interprofessional learning

The case for educating health care students in

professionalism as the core content of
interprofessional education
Ruth P McNair

BACKGROUND Professional teams are becoming sionalism, and that this will ultimately contribute to
more central to health care as evidence emerges overcoming uni-professional exclusivity.
that effective teamwork enhances the quality of
patient care. Currently, health care professionals KEYWORDS education, medical, undergraduate ⁄
are poorly prepared by their education for their *methods; interprofessional relations; patient care
roles on the team. In parallel, there are increasing teams; curriculum; students, medical ⁄ *psychology.
demands from consumers for health care profes-
sionals to serve the interests of society and patients Medical Education 2005; 39: 456–464
through engaging in effective professional partner- doi:10.1111/j.1365-2929.2005.02116.x
ships. Professionalism for health care providers is
now being defined as a commitment to standards
of excellence in the practice of the profession that INTRODUCTION
are designed primarily to serve the interests of the
patient and to be responsive to the health needs of Health care work patterns are rapidly shifting
society. Yet, there are multiple barriers impeding towards being team-based.1 Effective teamwork has
the development of professionalism beyond a uni- been shown to improve the quality of patient care,
professional frame of reference. yet until recently has not been included in pre-
registration curricula.2 As a result, students in
METHOD Incorporating teamwork and profession- health care professions, including students of nur-
alism into health care professional curricula at pre- sing, medicine, allied health and social work
registration level is proving to be challenging. These professions, are entering the workforce poorly
2 areas of learning are brought together in this paper prepared for the inevitable teamwork in which they
through a discussion of the role of interprofessional will be required to engage. The difficulties
education in preparing all health care professional encountered in working with professionals from
students for the workforce. different disciplines arise from a lack of knowledge
of different roles, lack of skills in teamwork and
CONCLUSION Interprofessionalism is presented as a variable levels of respect, all of which are amenable
pre-registration curriculum framework that includes to change through education. The Institute of
values shared by all health care professionals, which Medicine, USA has recently stated that Ôall health
should be learned in order to more adequately pre- professionals should be educated to deliver patient-
pare students for working in health care teams. It will centred care as members of an interdisciplinary
be argued that interprofessional education provides team.Õ3 The National Health Service workforce plan
appropriate methods by which to learn interprofes- in the UK emphasises the need to prepare students
for interprofessional practice (teamworking and
Department of General Practice, University of Melbourne, Carlton, collaboration between disciplines) and recommends
Victoria, Australia
the development of pre-registration common
Correspondence: Dr Ruth P McNair, Department of General Practice, learning programmes.4 The stated outcomes of
University of Melbourne, 200 Berkeley Street, Carlton, Victoria 3053,
Australia. Tel: 00 61 3 8344 6077; Fax: 00 61 3 9347 6136; common learning programmes include not only the
E-mail: [email protected] ability to work in interprofessional teams, but also

456
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457

PROFESSIONALISM DEFINED
Overview
Professionalism has a long history, during which it
What is already known on this subject has had multiple meanings, has been discredited and
has recently re-emerged as an important element in
Significant barriers to the development of all health professional learning.5 Its period in the
respectful and effective relationships between wilderness during the 1970s and 1980s was under-
different health care professional disciplines pinned by the dual meaning attributed to profes-
exist. These include a largely uni-disciplinary sionalism, framed as a conflict between altruism and
education; distinct professional codes of eth- self-interest.6 During this period professions were
ics, which can fuel interdisciplinary rivalry, and seen as powerful, privileged, self-interested mono-
the drawing of boundaries around uni-profes- polies, which engendered scepticism for the value of
sional knowledge that enhance exclusivity. professionalism.6 Similarly, Senhauser describes a
These barriers are reinforced for pre-registra- shift in the definition of a professional at that time
tion students through a powerful hidden from Ôone who engages in a vocation or occupations
curriculum of role-modelling of negative requiring a long period of intense study, to anyone
attitudes and behaviours towards other disci- who performs specialised work for pay.Õ7 (p 402)
plines. Increasing public mistrust of the medical profession
has been founded on the belief that the profession
What this study adds exists to protect its members. This protection is seen
to extend even to incompetent or unethical col-
It is proposed that professionalism should be leagues, and has been highlighted in high profile
redefined as an essential and shared pre- cases such as the Bristol enquiry in the UK.8
registration curriculum, which includes the
learning of shared values, using interprofes- Some suggest that Ôprofessionalism is an ideal to be
sional education methods. Methods of evalu- pursuedÕ6 (p 209), a cynical perspective implying that
ation of educational and workforce outcomes professionalism cannot truly exist in a climate of
are suggested. individualism. During the 1990s, the increasingly
influential consumer lobby, as well as the outcomes-
Suggestions for further research focused health care education framework,9,10 high-
lighted a need to reclaim professionalism. It has been
Research is needed to determine the most re-interpreted to incorporate a core humanistic focus,
effective methods of evaluation of outcomes in which the interests of the patient and the commu-
for students learning within an interprofes- nity are central.5 This commitment to social respon-
sionalism framework. sibility is increasingly becoming a focus of more
responsive educators and universities.11,12 Profes-
sionalism in this form has since been included among
the essential components in the post-registration
the ability to substitute roles and have career arena across a range of health professions.13–17
flexibility. A review of over 30 years of literature on profession-
alism outlined the core values of professionalism,
Alongside the development of health care teams is which will be used as a point of reference for this
the shift towards a partnership model of health care paper (Table 1).18
between patients and their health care providers.
Society demands an increasing level of accountability
and co-ordination between health care profession- INTERPROFESSIONALISM
als.5 This paper will explore reasons for the poor
educational preparation for this work and look at the Various medical bodies have attempted to define
core elements that are needed within curricula to fill medical professionalism, a high-profile example
the gap. Professionalism will be presented as the being the ÔMedical Professionalism ProjectÕ, which
missing ingredient, particularly as it applies to inter- was established to develop a set of principles for all
professional relationships. The paper will then pre- medical professionals.19 This project was undertaken
sent a model of interprofessional education that by the European Federation of Internal Medicine,
includes professionalism at its core. the American Board of Internal Medicine (ABIM),

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458

greed, misrepresentation, impairment, lack of con-

scientiousness and conflicts of interest. They are
Table 1 Elements of professionalism18
personal, value-based factors that emphasise the need
Central values of professionalism for health care professionals to be reflective and
Altruism aware of their own behaviour and its impact on
Accountability others. However, these are not the only barriers. I will
Excellence argue below that a uni-professional approach to
Duty and advocacy regulation, ethical standards and education has a
Service strong, yet largely hidden, negative influence on
Honour practitioners’ interprofessional values.
Integrity
Respect for others Uni-professionalism
Ethical and moral standards
For the purposes of this paper, uni-professionalism is
defined as the pursuit of goals for single health care
professional disciplines to the exclusion of other
and the American College of Physicians and Society disciplines. Uni-professional collegiality has its place
of Internal Medicine. The 3 principles in this charter in the necessary formation of a single professional
are the primacy of the patient’s interests above self- identity and the definition of specific value-systems.
interest (altruism), respect for patient autonomy, and Indeed, professions exist, in part, to develop and pass
social justice; these are followed by several profes- on specific and burgeoning specialist knowledge,
sional responsibilities. This definition of profession- which is essential for the effective functioning of the
alism was developed by doctors for doctors, however, health care system, whatever the discipline. However,
it equally applies to any health care professional. the power invested in having control over a distinct
Evetts argues that the re-interpretation of profes- body of knowledge and the development of Ôcognitive
sionalism should occur through ideas about inter- exclusivityÕ23 creates a significant barrier to effective
professional collaboration and shared social relationships with other professionals and with
responsibility.5 The American Association of Colleges patients24 and, therefore, undermines interprofes-
of Nursing (AACN) has clearly defined the skills sionalism. The accompanying status, including dif-
required for collaboration as being negotiation, team ferential levels of financial remuneration awarded to
building, joint decision making, problem solving and different health professions is also a systemic barrier.
development of joint values.13 I propose that the Evetts suggests that the Ômonopoly use of expert
elements of professionalism in Table 1 form the basis knowledge for economic gain poses real dilemmas
of this joint value system for interprofessional prac- for developments in interprofessional collabor-
tice and will be redefined as interprofessionalism in ation.Õ5 (p 120)
this paper. Interprofessionalism can be learned using
interprofessional education and emphasising a Distinct boundaries have been drawn between the
patient-centred rather than a profession-centred knowledge bases of various health care disciplines in
approach.20,21 the creation of professional identities. This can
become problematic when health care professionals
are required to widen their scope of practice. Terri-
BARRIERS TO INTERPROFESSIONALISM torialism can occur and this has been related to the
AND EFFECTIVE INTERPROFESSIONAL concept of tribalism,25 where professionals can feel
WORK threatened by others who are seen to be encroaching
upon their ÔterritoryÕ. This is particularly divisive
Given that professionalism and teamwork are so within health care teams, where effective team
fundamental to the practice of health care, and now working requires some blurring of role boundaries.2
centralised in post-registration training, why are they
not at the forefront of pre-registration health care A further aspect of uni-professionalism is the devel-
professional education? Why indeed does effective opment of distinct codes of ethics by each discipline.
interprofessional teamwork remain such an illusive These move beyond discipline-specific knowledge to
ideal?6 The ABIM has outlined a series of challenges capture the distinct values of the particular discipline.
to professionalism22 that contribute to preventing However, when comparing ethical codes of various
effective teamwork and interprofessional relation- health disciplines, the principles are found to be very
ships.2 These include abuse of power, arrogance, similar.26 The distinct codes would not be a problem

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459

if not for the divisiveness that can result between teamwork required in practice is seen as a Ôprofound
disciplines when valuing 1 code over another. Ethical disconnectÕ through which education is failing to
codes thus can be Ôused as ammunition in interdis- adequately prepare students for their professional
ciplinary battlesÕ by fuelling interdisciplinary rivalry work.17 (p 30) Medical, nursing and allied health
and territorialism.27 (p 616) An example of this is the students are found to enter their specific health
preamble to the Australian Medical Association’s professional courses with pre-formed and stereotyped
code of ethics, which states: Ôbecause of their special ideas about their own and other disciplines.30,31
knowledge and expertise, doctors have a responsi- Negative stereotypes regarding other disciplines can
bility to improve and maintain the health of their lead to professional arrogance and hamper effective
patients.Õ28 This implies that doctors have sole collaborative relationships.32 Social identity theory
responsibility, as there is no mention within the suggests that identifying with a particular group
preamble of working with others. Indeed, none of the actively determines interpersonal attitudes and
4 clauses that follow specifically refer to working with behaviour towards other groups.33 Uni-professional
colleagues beyond medical colleagues. course work perpetuates such stereotypes and result-
ing behaviours. Group membership can be fluid,
In contrast, the Tavistock Group, a multidisciplinary however, and amenable to change if there is
group of health care and ethics leaders, has devel- adequate exposure and interaction with related
oped a set of ethical principles that can apply to all groups. In this way, interprofessional learning has
members of the health care team, in Ôrecognition that been shown to positively influence attitudes towards
much of health care is multidisciplinary, yet ethical other professionals,32 particularly when introduced
codes usually cover only one disciplineÕ.23 (p 616) early in the course.34 This is congruent with theories
Following extensive consultation in the USA and UK, of situated learning, which argue that social interac-
they now include 7 principles: rights (to health care), tion within learning communities is a critical element
balance (between individual and population health), of adult learning.35
comprehensiveness, improvement, safety, openness
(honesty, trustworthiness) and co-operation (with A hidden curriculum involving role-modelling of
patients, each other and other sectors). These prin- negative attitudes can also undermine interprofes-
ciples enact the elements of professionalism. Co- sionalism.36 The acquisition of negative attitudes
operation is seen as the central principle in recogni- towards other health care professionals during the
tion of the fact that all of those working in health care course has been described by recently qualified
depend on each other. health care professionals, including doctors, nurses,
dentists, allied health professionals and radiogra-
Professional associations have contributed to creating phers, who attributed this partly to the influence of
barriers to professionalism in other ways than attitudes expressed by their tutors and clinicians.37
through the development of individual codes of The USA’s Institute of Medicine highlights the fact
ethics. They have dual roles as advocates for the that education does not occur in a vacuum: Ôhidden
health of the community, and representation of their curricula of observed behaviour, interactions and
members, and at times defenders of a specific the overall norms and culture of a studentÕs training
profession.5,6 This again reflects the duality of altru- environment are extremely powerful in shaping
ism versus self-interest. The development of distinct values and attitudes. It often contradicts with what is
systems of accreditation and licensing, although learned in the classroom.’3 (p 9) Leaviss calls for
essential for the development and maintenance of further study on the impact of the customs, rituals
competency and professional standards, further alie- and other structural factors influencing negative
nate the disciplines from one another. A key recom- attitude formation and maintenance.37
mendation of the recent Institute of Medicine report
on health professional education in the USA is that
the uni-professional accreditation and licensing sys- CHALLENGES TO CURRICULUM
tems be broken down.3 DEVELOPMENT
Uni-professional health care professional education Spencer suggests that Ôteaching about professionalism
is an idea whose time has come, and given public
This uni-professional approach to licensing is merely demands for greater accountability, partnership
the end-point of a vertical uni-disciplinary stream and better communication, is unlikely to go
throughout the education process from entry.29 This away.Õ38 (p 288) His context is medical
uni-professional academic preparation versus the

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460

professionalism, but his words apply equally to inter- shown that IPE can influence attitudinal change in
professionalism. However, despite the urgings of improving perceptions of other health care profes-
senior academics and the pressure of public expecta- sionals.30,32,43 Hammick argues that IPE not only
tions, inserting professionalism and teamwork into creates an opportunity to integrate knowledge from
the curriculum is proving to be challenging. This may various disciplines, but also to create a Ônew terrain of
relate to barriers to the explicit teaching about values, knowledgeÕ.24 (p 326) What is this new terrain,
due to an expectation that appropriate values will however? Are IPE curriculum designers merely
simply emerge without the need for direction.39 repackaging pre-existing learning?
Similarly, students’ interprofessional behaviours have
rarely been observed within courses, let alone assessed Interprofessional education has been criticised for
or constructively criticised. Yet Cruess et al. emphasise lacking Ôconceptual clarityÕ and, therefore, being
that professionalism must be taught explicitly,6 and merely a trend in medical education.44 Finch suggests
there is increasing interest in and incentives to that training courses will continue to marginalise IPE
incorporating ethics, communication and humanism until a clear and unified set of objectives are agreed
into curricula.38 Howe has suggested that professional upon.45 Campbell and Johnson also challenge pro-
development curricula within medicine suffer from a ponents of interprofessional learning to develop a
lack of framework to ensure that students attain robust conceptual basis with agreed (and measur-
appropriate professional competencies.40 In re- able) goals.44 In a climate of increasing pressure on
sponse, Jill Gordon at the University of Sydney has all pre-registration health care curricula to deliver
produced such a framework, based on the ABIM more content in less time, it is not surprising that,
attributes of professionalism, in which the key without a strong argument that IPE content is unique
learning outcome is to foster professional beha- and essential, a significant proportion of senior
viour.39 The personal and professional development faculty will continue to resist its incorporation. The
(PPD) curriculum that Gordon has developed content of IPE described above can easily be
includes communication skills and teamwork between repackaged within the broader framework of inter-
patients and doctors, but only a passing reference to professionalism. Assuming that it is accepted that
interprofessional learning. Spencer suggests that learning the shared values, skills and knowledge of
medicine cannot forge change alone and that a interprofessional practice and professionalism should
contract between society and the (medical) profes- be core to the pre-registration curriculum, such
sion must be honest and open.38 As educators for content becomes the unique, new terrain sought by
health care professional practice, we need to IPE proponents and required by senior faculty.
acknowledge that the contract must also be between
health care disciplines, and incorporate a framework
that includes interprofessional values and behaviours. CURRICULUM RECOMMENDATIONS
I will now present a suggested model for learning
THE CASE FOR USING AN professionalism as it applies to interprofessional
INTERPROFESSIONAL EDUCATION practice at a pre-registration level (Table 2). The
FRAMEWORK TO LEARN elements listed should be seen as a shared curriculum
for health care professions, incorporating curriculum
INTERPROFESSIONALISM
outcomes that are meaningful for future health care
practice. The curriculum material would be new to
Interprofessional education (IPE) is defined as
some health professional courses, or would partially
Ôoccurring when 2 or more professions learn with,
replace uni-professional curricula. Rather than using
from and about one another to facilitate collabor-
competencies, which tend to measure a student’s
ation in practiceÕ.41 (p 3) Core IPE content was
ability against a set of minimum standards, a capa-
outlined initially by the World Health Organisation42
bility framework has been chosen, which is more
and includes competencies for effective teamwork,
dynamic.46 Capability is Ôthe ability to adapt to
such as the development of respect between profes-
change, generate knowledge and continuously im-
sionals. Further elements include learning about
prove performanceÕ.47 (p 799) It includes principles
professional roles, conflict resolution, leadership,
of reflectiveness and lifelong learning, and uses
health care systems and ethics.7,20 Barr comments
immediate feedback about performance to enhance
that ÔIPE was conceived as a means to overcome
capability. The Sainsbury capability framework has
ignorance and prejudice amongst health and social
been used as the basis for the proposed model.48 It
care professionsÕ20 (p 10), and several authors have

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461

Table 2 A framework for learning professionalism and interprofessional practice

Areas of Interprofessionalism and
capability* interprofessional practice curriculum Methods of evaluation of outcomes
1 Values The elements of professionalism which Observation of interprofessional behaviour
form the joint value system (see Table 1) during shared tasks as measure of values
Attitudes towards collaboration
Attitudes towards other disciplines Longitudinal tracking by student reflective
diary through course
2 Ethics Interprofessional ethical principles Self-appraisal
(e.g. Tavistock: rights, balance,
comprehensiveness, improvement, safety,
openness and co-operation) Peer appraisal
3 Knowledge Understanding of health care professional Pre- and post-questionnaires
roles of perceived learning
Principles of effective teamwork
4 Skills for the Interpersonal communication Objective structured clinical examination
process of care between disciplines involving interprofessional practice
Skills for collaboration, and teamwork Observation and group appraisal of shared
including dealing with error and joint tasks such as problem solving and group
decision-making presentation of learning task
Skills for appropriate and respectful
leadership including change management
Reflectiveness Reflective diary
5 Application Adaptability across a range of health care Patient satisfaction measures
(mostly settings and health care teams
post-registration)
Ability to shift personal role in different teams Teamwork: quality of meetings,
leadership, division of roles,
measured by peer appraisal and
external observation
Clinical audit cycle
48
* Adapted from the Capability Framework.
Includes measures of effective teamwork described by Borrill et al.2

has 5 areas, starting with ethical practice, followed by ÔVirtue ethicsÕ suggests that behaviour is determined
knowledge, the process of care (which is largely about by internally adopted qualities or values (in this
teamwork), interventions (which include bio- context, the shared elements of professionalism)
psycho-social care), and, finally, application to rather than by concepts or external rules.49 It moves
various health care settings. beyond a desire purely for attitudinal change as a
learning outcome, which remains difficult to measure
The capabilities are listed in Table 2 in order of and highly vulnerable to the influences of the
acquisition. This is designed to be incorporated Ôhidden curriculumÕ. Ethics educators emphasise the
throughout the pre-registration course, alongside the dynamic nature of ethics teaching and learning:
necessary uni-disciplinary learning. The ultimate aim Ôethics offers a place for the consideration of values
of a professionalism curriculum should be for and for dialogue across boundaries and between
students to adopt a value-based perspective6 that will different perspectives.Õ49 (p 205) Similarly, social
then have a powerful influence on professional identity theory suggests that group membership is
behaviour; therefore, the model starts with values. dynamic and context-dependent, in that the group

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462

boundaries can shift. So it is possible for students to there is now government policy and considerable
learn values applicable to their own distinct disci- funding supporting undergraduate IPE pro-
pline, as well as those that apply to all health care grammes, there is not yet a shared framework for
disciplines, and in this way see their own discipline what should be delivered or how.
merely as a subgroup, broadening the group bound-
aries to regard themselves as members of the more Meanwhile, the interdisciplinary barriers that have
inclusive ÔgroupÕ that is the health care profession. developed between our various uni-professional cur-
ricula, with our distinct codes of ethics, bodies of
Students may begin to learn elements of this knowledge and profession-specific skills, may seem
shared curriculum within their uni-disciplinary almost insurmountable to individual curriculum
courses; however, students from different disci- designers and educators. International groups such
plines must be brought together periodically to as Tavistock have demonstrated that it is possible to
create a true interprofessional learning community. develop a core set of shared ethical principles
The IPE method used would vary according to the between health care professionals, while recognising
sophistication of student understanding and could that application at curriculum level is difficult. As
include everything from class-based, common educators, can we overcome the exclusivity of our
learning tasks, to combined clinical placements and own discipline that has been embedded into us from
shared patient-care activities. At regular points our own undergraduate training? Our challenge is to
throughout their courses students would also establish a situated learning environment Ôwhere new
ideally have opportunities to learn and apply the and expansive patterns of thinking are nurtured,
shared curriculum in an interprofessional clinical where collective aspiration is set free, and where
setting. A brief proposal for methods of evaluation people are continually learning how to learn
of educational and workforce outcomes is presen- togetherÕ.50 (p 51)
ted in Table 2. Learning objectives and their linked
assessment tasks would overtly include the inter- Unless we respond to these challenges, we will
professional curriculum, with an emphasis on continue to set our students up to fail in their roles as
measurable outcomes. The assessment should be collaborative health care professionals. We must
behavioural, in order to observe students enacting place due emphasis on the many values we all share.
the values in their day-to-day practice with each A core set of values for professionalism can provide
other, their patients and professional colleagues. As an agreed framework through which our students can
part of this behavioural approach, students can be form respectful relationships not only with their
encouraged to recognise role models as negative or patients, but also with the other health care profes-
positive and to make active and reflective decisions sionals with whom they will work.
about their own behaviours.

Acknowledgements: thanks are due to Professor Amanda

CONCLUSION Howe, University of East Anglia, UK and Dr Jane Sims,
University of Melbourne, Australia for their valuable
The call to develop a unified set of objectives for editorial advice, and to the team at the Combined
IPE has not gone unheeded. The model presented Universities Interprofessional Learning Unit (CUILU),
Sheffield University for introducing me to the Sainsbury
is an attempt to do just this by placing the values of
Capability Framework and highlighting its application to IP
interprofessionalism that can apply to all health
learning.
care professions at its centre. This will enable Funding: none.
students to learn within a common framework. The Conflicts of interest: none.
momentum is present at a uni-disciplinary level, Ethical approval: none sought.
with, for example, endorsement from the Austra-
lian and British Medical Councils for the inclusion
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