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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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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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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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