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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 73-78

Enhancing professionalism in physiotherapy interns using a structured teaching and assessment module


Physiotherapy School and Centre, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Submission27-Apr-2018
Date of Acceptance28-Aug-2018
Date of Web Publication17-Dec-2018

Correspondence Address:
Dr. Mariya Jiandani
Physiotherapy School and Centre, Seth G.S. Medical College and K.E.M. Hospital, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_16_18

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  Abstract 

INTRODUCTION: Professionalism describes the skills, competency, attributes, and behavior of an individual belonging to a profession. The physiotherapy graduate on completion of internship has direct access with the community as a professional. Hence, there is a need to explicitly teach and assess professionalism. The purpose of this study was to prepare a module to enhance professionalism and use tools to assess the professional attributes uniformly.
MATERIALS AND METHODS: A module was formulated with the help of experts, literature review, and guidelines of various physiotherapy regulatory bodies nationally and internationally. Focused group discussions were used as a method to identify competencies. After designing the module, a prospective intervention trial was conducted wherein 40 students who joined the internship program of a tertiary care hospital of India, were enrolled for the study. A participatory approach was used which included an interactive workshop on “ethics in clinical practice, communication skills, and professionalism.” A written pre-post evaluation and workplace-based assessment were carried out in four core physiotherapy areas. Competencies and attributes were measured using tools such professional mini-evaluation exercise (P-MEX), prevalidated checklist for clinical reasoning, patient feedback form, and a retro-preevaluation of self-assessment form of the American Physical Therapy Association.
RESULTS: A total of 34 students completed the module. Data were analyzed using SPSS 16 software. Nonparametric Wilcoxon Signed Rank test was used to analyze the descriptive data. The statistical significance was kept at P < 0.05 at a confidence interval of 95%. There was a statistically significant increase in the knowledge component pre-post analysis (P < 0.00). Change in professional attributes as measured by P-MEX showed a significant change in Doctor-patient relationship (P < 0.01) and interprofessional skills (P < 0.001) followed by reflective skills (P < 0.007) and time management skills (P < 0.003). There was also a significant difference in total patient feedback scores from baseline (P < 0.01).
CONCLUSION: The module helped students gain the knowledge and skills required to communicate and handle difficult situations relevant to physiotherapy practice.

Keywords: Assessment, ethics, professionalism, teaching


How to cite this article:
Jiandani M, Mehta A. Enhancing professionalism in physiotherapy interns using a structured teaching and assessment module. Physiother - J Indian Assoc Physiother 2018;12:73-8

How to cite this URL:
Jiandani M, Mehta A. Enhancing professionalism in physiotherapy interns using a structured teaching and assessment module. Physiother - J Indian Assoc Physiother [serial online] 2018 [cited 2019 Oct 23];12:73-8. Available from: http://www.pjiap.org/text.asp?2018/12/2/73/247604


  Introduction Top


There has been growing concern regarding ethical conduct of health-care professionals in the general public. Perceptions of the public about a health-care provider have changed over time. There has been an increasing focus in the media on the behavior and role of healthcare practitioners.[1] Ethics and professionalism are the central core of any health-care profession and dates back to ancient civilization.[2],[3] The Merriam-Webster dictionary defines professionalism as “the conduct, aims, or qualities that characterize or mark a profession or professional person.” It encompasses number of different attributes making it complex and multidimensional.[4] These are difficult to teach and measure and generally considered as an implicit part of training by observation of role models.[5] Guidelines to ethical code of conduct in physiotherapy practice have been provided by various regulatory bodies including Indian Association of Physiotherapist and World Confederation of Physical Therapy and other societies all over the globe.[6],[7] With Vision 2020 of the American Physical Therapy Association (APTA) and first contact practice, the graduate is in direct communication with the community as a professional. This makes it mandatory to demonstrate appropriate professional behavior and accountability to uphold the standards of the profession.

Although significant progress has been made in developing a place for ethics and professionalism in physiotherapy undergraduate curriculum at the Maharashtra state university along with few other universities; there is lack of formal education, training, and assessments in professionalism. Didactic lectures are generally the method of choice to deliver knowledge concerning ethics and professionalism in general. However, there is a need to transfer knowledge into attitude and behavior, upholding the ethical virtues of professional practice. The vast majority of unsolicited healthcare complaints are related to professionalism aspects of care.[8] Training explicitly in professionalism has, therefore, been recommended as an integral part of the medical curriculum.[9]

Hence, the aim of this study was to develop a module to enhance professionalism for physiotherapy undergraduates and assess the professional attributes and competencies using various tools uniformly.


  Material and Methods Top


It was a prospective educational intervention carried out in a physiotherapy school affiliated to a Maharashtra state university of India. The Institutional Ethics Committee approval was obtained, and all participants signed an informed voluntary consent. All 40 physiotherapy interns willing to participate were enrolled. Those participants who did not attend more than 50% of the workshop were excluded from the study.

The study was carried out in four steps.

Need analysis

A need assessment was done using semi-structured interview and multiple focused group discussions with physiotherapy faculty of various national and international universities. They were asked their views on the (a) if students lacked in ethical and professional behavior, (b) need for a module to enhance professionalism, and (c) awareness or use of any module to teach ethics and professionalism. A total of 40 faculties participated in the interview with mean experience of 9.6 years 30 (75%) out of these felt that though students did not lack ethical behavior they certainly lacked on professional behavior, three (7.5%) did not find a deficiency in either of the behavior whereas three faculties (7%) felt that both needed to be trained. None of the faculties were aware of any teaching module in professionalism, 3 (7.5%) faculties were aware and practiced module to teach ethics but not professionalism.

Development of module

A module was designed with the help of physiotherapy experts, using literature review, and guidelines of international and Indian regulatory bodies including Maharashtra University of Health Sciences.[10],[11],[12],[13] Using multiple focused group discussions, a consensus was then reached for the definition of “Professionalism in physiotherapy” at the institutional level and core competencies to be introduced in the module. All experts participating in focused group discussions were made aware of the purpose and the subsequent procedure. Each expert wrote down what they considered as competencies required to be included in the module for training purpose, how would it be taught and assessed. All items were noted, and consensus was reached to either combine similar competency or discard a particular competency if not relevant to professionalism. Then, they were prioritized as to least important and most important.

There is a significant variation in definitions across the world.[1] A common definition of professionalism in physiotherapy for students and faculty of the institute was derived on which was in line with the vision and mission as “A physiotherapy professional should have the clinical decision-making ability to arrive at functional diagnosis along with the skill to plan and deliver patient care effectively, efficiently, and ethically demonstrating the best interest of the patient ahead of self and an accountable behavior towards self and society. The therapist should also be able to communicate and collaborate effectively with a patient, caregivers, peers, and other health-care professionals keeping his/herself abreast with the recent advances and evidence-based care.” The definition was translated into practically observable skills that can be measured.

Clinical competencies, communication, and ethics being the foundations and humanism, excellence, altruism, and accountability being the core principles of professionalism.[11] The following competencies [Figure 1] were identified to be included in the module on the basis of focus group discussion and literature[10],[11] (a) clinical competency: Ability to reason and arrive at a functional diagnosis, followed by an appropriate plan of treatment with therapeutic skills proficiency, (b) communication skills: verbal, nonverbal, and written as relevant to building doctor–patient relationship, interpersonal, and interprofessional collaborations, (c) ethical and moral values: Qualities such as honesty, integrity, accountability, and self-regulation exhibited during experiential practice, along with the ability to recognize and solve ethical problems and dilemmas, (d) adequate professional attributes of overall personal presentation, grooming, organizational ability, time management, and administrative skills, (e) reflection: ability to reflect on and in action.
Figure 1: Core competencies of professionalism

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Delivery

The module was designed as an interactive workshop on “ethics in clinical practice, communication skills and professionalism” and experts in the field were invited to conduct the sessions. The total duration of Module was 24 h and conducted over 3 days. It included sessions to explicitly identify attributes, ethical conflicts and dilemmas, effective communication skills, and writing reflections. The concept of professionalism was brought to a conscious level through interactive teaching-learning methods using role plays, dramatics, case vignettes (modified from jurisprudence education program: Module 1 companion document) for ethical dilemmas and movies in regional language. Debriefing was carried out after each session.

Evaluation

After analyzing various curricular designs and assessment models[12],[13],[14],[15],[16],[17] the students were divided into four groups for training in core physiotherapy practice area for 6 weeks each in rotation The workshop was held at the end of first clinical posting of 6 weeks which was considered as preintervention period. During the internship training program formative assessments and constructive feedback on various aspects related to professionalism was provided by the supervising faculty in a structured format.

In order to assess the change in knowledge based on ethical principles and dilemmas after the workshop, a pre- and post-test was done using case vignettes and multiple choice problem-based questions.

Workplace-based assessment was carried out in four core physiotherapy areas using. “Professional mini evaluation exercise” (P-MEX) designed and validated by Cruess et al. to evaluate professionalism.[18] Permission for the use of P-MEX was obtained from the authors. It focused on healing and professional behaviors that student demonstrates in various settings during their daily professional activities. The behavior is marked as unacceptable, below expectations, met expectations, excellent expectations, and critical event. It includes 21 items under the components of doctor–patient relationship, interprofessional skills, time management, and reflection. The interns were observed for professional behavior using P-MEX on four occasions during 6 weeks' period of each core physiotherapy practice area. A total of 24 observations were noted. The trend was observed and where required remediation was offered.

A validated checklist was used to assess the clinical decision-making ability for functional diagnosis and planning treatment. It included questions whether literature was reviewed, existing evidence-based practices were considered before planning treatment and if patient preference was considered. The effectiveness of treatment was measured using patient feedback wherein the patient graded them on a patient satisfaction scale of 1–10. Furthermore, the student's ability to communicate both oral and written, including listening attentively was evaluated by the patient on the basis on Likert scale where 1 was very poor and 5 was very good.

Students being novice to the practice of reflection, a template was provided where they were asked to reflect on what was done, how it was done, what could have been done better on patient encounters during each clinical posting.[19] A retro preevaluation was conducted at the end of the internship using APTA self-evaluation of professional skills. The students were asked to mark scores on a scale of 1–10 on the components of knowledge, reasoning, reflection, communication skills, and professional attributes. Permission from APTA was obtained for the same.


  Results Top


A total of 34 students completed the module, and their data were analyzed using SPSS 16 software. Nonparametric Wilcoxon signed rank test was used to analyze the descriptive data. The statistical significance was kept at P < 0.05 at a confidence interval of 95%. Change in professional attributes as measured by P-MEX showed a significant change in doctor–patient relationship (P < 0.00) and interprofessional skills (P < 0.001) followed by reflective skills (P < 0.007) and time management skills (P < 0.003) [Table 1] There was also significant difference in total patient feedback scores from baseline (P < 0.00). There was a statistically significant increase in written pre-post analysis (P < 0.00) of case-based knowledge and ethical dilemmas [Graph 1] The retro pre-evaluation of APTA done at the end of internship showed a significant change in all core components, i.e., knowledge, communication skills, reasoning, reflective ability, and professional attributes [Table 2].
Table 1: Pre-post mean ranks of various components of measurement of professionalism

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Table 2: Retro pre evaluation self assessment of professionalism (APTA)

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  Discussion Top


Over the centuries, professionalism is interpreted in various ways. Setting the values in alignment with the institution is of paramount importance.[20] A definition of professionalism was derived on, and related competencies were identified for learning and assessing. The module of professionalism was based on values and traditions in the Indian socio-cultural context in the form of interactive workshop. This helped students to explicitly understand, identify and observe the various attributes and traits of professional behavior. The foundation of ethical principles and process of resolving dilemmas through case-based scenarios using a jurisprudence module gave them the confidence to make ethical patient-centric decisions during supervised clinical practice.[15]

Communication skills improvement as seen on patient feedback and as a component of P-MEX during the clinical posting improved not only patient-therapist relationship but also interpersonal communication. Item analysis of patient feedback showed a significant positive change in verbal communications, and increased patient satisfaction, however, the students failed in the ability of written communication. This meant that documentation, how to write home programs, prescription, and discharge summaries also needs to be addressed in teaching communication.

The clinical decision-making ability did not show a significant difference as the students were novice and lacked expertise. Clinical decision-making ability was better with simple cases. The clinical decision-making checklist helped them to identify their gaps in knowledge. Item analysis of clinical decision-making ability in functional diagnosis and treatment checklist showed poor significance in using evidence-based practice. A need for formal training in using evidence-based practice and incorporating it in treatment decisions was identified.

The ability to reflect scored a lower mean rank compared to others. Reflection was a very new activity for the students; nonetheless, it is the most important activity to train professionalism.[19] Moon in her book “Reflection in learning and professional development” holds a view of reflection as a form of “mental processing with a purpose and/or anticipated outcome.”[21] This is ideal for learning about professionalism. It can be applied to relatively complicated or unstructured ideas for which there is no obvious solution.

Kolb experiential learning model offers a most useful theoretical framework and teaching model for developing professionalism. It emphasizes the role of experience in direct contrast to other more cognitive learning theories. The model highlights two contrasting ways of learning through experience - “concrete experience” and “abstract conceptualization.” Two opposite ways of transforming experience follow “reflective observation” and “active experimentation.” We tried to make an attempt to incorporate this in our module.

Professionalism is not a static or amorphous construct but reconceptualized as a set of concrete observable behaviors, enabled by a specific set of skills and can be nurtured over time. It is an emerging quality of a health-care system.[22]

The overall feedback of the module was very satisfactory. Both students and faculty felt the module should be introduced from 1st year. The module helped the faculty to closely monitor students, assess them uniformly, and offer corrective measures. The assessing tools ensured a continuous and uniform evaluation and gave a sense of close supervision to the students. All supervising faculty felt module enhanced the professional behavior however clinical competencies of complex cases needed more experience. Students perceived the module helped them gain knowledge and skills required to develop professionalism. They also expressed the need of including stress management in the module.


  Conclusion Top


In order to retain “Internal morality” the health-care profession has to produce a meaningful commitment to upholding the standards of care with which one is entrusted to generate professionalism prepares the health-care practitioner to serve the interest of the patient before himself or herself. Greater academic rigor has to be applied to the teaching, assessment, and ongoing promotion of the ethical and professional conduct of students in health-care profession. It is important that the professional expectations are made very clear to the students in the beginning of the curriculum. The results of the study showed that such modules need to be implemented in the health professional education to facilitate culture of professionalism among the students to bridge the gap between theory and practice.

Acknowledgments

  • Dr. Avinash Supe, Dean and Director (ME and MH). Director GSMC Faimer
  • Dr. Rashmi Vyas, FAIMER Faculty Philadelphia Students and Staff, PT School and Centre, Seth GSMC and KEMH
  • Dr. Rashmi Vyas, FAIMER faculty Philadelphia.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Van Mook WN, Van Luijk SJ, O'Sullivan H, Wass V, Zwaveling JH, Schuwirth LW, et al. The concepts of professionalism and professional behaviour; Conflicts in both definition and learning outcome. European Journal of Internal Medicine 2009b;20:e85-9.  Back to cited text no. 1
    
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Li H, Ding N, Zhang Y, Liu Y, Wen D. Assessing medical professionalism: A systematic review of instruments and their measurement properties. PLoS One 2017;12:e0177321.  Back to cited text no. 5
    
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World Confederation of Physiotherapy: Declaration of Principles and Position Statements. Available from: https://www.wcpt.org/ethical-principles. [Last accessed on 2018 Mar 08].  Back to cited text no. 6
    
7.
Indian Association of Physiotherapist: Constitution and Ethical Code of Conduct. Available from: http://www.physiotherapyindia.org/about/moa/3130-ethical-rules-guidlines.html. [Last accessed on 2018 Mar 08].  Back to cited text no. 7
    
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Ho MJ, Yu KH, Hirsh D, Huang TS, Yang PC. Does one size fit all? Building a framework for medical professionalism. Acad Med 2011;86:1407-14.  Back to cited text no. 10
    
11.
Project Professionalism. American Board of Internal Medicine. 510 walnut street, Suite1700; Philadelphia, Pennsylvania. 2013 19106-3699. Available from: https://medicinainternaucv.files.wordpress.com/2013/02/project-professionalism.pdf. [Last accessed on 2018 Mar 08].  Back to cited text no. 11
    
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O' Sullivan H, Van Mook W, Fewtrell R, Waas V. Integrating professionalism into the curriculum: AMEE Guide No. 61. Med Teach 2012;34:e64-77.  Back to cited text no. 12
    
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Boon K, Turner J. Ethical and professional conduct of medical students: Review of current assessment measures and controversies. J Med Ethics 2004;30:221-6.  Back to cited text no. 13
    
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Pauls MA. Teaching and evaluation of ethics and professionalism: In Canadian family medicine residency programs. Can Fam Physician 2012;58:e751-6.  Back to cited text no. 14
    
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Goldie J. Review of ethics curricula in undergraduate medical education. Med Educ 2000;34:108-19.  Back to cited text no. 15
    
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Mak-van der Vossen M, Peerdeman S, Kleinveld J, Kusurkar R. How we designed and implemented teaching, training, and assessment of professional behaviour at VUmc school of medical sciences Amsterdam. Med Teach 2013;35:709-14.  Back to cited text no. 16
    
17.
Aguilar-Rodríguez M, Marques-Sule E, Serra-Añó P, Espí-López GV, Dueñas-Moscardó L, Pérez-Alenda S, et al. Ablended-learning programme regarding professional ethics in physiotherapy students. Nurs Ethics 2018. Available from: https://doi.org/10.1177/0969733017748479. [Last accessed on 2018 Mar 08].  Back to cited text no. 17
    
18.
Cruess R, McIlroy JH, Cruess S, Ginsburg S, Steinert Y. The professionalism mini-evaluation exercise: A preliminary investigation. Acad Med 2006;81:S74-8.  Back to cited text no. 18
    
19.
Bryan CS, Babelay AM. Building character: A model for reflective practice. Acad Med 2009;84:1283-8.  Back to cited text no. 19
    
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Lesser CS, Lucey CR, Egener B, Braddock CH 3rd, Linas SL, Levinson W, et al. Abehavioral and systems view of professionalism. JAMA 2010;304:2732-7.  Back to cited text no. 20
    
21.
Jennifer A. Moon. Some background to the study of reflection in Reflection in Learning and Professional Development: Theory and Practice, Kogan Page, London Psychology Press; 2000. p. 10.  Back to cited text no. 21
    
22.
Hawkins RE, Katsufrakis PJ, Holtman MC, Clauser BE. Assessment of medical professionalism: Who, what, when, where, how, and why? Med Teach 2009;31:348-61.  Back to cited text no. 22
    


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