavoidtheissueoffailingastudentwhodoesnotmeetthestandards.
Insummary,literaturereviewedinthisareaconcernsassessmentpriortoadmissiontoaprogrammeaswellasformativeandsummativeduringthecourseofprofessionaleducation.Therearedoubtsabouttheaccuracyofassessmentforselection,otherthanasameansofexcludingthe'obviouslyunsuitable'candidates.Theliteratureadvocatesformativeandsummativeassessmentduringeducation,withformativeassessmentsgiving
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rise,whereappropriate,tobetterunderstanding,moresupportandfurtherdevelopment.Arangeofdifferentmethodsofassessmentisadvocated.Thechallengetostaffofgivingcriticalfeedbackonmattersofpracticeandattitudeisthefocusofanumberofpapers,indicatingthatthisisanareawhereclearguidelinesshouldbedevelopedandcommunicatedtostudentsandstaff,andwherestaffwillbenefitfromtrainingandsupport.
Fitnesstopractise:investigationanddisciplineFailuretopassassessmentsofprofessionalism,orprofessionalsuitability,maygiverisetotheneedfortheeducationalinstitutiontoexercisesanctions.Allegationsorincidencesofmisconductwillalsogiverisetotheneedtoinvestigateand,wheretheallegationsareproven,totakeappropriateaction.Misconductmayincludepoorclinical/professionalpracticesrelatedtothestudent'sspecificareaofstudy,andalsoacademicpractices‐plagiarismandotherformsofcheating–whichmayequallybecommittedbystudentsnotstudyingtoqualifyasahealthorsocialcareprofessional.
ThereislittleavailabledataaboutincidenceofstudentfitnesstopractiseproblemsacrossthehealthandsocialcareprofessionsintheUK.Inmostoftheseprofessionsstudentproblemsarehandledbytheeducationprovider,nottheregulator,soaggregatedataisnotavailable.Justtworegulators–theGeneralOpticalCouncilandtheGeneralSocialCareCouncil–register(anddiscipline)students.Statisticsrelatingtothesetwostudentgroupsareprovidedinchapter4,butneedtobetreatedwithcautionbecauseofthedifferentpoliciesandthresholdsforreferraltotheregulatorthatmaythereforeunder‐reporttheprevalenceof(lessserious)poorprofessionaloracademicpractice.Someoftheregulatorswhodonothavesystemsofstudentregistrationoftenreceiveaboutindividualstudentswhohavebeendismissedfromprogrammes,buttheydonotnecessarilyreceivedetailsofotherstudentswherefitnesstopractisehasbeencalledintoquestionbuthandledremediallybytheeducationprovider.
Educationalistsfrommanydisciplinesareinterestedinunderstanding(andpreventingormanaging)academicmisconduct,andtheliteraturereviewedincludesstudiesthatgiveindicationsoftheprevalenceofthisamonghealthandsocialcarestudents.Whilstthereappeartobenosector‐widestudies,anumberofmorelimitedsurveyshavebeenundertaken.InonesurveyofUSmedicalstudents,with2459respondents,concerningacademiccheating,itwasfoundthat39%ofrespondentshadwitnessedcheatingand4.7%confessedtodoingit(Baldwinetal,1996).Anotherstudyofcheating,inacademicandinclinicalactivities,inaUSmedicalschool,usingaself‐reportsurvey,foundthatofover300graduatingstudents,23%admittedtoacademiccheatinginsomeform,includingasimilarfigurereportingcheatinginclinicalactivities,suchasbyrecordingtasksnotperformed(Dans,1996).InanotherUSstudy,surveyreturnsfrom571postgraduatemedicalresidentsreportedobservingmedicalstudentsfalsifyingpatientrecords(17%),mistreatingpatients(29%),workingwheninanimpairedcondition(31%),andtakingcreditfortheworkofothers(11%)(Baldwinetal,1998).
Academicdishonestyisnotlimitedtostudentsofcourse;asurveyofover2700,conductedbytheBritishMedicalJournal,foundthat13%ofUKbasedscientistsordoctorshadwitnessedcolleaguesintentionallyalteringorfabricatingdataduringtheirresearchorforthepurposesofpublication(Tavare,2012;cfalsoDyer,2012).AsaresultofaFreedomofInformationrequest,theHPCreportedin2011thatithadinvestigatedsevencasesinvolving
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plagiarism(althoughthatmaynothavebeentheonlyissueinvestigated).Ofthethreecaseswhichtothedateofreportinghadreceivedafinalhearing,tworegistrantshadreceivedaone‐yearcautionorderandtheotherwassuspendedfromtheregisterfor12months2.
Theactualincidenceofcheatingmaybeunder‐reported:twosurveystudiesofmedicalstudentattitudestowardsreportingacademicmisconductbytheirpeersfoundthat,whilstrespondentsrecognisedacademicmisconductaswrong,onlyasmallpercentagesaidtheywouldreportunprofessionalbehaviourofthiskind(RennieandCrosby,2002;ElzubeirandRizk,2003).
Theremainderofthissectionaddressesliteratureonmanagingtheacademicmisconductofhealthandsocialcarestudents,theoperationoffitnesstopractisepoliciesinHEIs,andtheexerciseofjudgementaboutfitnesstopractise.
FourstudiesaddressthesuitabilityofHEIs'generalpoliciesregardingacademicmisconductforcasesinvolvinghealthorsocialcarestudents.AstudyofUKHEIsbyUnsworth(2011)foundthatgeneralpoliciesaddressingacademicmisconduct'willlackspecificdetailabouthowprofessionalsuitabilityandfitnesstopractiseissuesshouldbeaddressed'(p468).Unsworththereforerecommendsspecial,robustpoliciesforhandlingsuchissues.
Inasocialworkcontext,CurrerandAtherton(2008:282)foundthat‘theseriousnessofcertainissuesandbehaviourswerenotalwayssharedbycolleaguesinotherdisciplines‐asseeninUniversitypolicydocuments’or'inthecommentsofuniversity(asopposedtofaculty)personnelinvolvedintheFitnesstoPractiseprocedures'.Similarly,inanursingcontext,astudybySempleetal(2004)considereddishonestyamongnursingstudentsandwhatstandardsshouldbeexpectedofthesestudents.Sempleetal(2004:279)arguethathonestyandintegrityare'paramountformembersoftheprofession'.Thereforenursingstudents'mustdemonstratethesevaluesthroughouttheirtraining,sothatatthepointofregistrationwiththeNMCtheycanbedeemedtobeof"goodcharacter".Thetreatmentofpre‐registrationstudents...mayneedtobedifferenttothatmetedouttootherstudentswithinthesameuniversity'.
Inthecontextoftheeducationofclinicalpsychologists,Sofronoffetal(2011:128)alsoarguethatclinicaltrainingprogrammesshouldnotrelyongeneraluniversityrulesinordertoterminatetheeducationofstudentswhoaredeemedunfitforprofessionalpracticebecause:'ingeneraluniversityrulesandpoliciesregardingacademicprogressionandthegrantingofdegreesdonotdealwithissuesofprofessionalsuitabilityorfitnesstopractise.'
ThereareanumberofrelevantstudiesoffitnesstopracticeprocedureswithinHEIs.Onproceduresforinvestigatinganddealingwithstudentmisconduct,thereisagreementthatthereisaneedfortimely,robust,documentedpoliciesandprocedures(egHughesetal,2009;Howeetal,2010)whicharefollowed(Fiesta,1998),andthatthereshouldbereliablesystemsfordocumentingconcernsandidentifyingandmanagingstudentswhosebehaviourisproblematic(Reid,2010).DavidandEllson(2010)emphasisetheimportanceofensuringstudentfitnesstopractisepoliciesandproceduresarefair;theirpaperindicatesthatalthoughnumbersofmiscreantstudentsmaybesmall,thescaleofthetaskofdealingwiththemproperlyshouldnotbeunderestimated.
2 Available on the HPC website at: http://www.hpc-uk.org/assets/documents/10003624FR01285Fitnesstopractisecasesinvolvingplagiarism.pdf (last accessed 23/01/12)
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AcommonpatternoffitnesstopractiseproceduresinHEIsisforaseriesofgraduatedinterventions,suchas,informalconversations(forsingleincidents),moreformalmeetings(forseriousmisconductorwheretherearepatternsofbehaviour),formalactionplansifpatternspersist,andimpositionofdisciplinaryprocessesiftheplansfail(egHicksonetal,2007;Parkeretal,2008;Howeetal,2010;Stegers‐Jageretal,2011).
Parkeretal(2008)reportthatinoneAustralianmedicalschool19%ofstudents(567outof2630inthestudyperiod)werereferredtotheuniversity'sPersonalandProfessionalDevelopmentCommitteeforbehaviourgivingrisetoconcernsforfurthersupportandadvice,withonlyfourreferredtothenextstageoftheprocessfordisciplinaryaction(Parkeretal,2008).Howeetal(2010)reportthatoverasix‐yearperiodinoneUKmedicalschool,approximately15%ofstudents(118/803)werereportedforprofessionalbehaviourproblems;5%(41)ofthestudentshadmorethanoneissueraisedabouttheirprofessionalism(typicallyfromseparateincidents);and3%(25)ofthestudentsreachedthelevelofinformalorformalwarning.Onlyonestudentwasdismissedfromthecourseonthegroundsoffitnesstopractise.TheauthorsnotethesimilarityoftheirfindingstothoseofParkeretal(2008).
FourstudiesoffitnesstopractisepoliciesandproceduresacrossanumberofHEIsfoundvariationinapproaches.
Aldridgeetal(2009)foundthatall31UKmedicalschoolswithundergraduateprogrammeshadafitnesstopractisecommitteetoinvestigatecaseswheretherewereconcernsaboutstudents'fitnesstopractise.Thestudyfoundvariationsingovernancestructuresforthecommittees,whichcouldinpartbeexplainedbyvariationsinUniversitystructures,andtheextenttowhichUniversitiesco‐manageundergraduatemedicinewithothercoursessuchasdentistry,nursing,midwifery,physiotherapy,dietetics,socialwork,pharmacy,psychology,audiology,speechtherapy,operatingdepartmentpractice,veterinarymedicineandeducation.TheauthorsnotethatwiththesupportoftheGeneralMedicalCouncil,medicalschoolscontinuetoworktowardsachievinggreaterconsistencyinstudentfitnesstopractisepoliciesandprocedures.Theyalsoreflectonthefactthatthenumbersofmedicalstudentswhoare‘irretrievablyunsuitableforacareerinmedicine’areverylow,butthatsuchcasesarethe‘tipofanicebergofstudentswhosehealthorbehaviourcauseconcernabouttheirfitnesstopractise’,whichtheysayconfirmstheimportanceofeducatingstudentsaboutprofessionalismandofhavingsystemstodealwithproblemindividuals(Aldridgeetal,2009:3).
Asurveyof15Australianmedicalschoolsfoundthat12schoolsreportedusingafitnesstopractisepolicy.Therewaswidevariationinthecriteriausedinindividualpolicies,andthis,togetherwiththevariationsinthenumbersofstudentsexcludedbydifferentschoolsforreasonsofunprofessionalbehaviour,ledtheresearcherstosuggesttherewerevariationsinthemedicalschools’abilitiestodetectandmanagestudentswithproblemsofprofessionalism.TheycalledforanAustralia‐wideconsistentapproachinthisarea(McGurganetal,2010;asdoParkerandWilkinson,2008).
Unsworth(2011)reviewedfitnesstopractisepoliciesof44HEIsprovidingnursingeducationandfoundthatalmostallofthesepoliciescouldbeimproved.Themainareasforimprovementwere:
• theinclusionofaclearthresholdforreferraltoafullhearing
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• explicitreferencetoadutytogivereasonsateachstage
• makingclearthesystemforappeals
• makingexplicitthatactionshouldbetakenagainststudentsthoughttobeprofessionallyunfittopractiseinordertoprotectthepublicandtoupholdthestandardsoftheprofessionsandtomaintainthepublic'sconfidence.
UnswortharguesthatfailuretostrengthenthepoliciescouldleavetheHEIsopentochallenge.Wherestudentswhoareunfittopractiseareallowedtoregisterbecausetheysuccessfullyappealontechnicalities,'theentireprocessofselfregulationcouldbecalledintoquestion'(p471).
InastudyfocusingonanewintegratedfitnesstopracticeframeworkinoneHEI,TeeandJowett(2009:443)reportedthatthecomponentsincluded:
• 'A...MoU[MemorandumofUnderstanding]thatidentifiesathresholdforcriminalorunprofessionalactivityagainstwhichjudgmentsaboutfitnesstopracticecanbemadeatadmissiontoorthroughouttheprofessionalprogramme.Allplacementproviderssigneduptothisarrangementtoallowadmissiondecisionstobemadeasrapidlyaspossible.
• 'Asharedprotocolforreportingconcernsaboutastudent'sbehaviourinthepracticesetting.
• 'Afitnesstopracticepanelestablished,withmembershipdrawnfromserviceprovidersandHEIwhichwouldassessseverityandimplicationsofdatareceivedandmakejudgementsandrecommendationsaboutastudent'scontinuedprogressontheprogramme.
• 'Aself‐declarationofcriminalactivityprocessforcompletionbystudentsatprogrammere‐enrolment(annually)andatcompletionoftheirprogramme,whichwasunambiguous,easytocomplete,confidentialandreliable.'
However,justastherearedisagreementsaboutthemeaningandnatureofprofessionalismandsuitability,theremaybedisagreementsaboutapproachestoassessmentandtosanctions.InastudyonsocialworkeducationinCanadianHEIs,BarlowandColeman(2003:153)notedthatfacultyinthisprofessionhaveoftenopposedformalpoliciesforscreeningout'unsuitable'students,assuchpolicies'arethoughttocontradictthesocialworkvaluesandbeliefsofself‐determination,capacityforchange,andnon‐judgementalacceptance'.Theyadd:'Inaddition,facultymemberswhoopposescreening‐outseestudentsasdevelopingprofessionalswhowillmatureandlearnovertheeducationalcycle...'(ibid).Accordingly,BarlowandColeman(2003)encounteredargumentsfromcolleaguesthatfacultyshoulddotheirbesttobuild'bridgestosuccess'forstrugglingstudents,andthatsuitabilitypoliciesmaydiscriminateagainststudentsfromdiversebackgrounds.LafranceandGray(2004:326)expressthisconcernas:'Inaprofession[iesocialwork]thatespousesthebasicvaluethatallpeoplearecapableofgrowthandchange,canwejustifyexcludingpeoplewhomaybeunreadyratherthanunsuitable?'IntheUKcontext,McLaughlin(2010:80)arguesthatassessmentofsuitabilityshouldonlytakeplaceatappropriatetimesinthestudent'sdevelopment,andshouldbefair,transparentandcongruentwith'socialwork’savowedcommitmenttosocialjustice'.
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Returningtothedetailsofwhataprocessmightinclude,aUKstudybyBrockbanketal(2011)foundthatmembersofthepublicjudgedmisdemeanoursamongmedicalstudentsmoreharshlythandidmedicalstudentsandmedicalprofessionals.Theauthorsrecommendedthatviewsoflaymembersshouldbesoughtbymedicalschoolswhenpromotingprofessionalismandconsideringcasesofmedicalstudentmisconduct.
Anumberofstudiesdiscussarangeofpenalties,dependingonthedegreeofmisconduct.Thisrequirestheinstitutiontodefinedegreesofmisconductandsetoutappropriateactionstobetakeniftheyoccur.AndersonandObenshain(1994)suggestalistofoptionsforaction,dependingontheseverityofthebreach.Howeetal(2010)reportononemedicalschool'sapproachtomonitoringandassessingaspectsofunprofessionalbehaviour,whichincludedaseven‐pointscaleofresponse,fromtakingnoactiontosuspensionand/oramisconductinquiry,dependingonthedegreeofmisconduct.
InastudycarriedoutbyRoffetal(2011)theauthorsdevelopeda41‐iteminventoryofunprofessionalbehaviours,basedonananalysisoftheliteratureonacademicintegrityinthehealthprofessions,andsurveyed57facultyand689studentsfromaScottishCollegeofMedicine,Dentistry,NursingandMidwifery,askingwhatsanctiontheythoughtshouldbeappliedforeachtypeofmisconduct.
Itemsincluded:
• plagiarisingworkfromafellowstudentorpurchasingworkfromasupplier
• claimingcollaborativeworkasone’sindividualeffort
• alteringormanipulatingdata(egadjustingdatatoobtainasignificantresult)
• coercingfacultymembersintoprovidingcopiesofpaperspriortoexamthroughbriberyorintimidation
• intentionallyfalsifyingtestresultsortreatmentrecordsinordertodisguisemistakes
• failingtofollowproperinfectioncontrolprocedures
• examiningpatientswithoutknowledgeorconsentofsupervisingclinician
• sexuallyharassingauniversityemployeeorfellowstudent
• engaginginsubstancemisuse(egdrugs)
• drinkingalcoholoverlunchandinterviewingapatientintheafternoon.
Thescaleofpotentialresponsesrangefrom1(ignore)to10(reporttoprofessionalregulator).Theauthorsfoundthatthesamesanctionsaswereproposedbythefacultywereindicatedbythestudentsin26ofthe41items,whilesomeoftheotherbehaviourswereregardedmoreseverelyandsomeviewedlessseverelybystudentsthanbyfaculty.
Insummary,proceduresforhandlingfitnesstopractisecasesmayvaryacrossinstitutions,butstrongargumentsareexpressedthatprofessionalfitnesstopractisepoliciesandproceduresarerequiredinadditiontoanHEI'sgeneralacademicmisconductpolicies,asgeneraluniversitypoliciesdonotdealwithissuesofprofessionalsuitabilityorfitnesstopractise.Theintroduction,amendmentandapplicationoffitnesstopractiseproceduresmaygiverisetodisagreementanddebateaboutissuesoffairness.
DifferencesmaybeexpectedbetweentheproceduresindifferentHEIs,arisingfromdifferenthistoriesanddifferentstructures,buttheliteraturerecommendscharacteristics
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thatcouldbeembeddedwithinprocedures(suchasthoseidentifiedbyUnsworth,2011,above).Scalesofunprofessionalconduct,withcorrespondingscalesofseverityofpenalty,areputforwardbysomepapers,similartothosesetoutbysomeoftheUKhealthcareprofessionsregulatorsdiscussedinthenextchapter.
3.4 Regulatorybodiesandstudentfitnesstopractise
Thereislimitedliteraturethatrefersdirectlytotheroleofregulatorsinsettingtheparametersof,andassuring,studentfitnesstopractise.Fromtheliteraturethatdoesexistontheregulators’role,thethemesthatemergerelatetoquestionsabouttheconsistencyofeducationalinstitutions’policiesandpractices,theneedtoincludelayperspectivesonstudentfitnesstopractisepanels,thelackofpublisheddataabouttheoutcomesofstudentfitnesstopractisepolicies,andthevaluesaboutpublicprotectionconveyedtostudentsbyregulators’practices.
Inacomparisonofuniversityprocedurestoassesstheprofessionalsuitabilityofstudentsforsocialwork,Currerfoundthattheproceduresindifferentuniversitiesvaried‘inrelationtoanumberoffactors,suchaswhetherprofessionalsuitabilityisanacademicordisciplinarymatter;thenameoftheprocedureandrationale;itsfocusandscope;thepersonnelinvolvedandpossibleoutcomes’(Currer,2009).McLaughlininanarticledesignedtopromoteadebateaboutwhethersocialworkshouldhaveasystemofstudentregistrationarguesthatregistrationisinappropriateforstudentsastheyarestillintheprocessofdevelopingtheirknowledgeandskillstomeetthecodeofpracticeandthatthissituationiscompoundedbyacurrentlackofknowledgeof‘whethertheseprocessesarebeingoperatedinafairandjustmanner’or‘whethertheyarebeingoperatedequitablyacrossEngland’(McLaughlin,2010).
Unsworth(2011)foundsimilardiscrepanciesinanexaminationofthestudentfitnesstopractisepolicesin44of56HEIsprovidersofpre‐registrationnursingprogrammeswith16oftheinstitutionsusinggeneralstudentdisciplinepoliciesforthepurposeand28institutionshavingspecificfitnesstopractisepolicies.Therewasalsoconsiderablevariationinthecontentofthepolicies,particularlyintheareasofdefiningimpairedfitnesstopractiseandthresholdsforreferraltofullhearings.McGurganetal(2010)reportingonanAustralianstudyofmedicalschoolsalsofoundvariablepolicieslackinginanevaluationofeffectiveness.Alloftheseauthorsreachsimilarconclusionsthatthereisaneedforregulatorstodevelopanationallyconsistentapproachinordertoprotectthepublicandprovideconsistencyofoutcomeforstudents.
Asaresultofapilotcross‐sectionalsurveyofthepublic,medicalstudentsanddoctorsintheUKonthejudgmentstheymadeon10hypotheticalexamplesofstudentmisconduct,Brockbanketal(2011)concludedthattheviewsoflaypeopleaswellasthoseofdoctorsandstudentsshouldbeincludedinstudentfitnesstopanelsaslaypeopletendtobemorestringentinthesanctionstheyseek.Byinferencethisconclusionsuggeststhatregulatorsshouldconsiderwhetherlaypeopleshouldbeincludedasarequirementoneducationalinstitutions’studentfitnesstopractisepanelstomirrorwhathappensforprofessionalregistrants.
DavidandEllson(2010)fromaUKstudyonmedicalstudentfitnesstopractisehearingsnotethatwhileallUKmedicalschoolsnowhavestudentfitnesstopractiseproceduresinplace,
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thereisadearthofpublishedoutcomedata.ApointalsonotedbyRubin(2002).DavidandEllsonalsonotethatstandardtextbooksonhealthcareregulatorylaw,educationlaw,anddisciplinaryandregulatoryhearings‘makenodetailedreferencetostudentFTPprocedures,whichdiffersignificantlyfromcasesinvolvingregisteredprofessionals’.
TheeffectofthewholehealthcareenvironmentonstudentsisaconcernofSternandPapadakis(2006).Theysuggestthattheenvironment,includingtheactionsofregulators,sendspowerfulmessagestostudentsaboutculturalvalues.Theyconcludetopromotethedevelopmentofprofessionalism,regulators‘needtotakeswifteractionagainstunprofessionalbehaviourbecausepublicsafetyandthepublic’strustofourprofessionareatstake’.Tosupportthispoint,KellyandMiller(2009)foundfromaUSstudyoftheperceptionsoffirstandfourthyearmedicalstudentsthatbothgroupshad'overwhelminglynegativeperceptionsofthemedicalmalpracticesystem’(ielegalremediesandproceduresregardingmedicalmalpractice).
Inadditiontothespecificstudieswhichconsidertheroleofregulators,most,ifnotall,oftheoutcomesoftheliteraturereviewdiscussedinthefirstthreesectionsofthischapterhaveimplicationsforregulators,suchasinrelationtotherequirementstheysetfor,andtheguidanceandadvicetheyissueto,educationproviders.
Thereviewoftheliteraturehasprovidedevidenceofbenefitsinthefollowingareasthatareofrelevancetoregulators:
1. describingbothwhatismeantbyfitnesstopractiseaswellasexamplesofunprofessionalbehaviour/behavioursthatwouldcauseconcernaboutanindividual’sfitnesstopractise
2. requiringeducationalinstitutionstohavebothproactivemeasures(suchasembeddinganethicalfocusacrossthecurriculum,clarifyingtostudentsthestandardstobemet,rolemodelling,highqualitypracticeplacements,andclearpoliciesandpracticesthatareconsistentlyappliedbyallstaff)aswellasreactivemeasures(suchasconsistentlyaddressingunprofessionalbehaviourwhenitoccurs,investigatinganddealingwithstudentfitnesstopractiseissues)
3. staffdiscussing,developingandagreeingbehavioursthatwouldandwouldnotconstitutefitnesstopractiseandconsistentlyapplyingthem–suggestingstaffdevelopmentandappraisalsystems
4. assessingstudentfitnesstopractisebothformativelyandsummatively.
3.5 Conclusionsaboutthefindingsfromtheliterature
ThereisarelativedearthofsubstantiveliteratureaboutstudentfitnesstopractiseconcerningtheprofessionsregulatedbytheHPC,orindeedaboutsocialwork.Thefieldisdominatedbymaterialaboutmedicine.Thereislimitedempiricalworkinthisareaandmuchofwhatthereisreportssmall‐scalestudieswithinsingleprofessions.Thebodyofliteratureisdominatedbysmall‐scalesurveys,qualitativestudiesandcriticalreviews,discussionsandopinionpieces.Thereisalackofinformationabouttherisksposedbystudentsor,morespecifically,aboutstudentregistrationinmanagingthoserisks.
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Throughtheirprofessionaleducation,studentsacquiretheknowledge,skillsandattitudesthatenablethemtodemonstratefitnesstopractise.Themainfocusoftheliteraturerelevanttofitnesstopractiseandstudentsconcernsthedevelopmentandassessmentofnon‐cognitiveabilities,variouslydescribedas'professionalism'or'suitability'or'goodcharacter'.Therearenumerousdefinitionsoftheseterms,putforwardbydifferentprofessionalbodies,practitionersandresearchers.
Becauseofthepotentialforambiguity,itisgenerallyagreedthattherearebenefitsindescribingwhatismeantbythiscomponentoffitnesstopractise.Therearealsobenefitsinspecifyingexamplesofbehaviourthatareunprofessional,orthatindicateunsuitability,oralackofgoodcharacter.
Thereislittleevidenceabouttherisksthatstudentsposebeyonddescriptionsofunprofessionalbehaviour,suchaspoorpracticebystudentsresultinginharmtopatientsorserviceusers‐ariskpotentiallymitigatedbysupervision.Therearealsotherisksofpoorpracticeafterregistration:somestudiesfoundthatdisciplinaryactionbyamedicalboardwasstronglyassociatedwithpriorunprofessionalbehaviourinmedicalschool.Behavingwithalackofintegrityandhonestyinacademicmatters(suchasbyplagiarisingothers)maybeconsideredabreachofacodeofprofessionalethicsinitself,aswellaspotentiallyanindicatorofapropensitytobehaveunethicallyinothercontexts.
Somestudiesfoundarangeofjudgementsonthedegreetowhichaparticularunprofessionalbehaviourindicatesalackoffitnesstopractise.Issuestotakeintoaccountinmakingsuchajudgementincludethenatureofthemisconductandthestageoftheindividual'seducation.Certainbehavioursmaybeconsideredunacceptablefromthefirstdayofstudy,whereassomesituationsmayposeverydifficultethicaldilemmas,challengingeventoexperiencedpractitioners
Thereisgeneralagreementthatthecapabilitytobehaveprofessionallydevelopsoverthecourseofastudent'seducation,withprofessionalunderstandingandwisdomonlybeingacquiredovertime,withexperienceandlearning,alongsideadevelopingknowledgebase.Itisgenerallyassumedthatitispossibletodevelopvaluesandattitudesrelevanttotheprofessionincludingethicaljudgment,duringprofessionaleducation.
Theeffectsofhealthimpairmentanddisabilityonfitnesstopractise,andthedangerofunfairdiscriminationinthisarea,aresubjectsonlylightlytoucheduponinthisreview:theycouldwarrantaliteraturereviewintheirownright.InthisareatheliteraturewehaveconsideredarguesthatHEIsneedtobalancetherightsofstudentswithhealthdifficultiesordisabilitieswiththerightsofthepublic,serviceusersandpatients
ThereisaconsiderableliteratureondifferentaspectsoftheroleofHEIsindevelopingandassessingtheprofessionalismcomponentoffitnesstopractise.
Theliteratureemphasisesaneedforagreementamongstaff‐academictutorsandpracticesupervisors‐astowhatconstitutesacceptableandunacceptablebehaviour,asaprecursortocommunicatingclearexpectationstostudents.Thisagreementonwhatconstitutesstudentfitnesstopractise/professionalismisunlikelytooccurwithoutdiscussionanddialogue,andmaynotbeeasytoachieve.However,theliteratureinthisareaindicatesthattheconsequencesofnotachievingthisagreementwithinanHEIcanbemixedmessagestostudentsaboutthenatureofandtheneedforprofessionalbehaviour,difficultiesin
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assessingfitnesstopractise,andconfusionanddifficultyininvestigatinganddealingwithallegedfailures.
TheliteratureontheactionsthatHEIscantaketodevelopfitnesstopractiseencouragesstafftohaveregardtoawiderangeofactivities,bothformalandinformal,thatconstituteteachingandlearning,andtoseektocoordinateteachingandlearningacrossalltheseactivities.Theconceptofthe'hiddencurriculum'‐thelearningthatstudentstakefromplacements,andfrominformalinteractionswiththeirtutorsandpeers‐iswidelycitedasastronginfluenceonstudentbehaviouranddevelopment.
Thereappearstobebroadagreementthatimportantelementsofteachingandlearninginclude:clearcommunicationofprinciplesandprocedures;rolemodellingandexplanationofdesirablebehavioursbystaff;opportunitiestopractise,andtoreflectonandreceivefeedbackonpractice;monitoringperformance,reinforcinggoodpracticeandprovidingextrasupportwherenecessary;andhelpingstudentsdeveloptheskillsofself‐reflection.
Rolemodellingisseenasaparticularlyimportantcomponentofconveyingprofessionalvaluesandbehaviours,includingpotentiallylearningfromexperiencedprofessionalshowtheyhandleethicaldilemmas.Similarly,negativerolemodelsmayhavesignificanteffectonstudentunderstandingandbehaviour.
Self‐assessmentandreflectivepracticeisacomponentofreflectivelearning,andanumberofstudiesadvocateitasastructuredelementwithinformativeevaluation,whilstadvocatingfeedbackandsupportinordertoattainaccurateself‐awareness,andtodevelopself‐reflectionskills.
Theliteratureonthewholeadvocatestheassessmentofprofessionalismandprofessionalsuitability.Assessmentofprofessionalism,orsuitability,maybeexpectedtotakeplaceonapplicationtoaprogrammeofprofessionaleducation,andbothformativelyandsummativelyduringtheprogramme.
Overall,assessmentofsuitabilityatthepointofadmissionappearstobesubjecttoanumberofdifficultiesandtherearedoubtsaboutitsaccuracyofassessment,otherthanasameansofexcludingthe'obviouslyunsuitable'candidates.
Theliteratureadvocatesformativeandsummativeassessmentduringeducation,withformativeassessmentsgivingrise,whereappropriate,tobetterunderstanding,moresupportandfurtherdevelopment.Arangeofdifferentmethodsofassessmentisproposed.Thechallengetostaffofgivingcriticalfeedbackonmattersofpracticeandattitudeisthefocusofanumberofpapers,indicatingthatthisisanareawhereclearguidelinesshouldbedevelopedandcommunicatedtostudentsandstaff,andwherestaffwillbenefitfromtrainingandsupport.
Allegationsorincidencesofmisconductwillgiverisetotheneedtoinvestigateand,wheretheallegationsareproven,totakeappropriateactionthroughtheuseofsanctions.Misconductmayincludepoorclinical/professionalpracticesrelatedtothestudent'sspecificareaofstudyandalsotoacademicpractices,suchasplagiarism.ItisdifficulttodeterminetheincidenceofstudentfitnesstopractiseissuesacrossthehealthandsocialcareprofessionsintheUKastheextenttowhichthisisreportedand/ordealtwithbyacentralisedbody,suchasaregulator,isdependentonthesystemsandpracticesinthatprofession.
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StrongargumentsareexpressedthatprofessionalfitnesstopractisepoliciesandproceduresarerequiredinadditiontoanHEI'sgeneralacademicmisconductpolicies,asgeneraluniversitypoliciesdonotdealwithissuesofprofessionalsuitabilityorfitnesstopractise.
Thereisgeneralagreementthatpoliciesandproceduresshouldbetimely,robust,fairandclearlydocumented,thattheyshouldbefollowed,andthatthereshouldbereliablesystemsfordocumentingconcernsandidentifyingandmanagingstudentswhosebehaviourisproblematic.
AcommonpatternoffitnesstopractiseproceduresinHEIsisforaseriesofgraduatedinterventionsandthiscanbeseentoparallelthedefinitionandillustrationofthresholdsofconcernwithrelatedsanctions,whichhavebeensetoutbysomeoftheUKhealthcareprofessionregulators(seenextchapter).
StudiesshowthatdifferencesmaybeexpectedbetweentheproceduresindifferentHEIs,arisingfromdifferenthistoriesanddifferentstructures,buttheliteraturerecommendscharacteristicsthatcouldbeembeddedwithinprocedures.Regulatorsareseentohavearoleinensuringconsistencyofeducationalinstitutions’policiesandpracticesaswellasconveyingvaluesaboutpublicprotectionbytheirpractices.
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Chapter4:Regulatorsandstudentfitnesstopractise
ThischapterreviewsliteratureonstudentfitnesstopractisefromthehealthandsocialcareprofessionsregulatorsintheUKandalsoinsomeothercountries.
4.1 TheUKhealthandsocialcareprofessionregulatorsandtheirapproachestoregulatingstudentfitnesstopractise
Initsdocumentonhealthcareregulatorsqualityassuringundergraduateeducation,CHREemphasisesthat:
‘patientsafetyandpublicprotectionareattheheartofhealthcareprofessionalregulationandconsequentlyunderlieallworkinqualityassurance.Theweakeststudentwhopassesaprogrammehastobefittoentertheregisterandfittopractise.’(CHRE,2009)
Itrecommendsthat:
‘Allregulatorsmustbewillingandabletodemonstratehowtheirprocesseslinkproportionatelytopatientsafetyandpublicprotection,maintainingthefocusontheissueofbeingfittojointheregister,ormakingfurtherprogresstowardsthispoint,isessential.’(CHRE,2009)
Toprovideanoverview,Table3summarisesandcomparesthepositionofeachoftheUKhealthandsocialcareprofessionsregulators’keypoliciesconcerningstudentfitnesstopractise.ThisshowsthatthemajorityofUKhealthprofessionsregulatorshaveproducedspecificstandards/guidanceonstudentfitnesstopracticeand/orstudentethicsandconduct.
Table3:OverviewoftheapproachesandguidanceoftheUKhealthandsocialcareprofessionregulatorsforstudentfitnesstopractise
Regulator Student Registration
Student Fitness to Practice Guidance
Code of Conduct / Ethics for Students
Other / comments
General Chiropractic Council (GCC)
No specific Student FtP documents Reference to the need for student FtP policies and related student learning in its Degree Recognition Criteria, 2010.
General Dental Council (GDC)
GDC, April 2010, Student fitness to practise – covers both dentists and dental care professionals plus aspects related to disability and health of students
Acknowledges similarity to GMC document and that it drew from it in its development
General Medical 0Council (GMC)
General Medical Council and the Medical Schools Council, March 2009, Medical
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Regulator Student Registration
Student Fitness to Practice Guidance
Code of Conduct / Ethics for Students
Other / comments
students: professional values and fitness to practise
General Optical Council (GOC)
1. Registering with the GOC: A guide for students (no date)
2. Registration of students in optometry and dispensing optics: A guide for training providers (no date)
Code of Conduct Code of Conduct applies to full registrants and student registrants.
General Osteopathic Council (GOsC)
GOsC, 2011, Student fitness to practise Guidance for Osteopathic Education Institutions - Draft
GOsC, 2011, Student fitness to practise Guidance about professional behaviours and fitness to practise for osteopathic – Draft
General Pharmaceutical Council (GPhC)
GPhC, 2010, Guidance on Student Fitness to Practise Procedures in Schools of Pharmacy
GPhC, 2010, Code of Conduct for Pharmacy Students, 2010; Code of Conduct for Pre-registration Pharmacy Technicians
General Social Care Council (GSCC)
Student register – no specific guidance. Covered in: GSCC, Sept 2010, Arrangements for the funding of Practice Learning – Social Work Degree
Health Professions Council (HPC)
HPC, Guidance on conduct and ethics for students, 2009
No specific Student FtP guidance document. References to requirements for this in, Standards of education and training guidance 2009; An introduction to our
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Regulator Student Registration
Student Fitness to Practice Guidance
Code of Conduct / Ethics for Students
Other / comments
education processes, 2011 HPC, 2009, Guidance on Health and Character
Nursing and Midwifery Council (NMC)
Plans to introduce a student index in Spring 2012
NMC, 2010, Good health and good character: Guidance for approved educational institutions (Amended November 2010)
NMC, 2011, Guidance on professional conduct for nursing and midwifery students 3rd edition
The Good health and character document has Student FtP policies and practices as one element of a larger document
Pharmaceutical Society of Northern Ireland (PSNI)
Signposts to: GPhC’s Guidance on Student Fitness to Practise Procedures in Schools of Pharmacy, 2010
Signposts to: GPhC’s Code of Conduct for Pharmacy Students, 2010; Code of Conduct for Pre-registration Pharmacy Technicians, 2010
Thechapterproceedsbylookingingreaterdetailatthestandardsandguidanceonstudentfitnesstopractiseproducedbytheseregulators.Itthengoesontodescribetheapproachesofthoseregulatorsthathaveadoptedothermethods,orthathavenottodateundertakenspecificworkinthisarea.
4.2 UKhealthcareprofessionregulatorswhohaveproducedguidancerelatingtostudentfitnesstopractise
TheGMCwasthefirstUKhealthcareprofessionregulatortoinitiatedevelopmentsrelatedtostudentfitnesstopractise(includingconsiderationofwhetheritshoulduseasystemofstudentregistration).
In2001,UniversitiesUKandtheCouncilofHeadsofMedicalSchoolscommissionedthelawfirmEvershedstoconsiderfitnesstopractiseissuesfromtheviewpointofhighereducationinstitutions(HEIs)inEnglandandWales.UndertheMedicalAct(1983),HEIsareresponsiblefortheeducationandtrainingofdoctorsuptofullregistrationbytheGMC,includinghavingadutytoensurethatthosewhograduatefromundergraduatecoursesandcompletetheirinitialtrainingarefittopractise.
Evershedsrecommendedprinciplesforuniversitystudentfitnesstopractiseproceduresthatwouldbefairtoindividuals,reflectedlegislativerequirementsandallowedfordetailedprocedurestobedeterminedbyindividualinstitutionsagainstsomebroadprinciples.ThecriteriathatEvershedsdefinedasthebasisofstudentfitnesstopractiseproceduresrelated
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to:legality(egcommonlawofnaturaljusticeandfairness,HumanRightsAct1998),actualandperceivedfairness,effectiveness,consistency,efficiency,andfitwiththewiderstructureofregulationofthehealthprofessionsandofuniversities.
ThesebroadcriteriaandtheproposalsoutlinedbyEversheds(2001)areevidentintheguidanceproducedbytheGMCandtheMedicalSchoolsCouncil–Medicalstudents:professionalvaluesandfitnesstopractise(2009).Theguidanceisaimedatmedicalstudentsandanyoneinvolvedinmedicaleducationandcovers:theprofessionalbehaviourexpectedofmedicalstudents;thescopeofstudentfitnesstopractise;thethresholdofstudentfitnesstopractise;makingdecisions;andthekeyelementsinstudentfitnesstopractisearrangements.
TheinfluenceoftheGMCguidanceonstudentfitnesstopractiseisevdidentintheguidanceproducedbytheGDC,theGOsCandtheGPhC.TherearealsosomecommonalitiesbetweenthesedocumentsandthepublicationsoftheHPCandtheNMC.
Table4usesthebroadheadingswithintheGMCguidanceasameansofcomparingthecontentoftheguidancethathasbeenproducedbytheotherregulators.Itshowsthatthereisconsiderablesimilaritybetweenthestudentfitnesstopractisedocumentsoftheregulatorswhohaveproducedspecificguidance(ietheGDC,GMC,GOsCandtheGPhC).TherearealsosubstantialareasofcommonalitybetweentheNMCandHPCdocumentsandthedocumentsoftheotherfourregulators,althoughoveralltheNMCandHPCpublicationscoverfewerareas.
TheGDCproduceditsguidanceonstudentfitnesstopractisein2010foralloftheprofessionalgroupsinitsremit(iefordentistsandforalldentalcareprofessionalssuchasdentalnurses,dentaltechnicians,dentalhygienistsanddentaltherapists).Theguidancecoversaspectsofstudentfitnesstopractiserelatingtodisabilityandhealth,whichisincontrasttootherregulatorswhohavetendedtoproduceseparatedocuments.TheGDCguidanceacknowledgesitssimilaritytotheGMCguidancefromwhichitwasdeveloped.
TheGPhCpublishedguidanceonstudentfitnesstopractiseprocedures,acodeofconductforpharmacystudentsandacodeofconductforpre‐registrationpharmacytechniciansin2010.ThecontentofthesecodesandguidanceonstudentfitnesstopractisebroadlycoversthesamesubjectsasthatoftheGMCandtheGDC.Thepurposeoftheguidanceistoprovideadviceonhowtodevelopandapplyconsistentfitnesstopractiseproceduresforstudents.TherelevantstudentcodesofconductarebasedontheGPhC'sStandardsofconduct,ethicsandperformanceandapplytoallstudentsstudyingtoenterthepharmacyorpharmacytechnicianprofessions.Thedocumentsstatethatstudents‘mustabidebythecodeofconductatalltimesanddemonstrateprofessionalconductinthesamewayastheywillbeexpectedtooncetheyqualify’.
ThePharmaceuticalSocietyofNorthernIreland(PSNI)signpostsstudentstotheGPhC’sguidanceonconductandethics.Ithasnotproducedguidanceonstudentfitnesstopractiseprocedures.
TheGOsCconsultedin2011ontwodraftpublicationsrelatedtoStudentFitnesstoPractise–oneforOsteopathicEducationInstitutionsandoneforstudents.Theconsultationdocumentnotedthatadditionaldevelopmentworkwasbeingundertakentoproducemorefocusedguidanceondisabilityandhealthimpairmentforthesameprimaryaudiences.ThedraftguidanceonstudentfitnesstopractisefromGOsCbroadlycoveredthesamesubjects
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asthatoftheGMCandtheGDCalthoughitappearstoemphasisemorestronglythattheexpectationsonstudents’behaviourwouldincreaseasstudentsprogressedthroughtheprogrammeanddevelopedtheirknowledge,skillsandattitudes.Atitsmeetingonthe11October2011,theCouncilofGOsCnotedthepositiveresponsethathadbeenreceivedtothedraftguidanceandrecommendedthatitshouldbepublishedassoonaspossible.Theimplementationoftheguidanceistobesupportedbyanimplementationstrategyandanevaluationofitseffectiveness3.
Table4:AnoverviewofthecontentoftheguidanceonStudentFitnesstoPractiseoftheUKhealthcareregulators(wheresuchguidancehasbeenproduced)asatDecember2011
CONTENT AREA / BODY GDC GMC GOsC GPhC HPC NMC
1 PROFESSIONAL BEHAVIOUR LINKED TO REGISTRANT REQUIREMENTS
X X X X X X
COMMON PRINCIPLES agreed by the regulators Be open with patients & respect their dignity
X X X X X X
Respect patients’ rights to be involved in their treatment and care
X
X
X
X
X
X
Be honest and trustworthy to justify public confidence
X
X
X
X
X
X
Provide a good standard of practice and care
X X X X X X
Protect from risk of harm X X X X X X Cooperate with colleagues X X X - X X Teaching and training, appraising and assessing
- X - - - -
2 REGULATORS ROLE IN RELATION TO STUDENT FTP ARRANGEMENTS Purpose of guidance from the regulator
X
X
X
X
No specific guidance on FtP policies and practices - certain Standards for Education and Training (SETs) apply referenced below.
X
Specific FtP requirements made by regulator
X
X
X
X
SET 6.5 SET 3.16
X
Health and fitness to practise X
X
X
X
SET 2.4 A disabled person’s
X
3 At the time of writing the finalised guidance was not available on the Council’s website – last accessed 23/01/12.
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CONTENT AREA / BODY GDC GMC GOsC GPhC HPC NMC
guide to becoming a health professional. & Guidance on Health and Character
Relationship to registration and/or qualifications
X
X
X
-
SET 3.16
X
Requirements on disclosure of FtP when an individual seeks to join the register
X
X
X
X
X
X
Requirements for education providers to inform the regulator
X
X
X
X
X
X
3. THRESHOLD OF STUDENT FITNESS TO PRACTISE Meaning X X - X - - THRESHOLD FOR STUDENT FtP DECISIONS Defining the threshold X X X X - X Illustrating the threshold X X X X - - Categories of concern X X X X X X 4. ASPECTS OF STUDENT FITNESS TO PRACTISE PROCEDURES Admissions X X X X SET 2.3 X Communication and awareness X X - X - X Education
X -
X - SET 4.5
SET 5.12 -
Confidentiality and disclosure X X X X - - Pastoral care and student support
X X X X - -
FITNESS TO PRACTISE CASES Overview X X - X - - Investigation X X X X - - Fitness to practise panel - purpose and role
X X X X - X
Fitness to practise panels – make-up
X X X X - X
Fitness to practise panels – training
X X - X - X
Possible outcomes X X X X - - Timescales X X - X - - Hearings X X - X - - Support for students in hearings X X X X - - Appeals X X X - -
TheNMCproducedguidanceforeducationalinstitutionsongoodhealthandgoodcharacterin2010–thiscontainsguidanceonstudentfitnesstopractisepoliciesasoneelementofalargerdocument.TheNMChasalsoproducedguidancefornursingandmidwiferystudentsonprofessionalconduct(2011).TheNMCplanstointroduceastudentindexingsystemin2012.
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TheHPChasproducedguidanceonconductandethicsforstudents.Itwarnsthatinveryseriouscircumstancesstudents’conductmayaffectprogrammecompletion,theawardofafinalqualification,orregistrationwiththeHPC.Italsoexplainsthateducationalprogrammeshaveprocessesfordealingwithconcernsaboutstudents’behaviour(HPC,2009).TheHPCseesthisguidanceassetting‘usefulprinciplesforprospectiveregistrantsaroundtheexpectationsofaprofessional’butnotesthatitwillnotenforceit.
TheHPChasnottodateproducedspecificguidanceonstudentfitnesstopractiseapproachesbutmakesreferencetorequirementsforthisinotherdocuments,specificallywithinitsStandardsofEducationandTraining(SET)Guidance(2009).Therearesixstandardsofeducationandtrainingrelatingtostudentfitnesstopractiseandeachstandardhasguidanceattached.TherelevantSETsandrelatedguidanceareshownintable5below.
Table5:HPCStandardsofEducationandTraining(andrelatedguidance)relatingtostudentfitnesstopractise
SET 2.3 The admissions procedures must apply selection and entry criteria, including criminal convictions checks (normally at an ‘enhanced’ level disclosure or equivalent).
SET 2.4 The admissions procedures must apply selection and entry criteria, including compliance with any health requirements.
Guidance
These requirements could include vaccinations and occupational health assessments. Requirements vary across the professions and we will want to see that providers give applicants clear information.
Providers must take all reasonable steps to keep to any health requirements and make all reasonable adjustments in line with equality and diversity law. ‘Health’ does not mean people who are ‘healthy’ or in ‘good health’. Our guidance document, ‘A disabled person’s guide to becoming a health professional’, provides information for disabled people applying to approved programmes, and for admissions staff considering applications from disabled people.
The HPC Guidance on Health and Character (2009) states: We consider the effect that a health condition may have on someone’s ability to practise safely and effectively. We look at each case and make our decision based on the particular circumstances of the case. When making a decision about an applicant or a student with a health condition, there are a number of factors providers might want to look at: how they currently manage their condition; whether they have shown insight and understanding of their condition; whether they have got medical or other support4.
SET 3.16 There must be a process in place throughout the programme for dealing with concerns about students’ profession-related conduct.
Guidance
The purpose of this SET is to make sure that education providers play a role in identifying students who may not be fit to practise and help them to address any concerns about their conduct in relation to their profession. The process should focus on identifying and helping to address concerns, but should also allow an appropriate range of outcomes, including providing for an award which does not provide eligibility to apply to the Register (please see SET 6.8 for more guidance on this issue).
We will want to see evidence to support your choice of process, which must be appropriate to the programme and how it is delivered. It is important that you are able to justify, and be responsible for,
4 The HPC website (accessed 23/01/12) states that this document is currently under review and the HPC has removed the requirement for a health reference prior to entry to its Register.
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any decision you make, and that the process is thorough, fair and open.
We will want to see the process of communication between you, practice placement providers and practice placement educators. It will be important that you show the process is fair, that you have made every effort to allow the student to address any issues relating to their conduct, and that you can justify 00clearly all the decisions you have made.
To show that you meet this SET, you could refer us to where the process is laid out, and how you communicate it to students. You might include this, for example, on your website or in your student handbook. You may want to use our standards of conduct, performance and ethics to inform your process.
SET 4.5 The curriculum must make sure that students understand the implications of the HPC’s standards of conduct, performance and ethics.
Guidance
The standards of conduct, performance and ethics are broad standards that everyone on our Register must keep to. These standards must be taught and met throughout a programme. For example, they could be covered as part of a module on ethics or could be built into the curriculum as a whole. We will want to see that the curriculum refers specifically to the standards of conduct, performance and ethics, and that students understand these standards, including how and when they apply. We recommend that you include the standards of conduct, performance and ethics in your reading lists.
SET 5.12 Learning, teaching and supervision must encourage safe and effective practice, independent learning and professional conduct.
Guidance includes:
We will want to see information about how students learn about the behaviour expected of them on their placement.
SET 6.5 The measurement of student performance must be objective and ensure fitness to practise.
Guidance includes:
We will want to see information about how you monitor and measure student performance, and what criteria you use to assess students who are at different stages in their learning. We will also want to see how you use your guidelines or criteria to make sure students are fit to practise. A student who completes a programme must meet the standards of proficiency. The term ‘fitness to practise’ is specific to the process that professionals who are registered have to maintain. This includes the standards of proficiency, the standards of conduct, performance and ethics, and the health and character requirements of registration.
Althoughthedetailoftheotherregulators’studentfitnesstopractisepolicieshavenotbeenproducedinthesameway,itcanbeseenfromtheinformationintable5andtable4abovethattheHPCdoesprovideguidanceonsomeaspectsofstudentfitnesstopractisethatareincommonwithmostoftheotherhealthcareregulators.Throughitsstandardsofeducationandtraining,theHPCensuresthatstudentfitnesstopractiseisincludedasakeycomponentwithinitseducationalprogrammesleadingtoregistration.HowevertheSETsandrelatedguidancedonotcoverthesamebreadthordepthastheguidancefromotherhealthcareregulators,suchasinrelationto:
• thresholdforstudentfitnesstopractisedecisions
• allareasofmanagingfitnesstopractisecasesincluding:
- confidentialityanddisclosure
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- pastoralcareandstudentsupport
- fitnesstopractisepanels–purpose,roles,make‐upandtraining
- hearings
- outcomes
- appeals.
Asregardsthethresholdatwhichstudentfitnesstopracticeproceduresshouldbeinitiated,althoughtheHPCdescribesprofessionalconductitdoesnotgivespecificexamplesofunprofessionalconductwhichmighthelpillustratethetypesofbehaviourthatwouldbeamatterofconcern.
Drawingonthepoliciesoftheotherregulators,thethresholdtendstobedefinedbroadlyandrelatestoconductthatdoesnotjustifythetrustplacedintheprofessional,orconcernsbehaviourthatmayhaveharmedpatients/clients/usersorthathasputthematriskofharm.
AlloftheregulatorsthathavecoveredthisareatendtousethesamebroadquestionsfirstsetoutbytheGMCandwhicharetobeappliedonacase‐by‐casebasis.Theyare:
• ‘Hasastudent’sbehaviourharmedpatientsorputpatientsatriskofharm?
• Hasastudentshownadeliberateorrecklessdisregardofprofessionalandclinicalresponsibilitiestowardspatientsorcolleagues?
• Isastudent’shealthorimpairmentcompromisingpatientsafety?
• Hasastudentabusedapatient’strustorviolatedapatient’sautonomyorotherfundamentalrights?
• Hasastudentbehaveddishonestly,fraudulently,orinawaydesignedtomisleadorharmothers?’
(GMC&MSC,2009)
Thecategoriesofconcernusedforcriminalconvictionappeartobebroadlysimilaracrosstheregulatorsincludedintable4.Howevertheregulatorsthathaveproducedspecificguidanceonthesubjectalsoincludeotheraspectsofbehavioursuchas:
• drugoralcoholmisuse
• aggressive,violentorthreateningbehaviour
• persistentinappropriateattitudeorbehaviour
• cheatingorplagiarising
• dishonestyorfraudincludingoutsidetheprofessionalrole
• unprofessionalbehaviourorattitudes
• healthconcernsandinsightormanagementoftheseconcerns
• placinginappropriatephotographsorpostingsonsocialmediaorsocialnetworkingsitessuchasFacebook,Twitteretc.
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ThedefinitionsandillustrationsofthethresholdusedbytheregulatorsareconsistentwiththefourkeyelementsforassessinggoodcharacteridentifiedbytheCHRE(2008)anddescribedinchapter3.
Intermsofmanagingfitnesstopractisecases,mostregulatorsdonotprescribetheapproachandprocesstobeadoptedbutsetoutbroadprinciplesthateducationprovidersshouldincludeintheirpoliciesandprocedures–forexampletheseparationofrolesbetweencoursetutors,investigatorsandfitnesstopractisedecisionmakers;proportionalityoftheapproaches;timelinessandgoodrecordkeeping.
TheCHREsaysthatintheinterestsofpublicprotection,fitnesstopractisesanctionsagainstanindividualstudentshouldbesharedwithregulators,preferablybyboththestudentandbytheeducationprovideratapointdeterminedbyeachregulator.Italsorecommendsthatthroughtheirqualityassuranceprogrammes,regulatorsshouldcollectaggregateddataonstudentfitnesstopractiseandusethistoimprovetheirstandardsandguidance,andworkwitheducationproviderstosharegoodpracticeinmanagingstudentfitnesstopractise(CHRE,2010).
Wehavebeenunabletofindanypublishedinformationabouttheeffectivenessofregulators’studentfitnesstopractiseguidance,whichmaysimplyreflecttherelativelyrecentdevelopmentofguidanceandimplementationofformalisedpoliciesandprocedures.
Inconclusion,itcanbesaidthattheregulatorguidancereviewedisbroadlyconsistentwiththeapproachesfirstsuggestedbyEvershedsin2001,withthedutytocomplywithrelevantlegislation,andwiththeneedtoaccommodatethevarietyofeducationinstitutionsinwhichstudentfitnesstopractisepoliciesandproceduresareapplied.
4.3 Otherapproachestostudentfitnesstopractiseusedbythehealthandsocialcareprofessionsregulators,includingstudentregistration
Nospecificguidanceorothermeasuresyetinplace–theGCCTheGeneralChiropracticCouncildoesnotcurrentlyhavespecificguidancerelatingtostudentfitnesstopractise,butitdoesmakereferencetotheneedforrelevantpoliciesandproceduresinitsDegreeRecognitionCriteria,2010.WeunderstandthattheGCCiscurrentlyintheprocessofundertakingworkinthisarea.Ithasaddressedthepossibilityofcomplaintsbeingmadeinrelationtostudentsinanadvicenoteonsupervisionanddelegationinchiropracticundergraduateeducation(GCC,2010a).TheadviceoutlinestherolesandresponsibilitiesofeducationalinstitutionsandtheGCCindifferentscenarios,anditnotesthatachiropracticstudentmightbereferredtoaneducationinstitution’sstudentfitnesstopractiseproceduresforinvestigation.TheGCCrequireseducationinstitutionstoinformitoftheoutcomesofanystudentfitnesstopractisecasesconsidered.
Theintroductionofstudentindexing–theNMCTheNMCplansto(re)introduceastudentindexinthespringof2012followingaconsultationin20115.TheindexisdesignedforusebytheNMCandthenursingeducation
5 Information obtained from NMC website on consultations / student indexing modified date 01/09/2011 and student indexing, modified date 31/08/2011 (both last accessed 23/01/12).
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institutions–itwillnotbepubliclyavailable.Thestudentindexwillbeformedfromadatabaseofeverystudentenrolledonapre‐registrationnursingormidwiferyeducationprogrammeatanNMCapprovededucationinstitution(AEI).
TheNMCsaystheprimarypurposeoftheindexistoenhancepublicprotectionandcites‘programmehopping’asoneofthereasonsforitsintroduction.ItsaysthestudentindexwillenableAEIstoidentifywhetherstudentswhohaveenrolledonaprogrammeattheirinstitutionhadpreviouslybeendismissedfromanotherprogrammeforseriousconcernsormisconduct.OtherbenefitsidentifiedbytheNMCincludeaccesstothecontactdetailsforeverystudent–enablingtheregulatortocommunicatedirectlywithstudentsonavarietyofsubjects;enabletheNMCtobuildapictureofthefitnesstopractisedecisionstakenbyAEIs;andforuseinanalysingtrendsinnursingandmidwiferyeducationprogrammesforqualityassurancepurposes.
InitsresponsetotheNMCconsultation,theCHREnotedthat‘theconsultationpaperdoesnotdescribetheextentoftherisksinvolved,orexaminewhethertheremightbemoreproportionatemeansthantheproposedindextotacklethoseriskssuccessfully’(CHRE,2011).WehavenotfoundanyevidencepublishedbytheNMCaboutthesizeofthe‘programmehopping’probleminnursingandmidwifery,norhavewefoundanyevidenceinthepublishedliterature.TheCHREalsoemphasisesitsviewthattheintroductionofastudentindex,describedbytheCHREasalistofstudents,‘wouldnotbeatargetedsolutiontotheproblem,norwoulditbeinlinewithright‐touchregulation’(CHRE,2011).
Activelyengagingstudentsintheworkoftheregulatorandgivingconsiderationtostudentregistration–theGMCIn2008,theGMCundertookanimpactassessmentaspartofaconsultationtoreviewitsthenextantpublicationTomorrow’sDoctors,2003(GMC,2008).TheimpactassessmentnotedthattheCouncilhadanumberofoptionsopentoitincluding:doingnothingandkeepingtheexistingpublication;introducingamendmentstothe2003edition;preparinganeweditionbuildingonthepreviousoneandpursuingotheroptionssuchasanationalexaminationnearthestartofmedicalpractice;aUK‐wideregisterofmedicalstudentsandastrategytoengagestudentsfullyinprofessionalandregulatorymatters.ThediscussionwithintheimpactassessmentnotestheGMC’sintentiontocontinuetoworkwiththeKingsFundandtheRoyalCollegeofPhysicianstoengagestudentsintheconceptofprofessionalism.ItalsoreportsthattheGMCwasnotpersuadedthatthepotentialadvantagesofstudentregistrationwouldoutweighthedisadvantages.
Feedbackfromthe2008consultationwasreportedasbeinglargelysupportiveoftheproposalsbutemphasisedtheneedforgreaterclarityaboutresponsibilityforfitnesstopractiseandmanagingtraineesindifficulty,andtherespectiverolesoftheGMC,postgraduatedeaneries,foundationschoolsandmedicalschools.In2009,theGMCproducedandpublisheditsrevisedguidance(referredtoabove)entitledMedicalstudents:professionalvaluesandfitnesstopractiseanditsPostgraduateBoardnotedthattheGMChaddevelopedanongoingworkstreamtopromotetheworkoftheGMCandengagestudentswiththeirprofessionalvaluesearlyonintheirmedicaltraining(GMC,2009).
In2009–10,aseriesofeventsonmedicalprofessionalismwasheldwithmedicalstudents(Levensonetal,2010),continuingtheworkreportedinUnderstandingDoctors:Harnessing
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professionalism(Levensonetal,2008).Theauthorsnotethatthefindingswereencouragingandincludedaffirmingtheimportanceofmedicalprofessionalisminthepersonalandprofessionallivesofmedicalstudents,aswellastheneedforstudentstoengageintheprocessofdefiningprofessionalismanditsteachingandassessment.TheyalsoconcludedthatmedicalstudentsneededafullerunderstandingoftheregulatoryroleoftheGMCandhowitwillaffecttheirlives.
ThereviewofmedicaleducationbyLordPatel(Patel,2010)returnedoncemoretotheissueofstudentregistrationanditspotentialforcontributingtothedevelopmentofasenseofprofessionalisminstudents,aswellashelpingmedicalschoolstodealrobustlywithfitnesstopractiseissues.ThePatelreviewnotedthattherewassomeevidencethatbyintroducingtheMedicalStudents:ProfessionalValuesandFitnesstoPractiseguidance,medicalschoolswerebetterabletoadapttheirprocedurestodealwithstudentfitnesstopractiseissues(althoughthenatureandrobustnessoftheevidencewasnotcited).ThereviewwentontorecommendthattheGMCshouldevaluatetheeffectivenessofitsexistingarrangementsforengagingwithstudentsaswellasconsideringotherwaysofsupportingthedevelopmentofprofessionalbehaviour,valuesandidentity.
FollowingthePatelreview,theGMC’s2011BusinessPlan(asnotedinanUndergraduateBoardpaper–GMC,2011a)statedthattheGMC‘willprovideanintegratedapproachtotheregulationofmedicaleducationandtrainingthroughallstagesofadoctor’scareer’includinganevaluationofthecaseforestablishingstudentregistration.Thekeytestforstudentregistrationwasnotedas‘whetherit(studentregistration)willcontributepositivelytothepromotionofprofessionalvaluesandtosupportingasmoothertransitiontopractice(ratherthanmerelybeingamechanismforaddressingseriousfitnesstopractiseissuesamongstaverysmallminorityofstudents)’.
HoweverwiththepublicationoftheGovernment’sCommandPaperEnablingExcellencein2011–whichmadeclearthegovernment'sviewthatstatutoryregulationshouldbedeployedonlyifthereisnoothermeansofachievingthesameaim–andfollowingapreliminarydiscussionwithseniorcounselonthelegislativeimplicationsofintroducingstudentregistration,theGMCmodifiedtheaimoftheevaluationofstudentregistrationto:‘identifythemosteffectivewaysofenhancingourrelationshipwithmedicalstudents,sothatwecanpromoteadeeperunderstandingofprofessionalvalues,responsibilitiesandbehavioursandtherebyenablinganeffectivetransitiontopractice’(GMC,2011b).
Havingconsideredtheoptionsforconsultationonstudentregistrationandthecostsofintroducingsuchascheme,theGMCCounciltooktheviewthatmandatoryregistrationofallorsomestudentswasnotviableandthatitshouldnotformpartoftheconsultationprocess;rather,itshouldfocusonvoluntarystudentregistration,oralessformalsystemofstudentaffiliation/associationwiththeGMC(thethenpreferredGMCposition),ortheextantposition.Itappearsthatgiventhechangingeconomicandregulatorycontext,theGMCdidnotproceedwiththeproposedconsultation.On25October2011,GMCwebnewsreportedthat:
‘TheGMCconsidereditspositiononmedicalstudentregistrationatitsCouncilmeetingon27September2011anddecidedthatitwillnotintroduceeithermandatoryorvoluntaryregistrationofmedicalstudents.Insteadwewillcontinuetoworktostrengthenengagementwithmedicalstudents,andwillbringforwardthepointatwhichmedicalstudentsengageformallywiththeGMC.’(GMC,2011c).
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ThisannouncementalsoincludedinformationthatGMCreferencenumberswouldbeissuedtostudentsatanearlierdateinordertomakeprovisionalregistrationmorestraightforward.
ThemainreasonsbehindtheGMCdecisionnottoproceedwithafurtherexplorationofstudentregistrationrelatedto:cost,therebeingnocompellingcaseonthebasisofapublicsafetyrisk,andbecauseavoluntaryregisterwouldhavethepotentialtoconfusethepublic.
TheGPhChasstatedpubliclythatitdoesnotintendtoregisterstudentsatthisstage,notingthatitis:
‘theGovernment’sviewthateducationandtrainingprovidersareideallyplacedtoidentifyanddealwithstudentfitnesstopractisebycarryingoutpre‐educationcheckstodiscoveranyfactorswhichmighteitherindicateprospectivestudents’unsuitabilityfortrainingasapharmacistorpharmacytechnician,orwhichmightidentifyareaswheretheymayneedextrasupport’(GPhC’swebsiteFAQsection,2012).
TheCHREreachedsimilarconclusionstothoseofthetheGMCwhenitproducedadviceonstudentregistrationin2007:
‘MuchoftheevidencefortheneedforacloserrelationshipbetweenthestudentandRB(regulatorybodies)whichhasbeenpresentedtoCHREhasbeenexperientialandanecdotal.…Inconclusion,onthebasisofthesurveyofopinionitisourviewthatregistrationofstudentsforthepurposeofdevelopingaworkingknowledgeofprofessionalbehaviour,ethicsandvaluesisnotnecessarilyachievedthroughregistrationwithaRegulatoryBody.OnbalanceastrongerrelationshipbetweentheHEI,RBandstudentthroughCodesofConductandguidelinesforfitnesstopractisemightbeamorepragmaticwaytoproceedthatwouldprovideprotectionforthepatientwhilsttheindividualisastudentplusbetterpreparationforentryintoprofessionalpracticeonqualifying.’(CHRE,2007)
SincethattimetheCHREhasintroducedtheconceptof‘righttouch’regulation(CHRE,2010).Fromthisperspectivestudentregistrationmightbeconsideredtheimpositionofafurtherlayerofadministrationforfew,ifany,perceivedbenefits.Inessence,itisclearthattheCHREhasconcludedthatthereareother,moreproportionate,waysofdevelopingprofessionalbehaviour,ethicsandvaluesandofaddressingstudentfitnesstopractiseissues.
Asystemofstudentregistrationnotlinkedtofundingorotheradministrativeduties‐theGeneralOpticalCouncilTheGOCistheonlyUKhealthcareprofessionregulatortoregisterstudents.Itisrequiredtodosothisundersection8AoftheOpticiansAct1989(amended2005).Itisacriminaloffenceundersection28(1)(cc)oftheActforanyonetoholdthemselvesoutasastudentregistrantwhilenotbeingregisteredwiththeGOC.
TheGOCCodeofConductappliestoallitsregistrants(iethosewhoarefullyqualifiedandthoseintraining).Ithasproducedtwoguidesrelatingtostudentregistration–oneforstudentsandtheotherfortrainingproviders.Thelatterdescribesthepurposeofstudentregistrationasfollows:
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‘Studentregistrationisintendedtomakestudentspersonallyaccountablefortheirconductandtoensurethattheydonotposeathreattothesafetyofthepublicwhiletraining.RequiringstudentstoregisterwiththeGOChelpsthemdevelopaworkingknowledgeofprofessionalbehaviour,ethicsandvalues,astheyareboundbythesameGOCCodeofConductasfullregistrants.’(GOC,undated)
TheGOCstatesinitsguidancetostudentsthat‘thepatientsyoutreatandthecustomersyouworkwithneedtobeprotectedtoavoidproblems’(GOC,undated).Studentsareadvisedthatiftheyarenotregisteredtheyarebreakingthelaw,willnotbeabletositassessmentsorparticipateinclinicsortraining,oradvancetoprofessionalpractice.Theguidancefortrainingprovidersadditionallynotesthatstudentswhoarenotregisteredwillnotbecoveredbyanyindemnityinsurancepolicy.
NewstudentsmustapplyforregistrationwiththeGOCusingtherelevantforms.Theinformationisusuallysuppliedbytheeducationprovider.Registrationoccursannually,sostudentsmustremembertosubmitaregistrationretentionformafterthefirstandsubsequentyearofaprogramme.Thestudentregistrationfeeis£20fortheacademicyear2012–2013.
StudentsmustinformtheGOCofanythingthatmightaffecttheirfitnesstotrainandworkwiththepublic,suchasapastcriminalconviction,disciplinaryaction,orserioushealthcondition.Theyareadvisedthatiftheyhaveanythingtodeclarethentheformshouldbesubmittedwellbeforethecoursehasbegun.Allcriminalconvictions,cautionsanddisciplinaryproceedingshavetobedeclaredontheregistrationandretentionforms,includingminormisdemeanours(butnotroadtrafficoffencesdealtwithbyafixedpenaltynotice).Thetrainingproviderwithwhomthestudentisenrolledmustvalidateastudent’sform.StudentregistrantsarealsorequiredtoinformtheGOCassoonaspossibleofanychangeintheircircumstancesthatmightaffecttheirfitnesstotrain(ieratherthanonlydoingthisatthepointofretention).AlldeclarationsarereviewedbytheRegistrarinconfidenceandonacase‐by‐casebasisinlinewithasetprotocol(GOC,2009amended2010).
TheregistrationnumberastudentreceivesisnotnecessarilytheonetheywillretainwhentheybecomefullyregisteredwiththeGOC.Similarly,ifapractitionerleavestheGOCregistertheymayreceiveadifferentregistrationnumberwhenre‐registering–althoughallregistrationnumbersareunique.
TrainingprovidersassisttheGOCinthestudentregistrationprocessby:
• providingregistrationformstostudentsandsigningandstampingtheirapplications
• remindingstudentsoftheneedtorenewtheirregistrationannuallyandtokeeptheircontactdetailsup‐to‐date
• ensuringthatallstudentsremainregisteredthroughouttheirstudies
• dealingwithstudentswhohavebeenremovedfromtheGOCregistersuntiltheyarereinstated.
BothsetsofGOCguidanceonstudentregistrationfocusonthemechanicsofthesystemandwhatindividualsandorganisationsneedtodotomaintainregistration.TheGOCdoesnotappeartohaveproducedspecificguidanceonstudentfitnesstopractise,butitdoesmakereferencetoguidancedocuments(forexampleaboutmatterssuchasthesupervision
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ofstudents)availablethroughprofessionalbodies.Weunderstandthatthisreflectstheparticularcircumstancesofeye‐careprofessionaltrainingandtherespectiverolesoftheGOCandtheprofessionalbodiesinthatprocess.6
Wewereunabletofindspecificinformationontherisksposedbystudentsintheopticalprofession,northepolicyrationaleforstudentregistration.HoweverpublishedstatisticsdoshowthattheGOCreceived184complaintsagainstmembersofits24,656registrantsinthecalendaryearreportedinitslastannualreport(GOC,2011),ofwhich16wereagainststudents(11studentoptometristsand5studentdispensingopticians).Thisequatestoapproximately9%ofthefitnesstopractisecomplaintsreceived.Howeverthedatadoesnotrevealthenatureofthecomplaintsagainststudentsnortheextenttowhichtheywereupheld.TheGOChasstartedtoreviewhowstudentsshouldberegulated,therisksthatstudentsposeandhowtheriskscanbestbemitigated.7
Studentregistrationrelatedtothefundingofpracticeplacements–theGeneralSocialCareCouncilandotherUKsocialcareregulatorsTheGSCCregulatesthesocialworkprofessioninEngland–theotherthreeUKcountrieseachhavetheirownsocialworkregulator.ThestandardsandapproachesusedbythefoursocialworkregulatorsintheUKhavetodatebeenbroadlysimilar,sothisreviewhasconcentratedontheGSCCanddrawsonliteraturefromtheotherUKsocialcareregulatorsonlywhereitaddstotheanalysis.
SinceitsinceptiontheGSCChasregisteredsocialworkstudents.RegistrationisvoluntarybutislinkedtotheGSCC’sroleinadministeringfundingforstudentpracticeplacements.FundingforstudentpracticelearningisonlyprovidedforthoseindividualswhoareregisteredasastudentontheSocialCareRegister.Whilsteachstudentisresponsiblefortheirownregistrationandforpaymentoftheregistrationfee,HEIsareresponsibleforprovidingevidenceoftheregistrationofeachstudenttotheGSCCeachyear.TheGSCCisabletorecoupfundingpaidoutinrespectofanystudentswhohavenotbeenregisteredbytherequireddeadlineGSCC(2010b).
In2009‐10,6,113studentsenrolledonsocialworkdegreesacross278approvedprogrammesin83HEIs,manyofferingseveraldifferentroutestoqualification(suchasfull‐time,part‐time,undergraduate,Mastersdegrees)(GSCC,2010c).
InsocialworkeducationstudentregistrationappearstobeinextricablylinkedtothewayinwhichthesystemhasdevelopedsincethedecisiontoregulatesocialworkerswastakenbyGovernmentintheearlyyearsofthe21stcentury.Thesocialworkprofessionisunusualinthattherequirementsforsocialworkeducationandtrainingarenotonlylaiddownbythefourprofessionalregulators,butalsobytheGovernment(DepartmentofHealth,2002).IndecidingtoabolishtheGSCCandtovestresponsibilityforregulatingthesocialworkprofessionwiththeHPC,theGovernmenthasalsoindicateditsintentiontogivetheHPC
6 The relationship is evident in a news item on the GOC website: in 2009 the GOC felt it necessary to remind optical businesses, students and supervisors to ensure that their current arrangements for professional supervision continued to meet the standards outlined by the GOC following a case in which an optical business was found to have failed to take reasonable and proportionate steps to prevent a student from dispensing spectacles to a patient under the age of 16. 7 See GOC website: Stakeholder community contribute ideas at feedback event which can be found at: http://www.optical.org/en/newsletter/stakeholder-update/srgs-help-goc.cfm (Accessed 27/01/12)
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legislativepowerstoenableittoestablishavoluntaryregisterofstudentsifit(theHPC)considersitappropriatetodoso.TheGSCChasmadeitsviewsclearandarguesthattheHPCshouldregisterstudentsocialworkers.TheGSCChassaidthat:
• ‘Socialworkstudentshaveaccesstovulnerableserviceusers,intheirownhomes,oftenwithoutdirectionsupervision.
• Educationprovidersmaynotbebestplacedtomonitorstudents’conductonplacementsassystemstodosoarenot‘universallyeffectiveandconsistent’.Concernsexpressedbyemployersandexternalexaminersindicatethatprogrammesarereluctanttoexcludeunsuitablecandidatesbecauseofthefinancialpenaltiesinvolved.
• Registrationbringstostudents’attentiontheirresponsibilityforhighstandards,enhancingpublicprotection.
• Registrationmeansthecodeofpracticeisbinding.Thecodeisoftenusedtoinitiatedebatesaboutethicalissuesorusedbyeducationprovidersasthebasisofacontractwithastudent.Thisisimportantfortheprofessionalisationofsocialwork.”
(HPC,2011b)
Theremainderofthissectionexaminesthisdebateinmoredepth.
GSCC–suitability,fitnesstopractiseandriskTheGSCChasnottodateusedtheterm‘fitnesstopractise’.Thesocialworkprofessiontendstorefertotheconceptofsuitability(seechapter3)soitisnotsurprisingthattheGSCChasnotpublishedguidanceonstudentfitnesstopractice.Howeveritdoesrefertoparallelconceptsandprocesseswithinitsaccreditationcriteria.TheGSCCrequiresHEIsto:‘developeffectiveproceduresforendingastudent’sinvolvementinthesocialworkdegree,whereappropriate,tomakesurethatunsuitablepeopledonothavethequalificationtoallowthemintotheprofession’and‘makesurethatallgraduatesarefitforsocialworkpractice’;anditsaysthatproceduresdevelopedbyHEIs‘mustgivethestudenttherighttochallengeevidenceagainstthemandtherighttobeaccompaniedorrepresentedatanyhearing’(GSCC,2002a).ThisisreinforcedtostudentsintheGSCC’sstudentbooklet,which00statesthat:‘itistheuniversity’sresponsibilitytoensurethatonlypeoplewhoarecompetentandsuitableentertheprofession’(GSCC,2008).
In2007theGSCCandtheJointUniversityCouncilSocialWorkEducationCommittee(GSCC/JUCSWEC)producedguidanceentitledSuitabilityforsocialwork:Ensuringthesuitabilityofsocialworkstudentstoaccessandcontinuetheirtraining(GSCC&JUCSWEC,2007).ItspurposewastoclarifytherolesandresponsibilitiesofHEIsandtheGSCCinmakingdecisionsaboutthesuitabilityofsocialworkstudentstoenterthesocialworkprofession.TheguidancestatesthatHEIsareresponsiblefordeterminingsuitabilityby:selectingstudentsontoprogrammes,includingrequiringself‐declarationformsforcriminalconvictions;ensuringthatallstudentsaresubjecttoenhancedCRBchecks;andhavinganagreedprocesstomakedecisionsonaone‐to‐onebasiswheredeclarationand/orchecksidentifyconvictionsorhealthissuesthatraiseconcernsaboutsuitability.TheGSCCassessessuitabilitytojointhestudentregisterbyconfirmingthatindividualsonsocialworkdegreecoursesareofgoodcharacter,goodconductandarephysicallyandmentallyfit;andregistersstudentswithorwithoutconditionsandcanrefuseorwithdrawregistrationwhensuitabilityisboughtintoquestion.
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OnewayinwhichtheGSCCestablishesgoodcharacterisbyassessinganycriminaloffencesdeclaredattheapplicationstage(GSCC&JUCSWEC,2007).Itusesthreeriskcategoriesforoffencetypeasfollows:
Highrisk–offencesthatsuggesttheoffenderislikelytoposearisktothesafetyandwellbeingofserviceusersandsocialcare(egoffencesagainstchildrenandabductionofachild,offencesinvolvingtheabuseoftrust;offencesinvolvingviolenceorcruelty).
Mediumrisk–offencesthatsuggesttheoffendermayposearisktothesafetyandwell‐beingofserviceusers,andmaythereforebeunsuitabletoworkinsocialcare(egdrinkdriving,failuretoprovideabreathtest,theft,possessionofclassAdrugs,repeatedlowriskoffences).
Lowrisk–offencesthatsuggesttheoffenderisunlikelytoposearisktothesafetyandwellbeingofserviceusers,andthereforeislikelytobesuitabletoworkinsocialcare(egshopliftingoffencesasateenager,possessionofcannabis,minormotoringoffences).
Beyondcriminaloffences,considerationofunsuitableconductcanextendtobehaviourinanysphereofastudent’slife–itisnotconfinedtotheprogrammeoflearningwithintheHEIortopracticeplacements,butcouldalsoconcernbehaviourduringemploymentorinastudent’sprivatelife.Theguidancedoesnotofferspecificexamplesofbehavioursconsideredsuitableorunsuitable(exceptforplagiarism,whereitisnotedthatinsomecircumstancesthismaycallthestudent’ssuitabilityintoquestionifitinvolvesquestionsaboutthestudent’shonestyandintegrity)butitdoesindicatethattheconceptofreasonablenessistobeappliedintheassessmentofanyconductwhichcallsintoquestionastudent’ssuitability.
TheDepartmentofHealth(2002)documentonsocialworktrainingrequirementsalsousesthesamebroadconceptwithreferencetoapplicantsbeing‘suitableforadmissiontotheGeneralSocialCareCouncilregisterofsocialworkers’.Tohelpestablishsuitability,itrequiresHEIstoassessallshortlistedapplicantsthroughgrouporindividualinterviewsinvolvingemployersandpeoplewhouseservicesandtheircarers.
Incontrasttothewidespreaduseoftheconceptoffitnesstopractiseamongthehealthprofessions,insocialworktheconceptofsuitabilityisreinforcedbyreferencetothenotionof‘gatekeeping’.Inareportonthequalityassuranceofeducation,theGSCCreferstoitasfollows:
‘Highereducationinstitutionsseethemselvesasgatekeeperstotheprofessionthroughtheirselectionproceduresand,onceonthecourse,toendtrainingifastudentisfoundtobeunsuitable.Twenty‐fivestudentshadtheirtrainingendedonthegroundsofunsuitabilityduringthisreportingperiod.However,itisnotclearhowmanystudentseitherwithdrewvoluntarilyorwerecounselledoutwhensuitabilitywasquestioned.Thesematters,andtheneedforclarityabouttheinterfacebetweentheGSCCanduniversitiesinmakingdecisionsaboutsuitability,havebeenconsideredbyajointworkinggroupofGSCCandJUC‐SWECrepresentativesandguidancehasbeenissued.’(GSCC,2007)
Itisclearthatthenotionofsuitabilityisconsideredcrucialinstudentselectionandsocialworkeducationandtraining,andthatthisisrootedinaconcerntoprotectthepublic,not
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leastbecausesocialworkclientsareoftenextremelyvulnerable.Yetithasprovendifficulttofindevidenceabouttherisksposedbysocialworkstudentsorabouttheextenttowhichtheyposeagreaterormoreseriousriskthanstudentsinotherprofessionswhoarenotregistered.Ithasbeensuggestedthataparticularriskfromsocialworkstudentsarisesbecausetheyhavedirectandunsupervisedcontactwithvulnerableserviceusers(GSCC,2011),butwehavebeenunabletofindevidenceofthisinGSCCpublicationsorintheresearchliterature.
DatasubmittedbytheGSCCtotheHPCshowsthatof160conducthearingsin2010‐2011,eight(5%)werestudents.Thesecasesinvolvedfraud,dishonesty,abuseorconvictionsforviolentbehaviour(HPC,2011).TheGSCCrefusedregistrationtoninesocialworkstudents,andregisteredanothersevenwithconditions,between2005and20118.Reportingonprofessionalconductbetween2009‐2010,theCareCouncilforWalesnotedthatoutof155referralstotheCouncil,20wereaboutstudents(butnoinformationwasprovidedaboutthenatureoftheissuesconcerned).
Sincethemajorityofotherregulatorsdonotregisterstudentsandplaceinitialresponsibilityforcheckingcriminalconvictionsandstandardsofstudentconductwitheducationproviders,nocomparisonscanbemadetohelpdeterminewhetherratesofstudentmisconductinsocialworkareatypicalorcomparabletootherprofessions.WeunderstandthatthemajorityofstudentcasesheardbytheGOC(whichdoesregisterstudents)relatetocriminalconvictions(butwehavenospecificdataonthis).
In2011theGSCCpublishedadditionalguidanceonprofessionalboundariesbecause‘ofthosesocialworkerswhohavebeentakenthroughconductproceedings,aconsiderableproportionofcaseshavearisenduetobreachesofprofessionalboundaries’(GSCC,2011).Theguidancetakesabroadviewoftheconceptofprofessionalboundarieswhichittakestoincludenotonlydirectrelationshipsbetweensocialworkerandtheserviceuser,butalsothestandardsofbehaviourexpectedofsocialworkprofessionalsinsideandoutsideworkwhichcouldpotentiallydamagethereputationoftheprofession.Someoftheexamplesprovidedintheguidancerelatetosocialworkstudents,implyingthatthesamestandardsofconductapplythrougheverystageofprofessionaldevelopment.IndeedtheGSCCreportedthatallegationsofinappropriaterelationshipsbetweensocialworkersandpeoplewhouseserviceshavebeenaconsistentthemeincomplaintreferralsbetween1April2003and31March2007.AnalysisbytheGSCCrevealedthatthemostcommonareasofmisconductrelatetobreachingthetrustandconfidenceofserviceusersandthepublicinrelationtosection2oftheCode(honesty,trust,reliability,adheringtopolicyandproceduresanddeclarationsofissues),andsection5oftheCode(abuse,exploitation,boundaries,andplacingpeoplewhouseservicesatrisk)(GSCC,2008).
GSCC–qualityofpracticeplacementsInreviewingpublicationsfromtheGSCCandotherorganisations,wenotedarecurringthemerelatingtoconcernsaboutthequalityofpracticeplacements;andinparticulartheextenttowhichtheyarecapableofpreparingorassessingsocialworkstudents’suitabilityforpractice.Despiteusingthestudentregistrationsystemtofundplacements,theissueappearstohavebeenalongstandingconcern(atleastsincetheGSCCcameintobeingand
8 From GSCC website – latest news GSCC: Registration of social work students should continue in the future
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probablybeforeitwasestablished).IndeedthisisoneofthereasonsthattheGSCCputsforwardinitsreasonsforretainingstudentregistration(HPC,2011b).
TheGSCChasnotedpressuresacrossthecountrytoprovideappropriate‘practicelearningopportunitieswithappropriatelyskilledandqualifiedpracticeeducatorsandassessors’(GSCC,2007).TheproblemwasfurtherhighlightedinareportoftwostudentforumeventsinthenorthandsouthofEnglandinwhichtheGSCCengageddirectlywithstudents.9Thenegativepracticelearningexperiencesreportedbystudentsincluded:inadequatepreparationbothofthestudentand/ortheplacementprovider;inconsistentstandardsofpracticeteachingandassessment;discouragingworkplaceculturesthatwereexperiencedasuninterestedinthepresenceofastudentorwhichusedthemasunpaidworkers;andalackofbasicresourcessuchasdesksortelephone(GSCC,2007).TheGSCCreportedthatitwasintheprocessofdevelopingandpilotingasetofcriteriaforpracticeplacementsasaresponsetotheconcerns.
ConcernaboutthequalityofpracticeplacementswasonceagainhighlightedbythenationalSocialWorkTaskforce(establishedbytheSecretariesofStateforHealthandforChildren,SchoolsandFamiliesinresponsetothechallengesfacedbythesocialworkprofession).Itsreportrecommendedthatthereshouldbe:‘moretransparentandeffectiveregulationofsocialworkeducationtogivegreaterassuranceofconsistencyandquality’,andthat‘newarrangementsbeputinplacetoprovidesufficienthighqualitypracticeplacements,whichareproperlysupervisedandassessed,forallsocialworkstudents’(SocialWorkTaskForce,2009).TheGovernmentacceptedalloftheTaskForcerecommendations(DH&DCSF,2009).
InrespondingtotheSocialWorkTaskForceReview,theGSCCwelcomeditsrecommendationsandstartedonaprocessoftransformingitsmonitoring,inspectionandapprovalregimeasinthereportingperiod2008–2009,58%ofprogrammeshadhadconditionsset(61coursesacross24HEIs),mostofteninrelationtotheareasoffitnesstopractiseproceduresandpoliciesandalackofqualityassuranceofpracticeplacements.(GSCC,2009).
ToaddressthelackofqualityassuranceofpracticeplacementsandtohelpHEIs,theGSCCworkedwithSkillsforCareandtheChildren’sWorkforceDevelopmentConfederationtoproduceaqualityassuranceofpracticelearning(QAPL)benchmarkstatementandassociatedevaluationtools.Thebenchmarkstatementidentifieswhatneedstooccurintheplanningandprovisionofahighqualitypracticeplacementsuchas:systemsforassuringthequalityandsuitabilityofplacements;theallocationofstudentstoplacements;commencingtheplacement;supportarrangements,accountabilityandroleclarity;thelearningandassessmentprogramme;andevaluationandfeedback(SkillsforCareetal,2010,2ndedition).
InSeptember2009theGSCCconfirmedthatfromSeptember2010,HEIswouldbeformallyrequiredtoreportannuallyonhowpracticeplacementsmeettheQAPLbenchmarkstatement(GSCC,2009).ThisreportingrequirementwasfollowedupbytheGSCCinitsannualmonitoringofpracticeplacementsin2010,whichrevealedthat94%ofHEIsalwaysappliedtheauditingtoolwhenqualityassuringplacementsandthat57%ofHEIshadrejectedplacementsasunsuitable.12HEIsreportedthattheyhadhadtouseinappropriate
9 We have not found any similar reports of student engagement activities undertaken by other regulators (aside from the GMC).
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placementsbecauseofshortages,althoughtheabsolutenumberofplacementsinvolvedwassmall.Aqualifiedandexperiencedsocialworkerhadassessedthefinalplacementin99%ofcases.Thiswasseentobeasignificantimprovementfrompreviousyears(GSCC,2010c).
In2011theSocialWorkReformBoard(SWRB)lookedagainatsocialworkeducationtoassesstheextenttowhichtherecommendationsoftheSocialWorkTaskForcehadbeenimplemented,includingimprovingpracticeplacements.AsaconsequenceitfurtherstrengthenedtherequirementssetoutintheQAPLbyaddingaspectsrelatedto:partnershipsbetweenemployersanduniversities;agreedthresholdsforprogressionandtheoutcomesrequiredattheendofeachplacement;anewpracticeeducatorframeworkfrom2013‐14requiringpracticeeducatorstobequalifiedtoaspecificlevel;andarequirementthatallprogrammesuseaconsistentmodelofpracticelearning(SWRB,2011).TheSWRBindicatedthattheCollegeofSocialWorkwouldfurtherdevelopandoverseetheimplementationofthesearrangements(althoughitisnotclearhowthisistorelatetotheroleoftheHPC).
TheproposalforanewpracticeeducatorframeworkissimilartotheNMC’sdevelopmentofstandardsformentors,practiceteachersandteachers(NMC,2008)andtotheGMC’sconsultation(ongoingatthetimeofwriting)onrecognisingandapprovingtrainers(GMC,2012).ThisareaofregulationisbeyondthescopeofthisresearchbutishighlightedhereasanareathatmightbeofinteresttotheHPCinitswiderdeliberationsonmeasurestopromotestudentfitnesstopractise.
TheSWRBalsoreturnedtotheissueofstudentsuitabilityandexpresseditsconcernabout‘inconsistencybetweenprogrammeswithsomepassingstudentswhowereeithernotcompetentand/ornotsuitabletobecomearegisteredsocialworker’(SWRB,2011)notingthatitwasachallengingarea:
‘TheSWTFcalledforgreaterconsistencyinthequalityofsocialworkqualifyingeducation.Here,thereisacleargapintheliteratureintermsofwhatweknowabouttheeffectivenessofdifferingmethodsofassessingstudentsandtheoperationofprofessionalsuitabilityprocedures.Wealsoknowverylittleabouttheprocessofaccreditingprogrammesbeyondhowmanyprogrammesareconsideredtobeoperatingsatisfactorily.’(SWRB,2011).
TheSWRBreportalsonotesthatthe:
‘HPCwillrequireproviderstohaveinplaceaprocessthroughouttheprogrammefordealingwithconcernsaboutstudents’profession‐relatedconduct,SET3.16.Itisthereforeproposedthatprogrammesshouldretaintheirproceduresforconsideringstudent’ssuitabilitytopractise,andshouldhaveinplaceprocedurestoendastudent’ssocialworktrainingifthereareconcerns.TheexistingGSCCrequirementsaboutsuitabilityforpracticehaveservedtheprofessionwell,butwillnolongerapply.’(SWRB,2011).
ThisreviewofhowtheGSCChasaddressedissuesrelatedtostudentsuitabilityshowsthatthereareanumberoflongstandingissuesinsocialworkeducation,suchasthequalityofpracticeplacements,whichhavebecomeintertwinedwiththeissueofstudentregistration.
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4.4 OtherregulatedprofessionsintheUK
Awebsearchrevealedadearthofinformationaboutstudentregistrationorstudentfitnesstopractiseamongotherprofessions.TwoexamplesillustrateapproachesthathavebeenadoptedbyotherprofessionsintheUK.
InEnglandtheGeneralTeachingCouncil(GTC)keepsaregisterofthosetrainingtobecometeachers.Theseprovisionally‐registeredtraineeteachersaresubjecttotheGTC’sCodeofConductandPractice,whichsetsoutstandardsforthebehaviourandcompetenceofteachersgenerally(GTC,2009).AnytraineecanbereferredtotheGTCfollowingaconductmatterthathasledtotheirleavingateachertrainingcourse.Rulesreferringtocompetencecomeintoforceonlyafter‘qualifiedteacherstatus’(QTS)hasbeenawardedandfollowingfullregistrationwiththeGTC.HoweverthesearrangementsaresoontochangefollowingrecentlegislationabolishingtheGTCandtransferringsomeofitsfunctionstoanewTeachingAgency.TheGTCwillcloseon31March201210.TeachersmustcontinuetoregisterwiththeGTCuntilthenbutafterthatdateitappearsthattheTeachingAgencywillholdonlyarecordofteacherswhohavebeenawardedQTS,andthetraineeregisterwillceasetoexist.
Thesecondexampleconcernstheprofessionalelementoflegaltrainingtobecomeasolicitor.StudentsarerequiredtoenrolwiththeSolicitorsRegulationAuthority(whichregulatesqualifiedsolicitors)beforetheystartaLegalPracticeCourse(LPC),theprofessionalelementoflegaltraining.Theenrolmentincludeswrittenconfirmationofcompletionoftheacademicstageoftraining(usuallyalawdegree),andincludesa‘suitabilitytest’,whichhasreplacedpreviouscharacterand‘suitabilityguidelines’.
Weconcludedthattherewaslittletobelearntbyfurtherexploringthesearrangements,notleastbecausetraineeteacherregistrationissoontocease,andthattherewaslittletobegainedbycontinuingtosearchforevidenceofstudentregistrationinotherprofessions,manyofwhichhavenoregulatoryinterestintheundergraduateeducationthatproceedsentrytoprofessionaltraining.
4.5 NonUKhealthandsocialcareprofessionsregulators
AsasupplementandcomparatortothedetailedanalysisofUKhealthandsocialcareprofessionsregulatorsdescribedabove,wealsoreviewedaconveniencesampleofnon‐UKEnglishspeakinghealthandsocialcareregulators.Thereviewbelowprovidesnomorethananindicationoftheextenttowhichregulatorselsewhereintervenedirectlytoassurestudentfitnesstopractise.Itisbynomeanscomprehensive,notleastbecausethereare:
‘potentiallythousandsofRegulatorsandProfessionalBodieswhomaybeinvolvedintheregulationofhealthcareworkersoperatinginover190countries,30dependantterritoriesand200smallerregionaladministrativeareassuchasstatesandprovinces.’(HPC,2011)11.
Furthermore,thereisalackofdetailedpolicyinformationinpublishedsourcesoronregulatorwebsitesaboutstudentfitnesstopractiseandstudentregistration,andthereisa10 GTC website section: The future of the GTC dated 01/12/11 (last accessed 23/01/12). 11 HPC website ‘Health Regulation Worldwide’ accessed 14 December 2011 at: http://www.hpc-uk.org/aboutregistration/regulators/worldwide/
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dearthofinformationabouttheextenttowhichregulatorsuseothermeanstoengagewithstudentsortoregulatetheirpractise.Thescopeofthecommissionedresearchdidnotextendtomakingadirectapproachtootherregulators–butrathertoreviewingpublishedandgreyliterature–so,forthepurposesofthisreview,insomeinstancesaregulator’spolicypositionaboutstudentconductandfitnesstopractisehasbeeninferredfrommaterialaboutrelatedregulatorypoliciesandfunctions,suchaseducationalstandardsandeducationqualitymonitoring.
Itisevidentthatthemajorityofregulatorsoperatefromtheprinciplethatstudentconductislargelyamatterfortheinstitutionsapprovedtoprovideeducationandtrainingforfirstregistrationandentrytotheprofession.Whileregulatorsmaysetstandardsandprovideadviceabouttheconductexpectedofstudents,managingstudentconductandfitnesstopractiseappearstobeviewedbymanyasadevolvedregulatoryfunctionbestundertakenbyeducationproviders.Amongthemanyjurisdictionsinwhichhealthandsocialworkprofessionalsarestatutorilyregulated–anditisimportanttonoteherethatalthoughtheregistrationofmedicalprofessionalsisnearuniversal,thisisnotthecaseforotherhealthprofessionsorforsocialwork–itappearsthatonlyasmallminorityregisterstudents.Theexamplesbelowillustratesomeofthedifferentapproachesadopted.
AustraliaAustraliaisonejurisdictionwherestudentregistrationisbeingintroducedforanumberofhealthprofessions.Recentlegislation(HealthPractitionerRegulationNationalLawAct2009)establishedtheAustralianHealthPractitionerRegulationAgency(AHPRA),astatutorybodyresponsibleforimplementinganationalregistrationandaccreditationschemeacrossAustraliawhich,forthefirsttime,bringstheregulationof10healthprofessionsundernationallyconsistentlegislation.AfurtherfourhealthprofessionsaretojointhenationalregistrationandaccreditationschemeinJuly2012.
TheAHPRAsupportstheNationalHealthPractitionerBoardsestablishedforeachprofessionbymanagingtheregistrationprocessesforpractitionersandstudents,andbyadministeringinvestigationsintotheirprofessionalconduct,performanceorhealth.NineofthetenNationalHealthPractitionerBoards12thatfallwithintheAHPRA’sremitstartedtointroducemandatorystudentregistrationduring2011.Thepurposeandscopeoftheschemehasbeendescribedasfollows:
‘MinistersforHealthhavebeenguidedbytheprincipleofpublicsafetyanddeterminedthattheimpactofregistrationonstudentsshouldbeaslimitedasisnecessarytoachievethis.TheyagreedtheNationalSchemewouldenableNationalBoardstoactonstudenthealthimpairmentmattersorwhenthereisacriminalconvictionofaseriousnaturethatmayadverselyimpactonpublicsafety.However,theNationalBoardshavenoroletoplayintheacademicprogressorconductofstudents.
12 The nine Boards are: the Chiropractic Board of Australia, the Dental Board of Australia, the Medical Board of Australia, the Nursing and Midwifery Board of Australia, the Optometry Board of Australia, the Osteopathy Board of Australia, the Pharmacy Board of Australia, the Physiotherapy Board of Australia, and the Podiatry Board of Australia. The Psychology Board of Australia does not register students who must apply for provisional registration at the beginning of their 4+2 internship or their higher degree pathway.
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TheStudentRegisterisconfidentialthereforetheAustralianHealthPractitionerRegulationAgencycannotprovidevalidationofstudentenrolmenttohealthservicesthatarenotthedesignatededucationprovider.
TheNationalLawstatesthataNationalBoardmayrequestinformationfromaneducationalbodywheretheBoardrequirestheinformationtoexerciseitsfunctionsunderthisLaw.AneducationalbodyreceivingsucharequestisexpresslyauthorisedtogivetheinformationtotheNationalBoard.’(AHPRA,2011).
Anumberoffeaturesofthisdevelopmentarenoteworthy.Therearenofeesforstudentregistration.Theregisterisnotinthepublicdomain,norisinformationontheregisteraccessibletohealthserviceproviders.EducationprovidersarerequiredunderlawtonotifytheAHPRAiftheybelieveastudenthasanimpairmentthat,inthecourseofthestudentundertakingclinicaltrainingaspartoftheprogrammeofstudy,mayplacethepublicatsubstantialriskofharm;orifastudentisfoundguiltyofanoffencepunishableby12monthsimprisonmentormore;orifastudenthascontravenedanexistingconditionorundertaking(AHPRA,2011).WhenaNationalBoardsuspendsastudent,imposesconditionsontheirregistration,oracceptsanundertakingfromastudent,itisrequiredtogivewrittennoticetotheeducationproviderwhomust,assoonaspracticable,givenoticetoanyorganisationwithwhomthestudentisundertakingclinicaltraining(AHPRA,2011).Intheyear2010‐2011,thereweresevenmandatorynotificationsreceivedinrelationtojustunder100,000studentsregistered(AHPRA,2011).
TheAHPRAmakesitclearthatneitheritnortheNationalBoardshaveanyotherroletoplayintheacademicprogressorconductofstudents,andthatitiseducationprovidersthatremainresponsibleformanagingtheacademicprogressanddisciplinarypathwaysfortheirstudents.Sointhisinstancestudentregistrationappearstobeavehicletoenabletheregulatortodealwithalimitedrangeof(moreserious)studenthealthandconductissueswithoutusurpingtheresponsibilitiesofeducationproviderstoassureappropriatestandardsofstudentconductandhandleinstancesof(lessserious)misconduct–adistributionofresponsibilitieswhichitmightbearguedimpliesthepotentialforduplicationofeffortanddoublejeopardyforstudents.
Incontrasttomedicine,nursingandotherhealthprofessions,therearenolegalregistrationrequirementsforsocialworkersinAustralia.Socialworkisnotcurrentlyincludedinthenationalregistrationandaccreditationschemedescribedabove.Representativesoftheprofessionhaveformallyexpressedtheirdisappointmentaboutthisandindicatedtheirintentiontopursueregistrationinthefuture(AASW,2009).Nevertheless,mostemployersrequirethatsocialworkersbemembersoftheAustralianAssociationofSocialWorkers(AASW).TheAASWisaprofessionalassociationwhich,amongotherthings,accreditssocialworkdegrees,thesuccessfulcompletionofwhichconferseligibilityformembership.StudentsenrolledonanAASWaccrediteddegree,andthosealreadyeligibleforAASWmembershipandundertakingfulltimeMastersorDoctoralsocialworkstudies,areeligibleforstudentmembership.
TheAASWoperatesinaquasi‐regulatoryrole,notleast,asWilson(2005)observes,bysettingeducationandaccreditationstandards(AASW,January2010)and,forexample,byestablishingpracticestandardsforsocialworkers(AASW,2008)andpublishingaCodeofEthics.Significantly,thelattercallsuponbothpractitionersandstudents‘toaccountfortheirpracticeintheeventofcomplaintorinvestigationregardingunethicalconduct’(AASW,
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2010).However,whiletheAASWhasaformalsystemforreceivingandrespondingtocomplaintsabouttheallegedunethicalpracticeorbehaviourofitsmembers(includingstudents),becauseitisnotcompulsoryforSocialWorkerstobemembers,theAASWcanonlyreceiveanddealwithcomplaintsaboutthosewhoare.
NewZealandInNewZealandtheHealthPractitionersCompetenceAssuranceAct2003providesaframeworktoregulatehealthpractitionersinordertoprotectthepublicwherethereisariskofharmfromprofessionalpractice.TheAct–whichcameintoforcein2004andisadministeredbytheMinistryofHealth–repealed11occupationalstatutesgoverning13professions.NotallhealthprofessionsareregulatedundertheAct–somebecausetheyhavebeenjudgedtoposelittleriskofharmtothepublic,somebecausetheyworkunderthesupervisionofaregulatedprofession,andsomebecausetheyareregulatedinotherways,forexamplethroughtheiremployers.EachoftheregulatedprofessionshasaCouncilorBoardwhichworkstothecommonregulatorystandardsoftheAct.13IncontrasttotheAustralianhealthprofessionslegislationdiscussedabove,thereisnodutyorpowerintheActforCouncilsorBoardstoregisterstudents;andwecouldfindnoevidenceof(non‐mandated)studentregistrationamongtheregulatedhealthprofessionsinNewZealand.
TheNewZealandSocialWorkersRegistrationAct2003,whichintroducedregistrationonavoluntarybasis,‘arrivedrapidlyandwithouthugecontest’(Beddoe,2007).ItestablishedtheSocialWorkersRegistrationBoard(SWRB),aCrownagencywhichseekstoprotectthepublicbyensuringthatsocialworkersarecompetenttopractise.TheSWRBestablishedaregister,aCodeofConduct,andpoliciesandproceduresforcomplaintsanddiscipline.Inadditionit‘recognises’socialworkqualificationsawardedby18institutions–thereisnoindicationthatitinspectsormonitors,perhapsreflectingBeddoe’s(2007)observationthatsocialworkeducation‘haslongbeenasiteofstruggleinNewZealand,withthenatureofeducationalqualificationbeingthefocusoftheregistrationdebates’.Furthermore,whiletheCodeofConduct‘coverstheminimumprofessionalstandardsofbehaviour,integrityandconductthatapplytoregisteredsocialworkers’,itmightbeinferredthatitalsoappliestostudentsinsofarasthestandards‘shouldapplygenerallyinthesocialworkprofession’(SocialWorkersRegistrationBoard,2008).HowevertheSWRB’scomplaintsanddisciplinaryproceduresapplytoregisteredsocialworkersonly.Inthecontextofvoluntaryregistration,theabsenceofaCodeofConductexplicitlyencompassingstudents,andgiventheapparentlyweakerformofeducationqualityassuranceimpliedbythenotionof‘recognition’,itisnotsurprisingthatwewereunabletofindanyevidenceoftheregistrationofsocialworkstudentsinNewZealand.
SouthAfricaSouthAfricaisonejurisdictionwherestudentregistrationappearstobemorecommonplace,withnursing,socialworkandsome–butnotall–healthprofessionsstudentsbeingrequiredtoregister.Howeverthepurposeofregistrationandtheextentto
13 The professions regulated under the Act are: chiropractic, dentistry, dental hygiene, clinical dental technology, dental technology and dental therapy, dietetics, medical laboratory science, anaesthetic technology, medical radiation technology, medicine, midwifery, nursing, occupational therapy, optometry and optical dispensing, osteopathy, pharmacy, physiotherapy, podiatry, psychology, psychotherapy.
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whichregulatorsintervenedirectlyappearstovarybetweenprofessions.ForexampletheSouthAfricanNursingCouncilregistersallnursingstudentsaswellasqualifiednurses.Itsstatisticalbulletin(SouthAfricanNursingCouncil,undated)indicatesthatitcananddoestakeactionagainststudentsaccusedofprofessionalmisconduct,reportingthatbetween2003and2008,11studentswerethesubjectofprofessionalmisconducthearingsconcerningphysicalassault(1),medicationrelatedmisconduct(9)andfraud/forgery(1).
TheSouthAfricanCouncilforSocialServiceProfessions(SACSSP),whichisthestatutorybodythatregulatessocialworkers,alsoregistersstudents;butwhereasitsnursingcounterpartpublishesstatisticsreportingdisciplinaryactionagainststudents,wehavefoundnosuchpublicationsoranyotherconfirmatoryevidenceofregulatorybodyinterventioninrespectofsocialworkstudents.HoweverSewpaulandLombard(2004)assertthat‘socialworkersandsocialworkstudentsarerequiredtoabidebytheSACSSP’scodeofconductandfailuretodosomayresultindisciplinaryproceedings’.
TheHealthProfessionsCouncilofSouthAfrica,whichwasestablishedtoprotectthepublicandwhichprovidesguidancetoregisteredhealthcarepractitionerscoveredby12Boards14,alsoregistersstudentsinsome–butnotall–oftheprofessionsthatfallwithinitsregulatoryambit.Itpublishesstatisticsaboutthenumbersofstudentsregisteredbutitisnotclearwhetheritintervenesinrespectofstudentmisconduct(althoughtheActestablishingtheCouncilgivesitpowerstodoso).Itsmisconductstatisticsdistinguishprofessionsbutdonotdifferentiatepractitionersfromstudents(ifindeedthelatteraresubjecttoproceedings),soheretooithasnotbeenpossibletodeterminewhetherstudentregistrationservesanythingmorethanadministrativepurposes.
CanadaIntheCanadianfederalsystemtheregulationofthehealthprofessionsisamatterforeachProvince.Anumberhaveumbrellalegislation.ForexampleinOntariothereare23regulatedhealthprofessions,eachwithagoverningbody(acollege)whichsetsstandardsfortheprofessionbutwhichmustworktoacommonregulatoryframework.Similarlegislationexistsin,forexample,Ontario,BritishColumbiaandAlberta.Asinotherjurisdictionsthepositionvariesfromprofessiontoprofessioninthesameprovince.ForexampleinAlberta,whilemedicalstudentsarerequiredtoregisterandaresubjecttoconductandfitnesstopractiserequirementssimilartothosewhichapplytofullyqualifiedmedicalregistrants,aselsewhereinCanadastudentregistrationdoesnotapplytootherhealthprofessions.
GuidancetoemployersinAlbertaencapsulatesanapparentlycommonunderstandingandpolicypositionthatseemstoholdtrueforanumberofprovincesandforanumberofhealthprofessions.Theguidancestatesthat:
‘Whilestudentsmaypracticeinaregulatedhealthprofessionandperformrestrictedactivities,theyaregenerallynotrestrictedasregulatedmembers.Theyareconsideredtobeunderthecontroloftheireducationalinstitution.
14 The professional Boards cover dental therapy & oral hygiene, dietetics, emergency care, environmental health, medical & dental (and medical science), medical technology, occupational therapy, medical orthotics / prosthetics & arts therapy, optometry & dispensing opticians, physiotherapy, podiatry & biokinetics, psychology, radiography & clinical technology, speech, language & hearing professions.
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Whenstudents,likeotherunregulatedpractitioners,performrestrictedactivities,theydosounderthesupervisionofregulatedmembersandareauthorizedbythesupervisor’sregulation.CollegeRegulationsspecifyhowmembersofthecollegearetosupervisestudents(andunregulatedworkers)intheperformanceofrestrictedactivities.Theseregulationsmustidentifywhocanproviderestrictedactivitiesundersupervision,andthenatureofthatsupervision.Whilestudentsarenotnormallyregulated,theycanusethenameoftheprofessionincombinationwiththetitle“student”whileundertakingactivitieswithintheprogram.’
(AlbertaHealthandWellness,2004,p28)
InCanadatheregulationofsocialworkersisalsoaprovincialmatter.Someprovinceshaveprotectedtitleandrequireregistration;somehaveaqualifyingexaminationprovidedandmanagedbytheAssociationofSocialWorkBoards(anot‐for‐profitassociationofsocialworklicensingboardsinCanadaandtheUnitedStates).TheAssociationofSocialWorkBoardsdoesnotcreateorenforcelicensingorregistrationrequirementsforindividualjurisdictions;rather,itmaintainsthelicensingexaminationsusedbyitsmembersinrespectof600socialworkdegreesaccreditedbytheCanadianAssociationofSocialWorkEducationandintheUnitedStatesbytheCouncilonSocialWorkEducation.TheAssociationofSocialWorkBoardsmaintainsadatabasewhichrecordsandcomparestheLawsandRegulationsconcerningthesocialworkprofessionineachofthe62States,ProvincesandTerritoriesitcovers.15ThedatabasecomprisesinformationaboutBoardstructureandstatutoryprovisions;levelsofpracticeregulated;experienceandsupervisionrequirements;miscellaneousfeaturesoflawsandregulations;administrativeandlicensurefees;continuingeducationrequirements;andsocialworkpracticeandrelateddefinitions.Asearchofthedatabaseoflevelsofpracticeregulatedbythe62licensing(registration)jurisdictionsacrossCanadaandtheUnitedStatesfailedtorevealanythathaveastudentcategory.
UnitedStatesofAmericaTheregulationofhealthprofessionalsintheUnitedStatesisalsolargelyamatterforeachStateorterritorybutregulationisdistributedacrossanumberofbodies,witheducationprovision,educationaccreditation,examination,andlicensureundertakenbydifferentorganisations.FormanyprofessionsStatesco‐operateandworktocommonstandards.Forexample,eachStateorterritoryisresponsibleforlicensingnursesandprotectingthepublicinitsterritory,andeachhasaNursePracticeActenforcedbyaStateNursingBoard,butoperationsareharmonisedthroughtheNationalCouncilofStateBoardsofNursing(theFederationofStateMedicalBoardsservesthesamefunctionsformedicaldoctors,whomustbelicensedbyaStateMedicalBoard).Aqualifyinglicensureexamination(NCLEX)isanationalrequirementforlicensureasanurse(theUnitedStatesMedicalLicensingExamistheequivalentrequirementformedicaldoctors).Accreditationofnursingeducationprogrammesisundertakenbyseveralautonomousagencies(whichhavetoberecognisedbytheUSSecretaryofEducation).Theyprovideconfirmation–notleastforStateBoardsofNursing–thateducationisofasatisfactorystandardandisanappropriatepreparationforstudentswishingtoentertheNCLEX.Thus,astudentnursewillundertakeundergraduate
15 The database can be accessed by following the links to Social Work Laws and Regulations Comparison Guide at http://www.aswb.org/SWL/lincensingbasics.asp.
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educationinauniversitywithacourseaccreditedbyanindependentagency,sitanationalexaminationprovidedbyanotherbody,andapplyforlicensuretoaStateNursingBoard.SimilarStatelicensurearrangementsapplytootherhealthprofessions.
Asaconsequenceofthesedistributedresponsibilities,theprimeresponsibilityforundergraduatehealthprofessionalconductandfitnesstopractiserestswitheducationproviders.Licensingauthoritiesareconcernedwithregulationfromthepointatwhichastudentseeksalicensetopractice(orasthepreludetothat,whenapplyingtotakethenationalexamination).Regulatorinvolvementinstudentconductisthereforeminimalandstudentregistrationwith,forexample,aStateBoarddoesnotoccuruntilthestudentisapproachingtheendoftheireducationandbeginstheprocessofseekinglicensure,whentheyregistertotakeanationalqualifyingexamination.
RepublicofIrelandAsintheUKthereareseveralhealthandsocialcareprofessionsregulatorybodiesintheRepublicofIreland.UndertheHealthandSocialCareProfessionalsAct2005,anewbodyCORU(fromanIrishword,‘cóir’meaningfair,justandproper)hasbeenestablishedasanumbrellaorganisationresponsibleforprotectingthepublicbyregulatingbothhealthandsocialcareprofessionals.ThisisthefirsttimeinIrelandthatasinglestatutorybodyhasbeengivenresponsibilityfortheregulationofmultipleprofessions.Nursesanddoctorscontinuetohavetheirownregulatorybodies.OperatingundertheaegisoftheDepartmentofHealth,CORUisintheprocessofestablishingcriteriafortheregistrationofmembersofthedesignatedprofessions,codesofprofessionalconductandethics,andstandardsofprofessionalperformanceasabasisfordeterminingfitnesstopractise.Thereisnoevidencethatitcurrentlyhasanyinterestinregisteringstudents.
Incontrast,AnBordAltranais,whichregulatesthenursingprofessioninIreland,doeshavearegisterof“candidatesadmittedtonursetrainingprogrammes”(AnBordAltranais,2008).OnceontheregisterstudentsreceiveaCandidateRegistrationCard,identifyingtheholderas“acandidatememberofaprofessionalbodywhichadvocateshighstandards”(AnBordAltranais,2008).Theonlypurposecitedisthatthecardmayberequestedforidentificationonclinicalpracticeplacements–althoughbywayofareminderastoexpectationsregardingstandardsofconduct,studentsarereferredtotheprovisionsofSection28(5)oftheNursesAct,1985whichstatesthat:‘nothing...shalloperatetopreventtheBoardfromrefusingtoregisterthenameofanyperson,whoisotherwiseentitledtoberegistered,onthegroundsoftheunfitnessofthatpersontoengageinthepracticeofnursing’(AnBordAltranais,2008).Howeverquestionsaboutastudent’sfitnesstopractisecanbeaddressedonlyatthepointofapplicationforregistration.Decisionscannotbemadeatthepointofentrytoanursingeducationprogrammeoratanytimeduringanursingeducationprogramme(AnBordAltranais,2008).
Internationalperspectives‐conclusionAnumberofgeneralpointsemergefromthislimitedreviewofstudentfitnesstopractisearrangements,includingstudentregistration,incountriesotheroftheUK:
• studentregistration–asavehicletoenableregulatorstointervenedirectlyinrespectoffitnesstopractise–isbynomeanscommonplaceamonghealthandsocial
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careprofessionsregulators;themajorityofregulatorsdevolveresponsibilityforassuringstudentfitnesstopractiseandmanagingmisconducttoeducationproviders
• inthejurisdictionsandprofessionswherestudentregistrationhasbeenadopted,itservesdifferentpurposesindifferentcases,includingalargelyadministrativefunction(forexampletocollectaccurateworkforcedataaboutenrolmentsandcompletions),asameansofencouragingappropriatestandardsofconduct(forexamplebypromotingethicalbehaviourbybindingstudentstoaCodeofConducttoencourageadevelopingsenseofprofessionalism),andasavehicletoimposethesameorsimilarexpectationsandsanctionsinrespectofconductandfitnesstopractiseasapplytoqualifiedregistrants(enablingtheregulatortointervenetoinvestigatemisconduct,totakedisciplinaryaction,andtoimposesanctions)
• inrespectofmanagingmisconduct,someconstructionsofstudentregistrationappeartoyieldlimitedbenefit(asinIrelandwherenursingstudentmisconductcannotbeconsideredbytheregulatoruntilthepointofregistration),andinothersthereappearstobeariskofduplication(asinAustraliawhereboththeregulatorandeducationproviderrunparalleldisciplinarymachineryapplieddifferentiallyaccordingtothenatureofthemisconduct)
• transparencyaboutwhether,andifsowhy,studentregistrationhasbeenadopted(orrejected)islacking,withverylimitedinformationavailablefromregulatorsaboutthepolicyrationale,andnoneaboutcostsandbenefits(obtainingthis–ifitexists–wouldrequireadirectapproachtoindividualregulators)
• thereisverylittleinformationaboutstudentsgenerallyonregulatorwebsites,conveyingthestrongimpressionthatformany,regulatoryresponsibilitiesandinterventionsstartatthepointoffirstregistrationandentrytotheprofession(althoughofcoursemanyregulatestudentsindirectlybysettingstandardsforeducationandoperatingsystemstoaccredit,approveorrecogniseeducationprogrammesleadingtoregistrationorlicensure).
4.6 Summaryandconclusions
ThischapterhasreviewedthepositionofUKhealthandsocialcareregulatorsinrespectofstudentfitnesstopractise.Ithasalsoexaminedthepositioninsomeothercountriesbywayofcomparison.
TheGOCandtheGSCC(togetherwiththeothersocialcareregulators)aretheonlyUKhealthandsocialcareprofessionsregulatorsthatcurrentlyregisterstudents.TheNMCisplanningtointroduceaquasi‐registrationintheformofstudentindexing.ItisnotablethattheGMChasconsideredandrejectedthecaseforstudentregistrationandiscurrentlypursuingastrategytobetterengagewithmedicalstudentstopromoteprofessionalism.
Anumberofregulatorsprovideguidanceaboutstudentfitnesstopractiseandassociatedprocedures,and/oracodeofethicsthatappliestostudents.Thereisevidenceofagooddealofcommonalityinthecontentofthesepoliciesandguidancedocuments,particularlyintermsofthespecificationofstandardsofprofessionalbehaviourexpectedofstudents,andthebehavioursthatgivecauseforconcern.Muchoftheguidanceisconsistentwithprinciplesestablishedin2001fortheGMCbythelawfirmEversheds.
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Aconsiderablelevelofresponsibilityforthemanagementoffitnessforpractiseproceduresrestswitheducationproviders,operatinginaccordancewithguidanceaboutstandardsandrequirementsfromtheregulator.
TheGSCCstudentregisteriscloselylinkedtoitsroleinadministeringpaymentsforclinicalplacements,yetthereisevidencethattheavailabilityandqualityofplacementsisamatteroflongstandingandcontinuingconcerninthesocialworkprofession.Insocialworktheissuesofsuitability(ratherthanfitnessforpractise)andgate‐keeping(entrytotheprofession)areconsideredimportantpriorities.
Ingeneral,theguidanceprovidedbymostregulatorsisconsistentwiththeadvicefromtheCHRE.Itconcludedthat:
• ‘Professionalismandregulationshouldrunasadevelopingstrandofthecurriculumthroughoutthecourseofstudy.MeasuresshouldbeputinplacebetweentheRegulatoryBodyandHigherEducationInstitutionforthestudenttodevelopathoroughunderstandingofprofessionalismandthepurposeofregulation…sothatstudentsenterprogrammeswiththefullknowledgeofwhatwillbeexpectedofthembeyondthestraightforwardacademicachievement.
• Studentsshouldbemadeawareoftheinherentrisksinanylearningsituationandunderstandtheirresponsibilityinrelationtothesafetyofthepatient.Therisktopatientsfromstudentpracticevariesfromprofessiontoprofessionandwiththecircumstancesandstyleoftheirtraining.Asingleapproachisthereforenotdesirable.Thedifferentprofessionsexposestudentstopatientstodifferentextentsandusingdifferentlevelsofsupervision.Thereisstrongsupportfromregulatorsforprofessionalbehaviourbeingexpectedofstudentsthroughouttheircoursewhetherworkingdirectlywithpatientsornot.
• HigherEducationInstitutionsshouldhaveformallyagreedmechanismsforremovingstudentsfromcontactwithpatientsiftheirfitnesstopracticeisimpaired.OneapproachwouldbeforHigherEducationInstitutionstohaveFitnesstoPractisecommitteesthatfunctioninaccordancewithguidancefromtherelevantregulatorybodyandwiththeabilitytoremoveastudentfromacourseonthebasisofafinding.
• RegulatoryBodiesandHigherEducationInstitutionsshouldagreetoaCodeofConductforstudents.ThecommonvaluesagreedbytheRegulatoryBodiesshouldbeusedasthecoreprinciplesforthedocument.’(CHRE,2007)
Anexaminationofselectedregulatorsinothercountriesindicatesthatstudentregistrationisbynomeanscommonplace.Itappearsthatthemajorityofregulatorsdevolveresponsibilityforassuringstudentfitnesstopractiseandmanagingmisconducttoeducationproviders(althoughinsomecasestheyinfluencethisthrougheducationstandardsettingandmechanismstoassurethequalityofeducationandtraining).Injurisdictionsandprofessionswherestudentregistrationhasbeenadopteditservesdifferentpurposesindifferentcases,andinsomeinstancesappearstoyieldlimitedbenefitsintermsofmanagingfitnesstopractise,insteadfulfillinglargelyadministrativepurposes.
Wherestudentregistrationhasbeenadoptedthereisadearthofinformationaboutwhyithasbeenjudgednecessaryorhoweffectiveitis.Noinformationhasbeenuncoveredaboutcostsandbenefits.ThisreflectsCHRE’sconclusionthat‘thereisinsufficientevidenceto
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suggestthatregistrationofstudentsisnecessarytoprotectpatientsandthepublic’(CHRE,2007).
Thereisverylittleinformationaboutstudentsgenerallyontheregulatorwebsitesintheothercountriesreviewed,conveyingandconfirmingthestrongimpressionthatformany,regulatoryresponsibilitiesandinterventionsstartatthepointofentrytotheprofessionandfirstregistrationorlicensure.
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Chapter5:Conclusionsandrecommendations
5.1 Conclusions
ThepolicyobjectivesthattheHPChassetfordevelopingstudentfitnesstopractiseregulatoryprocesses,andtheeffectstheyareintendedtoachieve,haveformedthefocusofthisliteraturereviewie
• ‘Toensurethatthepublicareadequatelyprotectedfromthepotentialriskofharmposedbystudents.
• Toensurethatconcernsaboutstudentsareadequatelydealtwithsothatonlysomeonewhoisfittopractisecompletesaprogrammewithanawardthatleadstoeligibilityforregistration.
• Toensurethatstudentsareawareoftheduties,responsibilitiesandstandardsexpectedofthemasfutureregistrants.
• ToensureconsistencyandequityofregulatoryapproachacrosstheHPCregister,whereverpossibleandappropriate.
• Toensurethatanyvoluntaryregisterofstudentsisfeasibleonaself‐financingbasis,avoidingcross‐subsidisationfromtheHPC’sstatutoryfunctions.’
(HPC,2011b)
Ourconclusionsaresetoutbelowagainsteachofthesepolicyobjectives.Theliteraturereviewedhasprimarilybeenfromtheprofessionsofmedicine,nursingandsocialwork,asthereisapaucityofliteraturerelatedtotheprofessionsthattheHPCcurrentlyregulates.
Thepotentialriskofharmposedbystudents
Thereislittleintheliteratureontheriskofharmposedbystudents,althoughthereisconsiderableliteratureabouthowstudentsacquiretheknowledge,skillsandattitudesthatenablethemtopractisetheprofessionatasuitablelevel.Akeycomponentoffitnesstopractiseisvariouslydescribedasprofessionalism,suitabilityorgoodcharacter.Thereisgeneralagreementonthebenefitsofdefiningthiscomponentoffitnesstopractise,andthereisalsoagreementonthevalueofspecifyingexamplesofbehaviourthatareunprofessional,orindicateunsuitability.Whererisksofharmposedbystudentsarereferredtointheliterature,theytendtobedescriptionsofpoorpracticesbystudentsthatresultinharmtousersofservices,orthepotentialforharmtothepublicafterregistration.Studiesalsostresstheneedforintegrityandhonestyinacademicmattersasakeyindicatorofbehavingethicallyinprofessionalmatters.
Theliteratureindicatesthatitisoftendifficulttojudgethedegreetowhichabehaviourindicateslackoffitnesstopractiseandthatabehaviourneedstobeconsideredincontext.Thereisalsoaneedtotakeintoaccountthestageoftheprogrammeatwhichthebehaviouroccurred,althoughsomebehavioursmaybeconsideredunacceptablefromthestart.
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Areviewofthepracticesoftheotherregulatorsshowsthatthefourregulatorsthathavedevelopedstand‐alonestudentfitnesstopractiseguidelines(ietheGMC,GDC,GOsCandtheGPhC)haveallincludeddescriptionsofprofessionalandunprofessionalbehavioursandalsoinvariouswaysputthisinthecontextofthestudent’sstageofdevelopment.
1. Theliteratureindicatesthatitwouldbegoodpracticeto:
a. describebehavioursthatindicatefitnesstopractiseinstudentsandthosethatdonot,includinginthosedescriptionsexamplesofacademicbehaviourswhichrelatetoethicalprofessionalpractice
b. recogniseinanyguidanceproducedthecomplexityofmakingjudgmentsaboutbehaviourandthatsuchjudgmentsshouldtakeintoaccountthecontextinwhichtheyweresetandalsothestageofthestudent’sdevelopment.
Concernsaboutstudentsareadequatelydealtwith
Thispolicyobjectivefocusesonmanagingtheinstancesofindividuals’behaviourthatraiseconcernsaboutfitnesstopractise.Theliteratureisequallystrongonlookingatproactivemeasurestopre‐emptsuchinstancesarising,animportantpreventativeaspectofregulation,andthisisdiscussedfurtherbelow.
TheliteraturerevealsthatitisdifficulttodeterminetheincidenceofstudentfitnesstopractiseissuesacrossthehealthandsocialcareprofessionsintheUK,astheextenttowhichthisisreportedand/ordealtwithbyacentralisedbody,suchasaregulator,isdependentonthesystemsandpracticesinthatprofession.
TherearestrongargumentsforprofessionalfitnesstopractisepoliciesandproceduresbeingrequiredinadditiontoanHEI'sgeneralacademicmisconductpoliciesinordertoensurethatfitnesstopractiseisdealtwithappropriately,andalsotosendoutclearmessagestostudentsthatwhereproblemsexisttheywillbedealtwithfairlybutseriously.
Thereisgeneralagreementthatpoliciesandproceduresshouldbetimely,robust,fairandclearlydocumented,thattheyshouldbefollowed,andthatthereshouldbereliablesystemsfordocumentingconcernsandidentifyingandmanagingstudentswhosebehaviourisproblematic.Thereisalsogeneralagreementthatthereshouldbeaseriesofgraduatedinterventions,startingwithinformalconversationstomoreformalmeetingswhenthereisseriousmisconductorpatternsofbehaviouruptoandincludingformaldisciplinaryprocesseswithappropriatesanctions.StudiesrevealdifferencesinproceduresindifferentHEIsandconcernsaboutconsistency.Whilstthenumberofstudiesinthisareaisrelativelysmall,theinterventionsofregulatorsaresoughttoimproveconsistencyandassurepublicprotection.Itisalsosuggestedthatthereshouldbepublicinvolvementatthedisciplinarystage.
ThefourUKhealthregulatorsthathavedevelopedstand‐alonestudentfitnesstopractiseguidelineshaveallincludedthresholdsforstudentfitnesstopractisecasesandsetoutthespecificwaysinwhichtheyexpectconcernsaboutstudentstobeaddressed,focusingonthedifferentaspectsofstudentfitnesstopractisepanels.
2. Theliteratureindicatesthatitwouldbegoodpracticeforregulatorsto:
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a. requireeducationalinstitutionstohavespecificandseparateprofessionalstudentfitnesstopractisepoliciesandprocedures,whichhavethecapacitytoremovestudentsfromcoursesifrequired
b. requireeducationalinstitutionstomaketheirstudentfitnesstopractisepoliciesandprocedurestimely,robust,fair,clearlydocumented,containreliablesystemsfordocumentingconcernsandidentifyingandmanagingstudentswhosebehaviourisproblematic,usingasystemofgraduatedinterventionsandtoimplementthepoliciesandproceduresconsistently
c. evaluatetheconsistencywithwhichstudentfitnesstopractisepoliciesandproceduresareappliedandimprovetheirregulatoryapproachesasaresult.
Studentawarenessofduties,responsibilitiesandstandards
Thereisconsiderableliteratureontheproactivestepsthatcanbetakentoenablestudentstodeveloptheknowledge,skillsandattitudestheyneedtobefittopractise.Theapproachesproposedintheliteraturearemuchstrongerthanawarenessandinclude:
• describingbothwhatismeantbyfitnesstopractiseaswellasthebehavioursthatwouldcauseconcernaboutanindividual’sfitnesstopractise(asdescribedabove)
• embeddingthedevelopmentofprofessionalismacrossthecurriculum
• clarifyingtostudentsthestandardstobemet
• rolemodellingandmentoring
• highqualitypracticeplacements
• assessingstudentfitnesstopractisebothformativelyandsummatively
• clearpoliciesandpracticesrelatedtostudentfitnesstopractisethatareconsistentlyappliedbyallstaff,includingthoseinplacements(implyinghighqualitystaffdevelopmentandappraisalsystems)
• consistentmessagesineveryaspectofthestudentexperiencenotonlybytheeducationalinstitutionbutalsobythehealthandsocialcareenvironmentsinwhichtheyhavepracticeplacementsandbytheregulator(suchasinrelationtodealingwithfitnesstopractisecases).
ThereisasimilaremphasisintheguidanceonstudentfitnesstopractisefromthefourUKhealthcareprofessionregulators.Thesevariouslyhaveafocusonadmissions,communicationandawareness,education,andpastoralcareandstudentsupport.Specificconsiderationshouldalsobegiventotheneedsofstudentswithdisabilitiesandhealthconditionstoensurethattheygetthesupporttheyneedandarenotunfairlydiscriminatedagainstintheapproachesused.
3. Theliteratureindicatesthatitwouldbegoodpracticefortheregulatorto:
a. ensurethatitsapprovededucationalprogrammescontainarangeofproactivemeasuresfordevelopingandassessingstudentfitnesstopractise,includingtheassuranceofhighqualitypracticeplacements
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b. seekevidencefromapprovededucationalprogrammesastohowtheyensureconsistentapplicationofstudentfitnesstopractisepoliciesandprocedures
c. evaluateallofitsownapproaches,practicesandperformanceovertimeforthemessagesthatthesesendtothepublic,educatorsandstudents.
ConsistencyandequityofregulatoryapproachacrosstheHPCregister
TheliteratureontheprocedureswithinHEIstoassessstudentfitnesstopractisehasaconcernwithconsistency,toensurefairnesstoindividualstudents,aswellasclearstandardstoassureprotectionofthepublic.Publishedstudieshavegenerallyfocusedonproceduresrelatingtooneprofession;however,iftheoutcomesofthesestudiesarecombinedwiththeevidenceofrisksofharmfromstudents,adifferentpicturemightemerge‐ieifonegroupofstudentsisfoundtoposegreaterriskstothepublicthanothers,itcouldbearguedthatdifferentialprocessesshouldapply.
Theliteratureinthisareaindicatesthatthereisremarkableconsistencyacrosstheprofessionsaboutbehavioursthatareseentobeacceptableandunacceptableasindicatorsoffitnesstopractise.Theproactiveapproachesfordevelopingstudentfitnesstopractise,andaddressingpoorpractice,arealsoremarkablysimilaracrossprofessions.Thisfindingfromtheliteratureisalsosupportedbytheapproachesgenerallypromulgatedbytheotherprofessionregulators.
4. TheliteratureindicatesthatitisbothappropriateandpossiblefortheHPCtodevelopconsistentandequitableregulatoryapproachesforalloftheprofessionsinitsremit.
Anyvoluntaryregisterofstudentsisfeasibleonaself‐financingbasis
Thereviewoftheliterature,bothpublishedandgrey,showsthatstudentregistrationistheexceptionratherthanthenorm.Themajorityofregulatorsdevolveresponsibilityforassuringstudentfitnesstopractiseandmanagingmisconducttoeducationproviders(althoughinsomecasestheyinfluencethisthrougheducationstandardsettingandmechanismstoassurethequalityofeducationandtraining).
Wherestudentregistrationhasbeenadoptedthereisadearthofinformationaboutwhyitwasjudgednecessarytointroduceit,suchasincreasedrisksofharmtothepublicbythestudentsconcerned,oritseffectivenessinmeetingitsdesiredaims.Oftentheaimsappeartobeadministrativeratherthanrelatedtopublicprotection.Noinformationhasbeenfoundoncostsandbenefits.ThesefindingsconcurwiththoseoftheCHRE,whichfound‘thereisinsufficientevidencetosuggestthatregistrationofstudentsisnecessarytoprotectpatientsandthepublic’(CHRE,2007).
Inthecontextof'righttouch'regulation(CHRE,2010)andtheevidencefoundinthisliteraturereviewasawhole,itisdifficulttoseethevaluethatstudentregistrationinanyformwouldaddtothemechanismsdescribedabove.Inshortitmightbeperceivedasaregulatoryburdennotanecessaryregulatorylayer.
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5. Thereisinsufficientliteraturetocommentonthecostsandbenefitsofvoluntaryregistration,butanydecisionsontheuseofregistrationforstudentsneedtotakeintoaccountthevaluethatsuchasystemwouldaddtootherregulatorymechanisms.
5.2 Recommendations
TheconclusionssetoutaboveshouldbereviewedinthecontextofthelargerprogrammeofworkthattheHPCisundertakinginrelationtostudentfitnesstopractise.Fromtheevidencefoundinthisreview,itappearsappropriatethattheHPCfurtherconsider:
1. thewaysinwhichitcanimproveitsstandardsfor,andguidanceto,educationalprovidersinrelationtodevelopingandmanagingstudentfitnesstopractise
2. howitcanbestenhancestudents’understandingoffitnesstopractise,andtherelationshipoffitnesstopractisetopublicprotection.
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