Key points

  • Describes the way in which students are 'signed-off' to the General Dental Council as having achieved professionalism outcomes.

  • Highlights the questions which arise from the current constructs, or 'learning outcomes', used to present the educational attainment of professionalism.

  • Suggests the current status quo gives undeserved legitimacy to impoverished expressions of professionalism which risks halting debate about the complexity of judging professionalism and what are reasonable expectations from the newly qualified.

Background

In the UK, the General Dental Council (GDC) as the regulator of dental professionals, has responsibility for the quality assurance of training programmes. To this end, they produce documentation outlining the requirements for education and training. One such document, 'Preparing for practice: Dental team learning outcomes for registration',1 describes the learning outcomes that are required to be attained under four domains:

  1. 1.

    Clinical

  2. 2.

    Communication

  3. 3.

    Professionalism

  4. 4.

    Management and leadership.

Education providers must demonstrate compliance with, and alignment to, all of these requirements.

The use of learning outcomes is well established in the educational literature, with significant amounts written on what constitutes an 'ideal' outcome, along with guidance on which taxonomies to employ when writing learning outcomes.2,3,4,5,6,7,8 Learning outcomes have differing purposes, dependant on the stakeholder.9 For students, outcomes can signpost elements of a programme and enable self-directed study and assessment of understanding and development.10 Programme providers can use outcomes to not only express a focused endpoint but also to inform and align curriculum design and delivery and assessment strategy.

Alongside the shift in how products of learning are expressed, both medicine and dentistry have moved from an implicit understanding of professional conduct, to overt reference and attempted itemisation of professionalism within the curriculum.11,12,13 This has been reinforced by the requirements of external regulatory bodies that education providers demonstrate attainment through assessments of specific learning outcomes associated with being a 'professional'.1,14 The use of outcomes by the GDC for specifying attainment requirements implies that professionalism can be described, with the use of learning outcomes, in a comparable way to other elements in the curriculum, such as clinical skills. However, the clinical education literature acknowledges the wide-ranging challenges of integrating the diverse values within a profession into measurable behaviours of its newly formed clinicians.15,16,17 A potential disconnect, therefore, exists between the application of regulator-produced outcomes and the complexity of the lived phenomenon referred to as professionalism. The current descriptors present education providers with significant challenges: what to demonstrate, how to deliver these and what to record.

This study stems from our belief that by problematising the issues faced by education providers when responding to the set of learning outcomes, we can then look toward proposing a format and presentation of attainment that will satisfy the dual functions of feasibility for the provider and assurance for a regulator. The overarching aim of this study was to critically review the utility of the GDC's prescribed list of professionalism learning outcomes to the dental undergraduate education context.

Method

Overarching conceptual approach

In analysing the learning outcomes, the researchers adopted a pragmatic approach;18 putting aside the challenges associated with conceptualising professionalism and acknowledging that educational providers must still be compliant with the documentation produced by a regulator. The outcomes were therefore evaluated according to their utility and the consequences of applying them within an undergraduate context.19 The outline of the method followed in this study is displayed in Figure 1.

Fig. 1
figure 1

To show the process of document analysis of the professionalism domain within the 'dentist' section of the 'Preparing for practice' document1

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Data source overview

The current GDC 'Preparing for practice' document, last updated in 2015, was the focus of this analysis. The document is freely available in the public domain and via the GDC website.1 The document specifies that it is applicable to 'all courses that lead to registration with the GDC'. It was analysed in isolation from other documentation, albeit there were references within the text to other GDC produced documents.

Initial data analysis

The initial sorting of statements was conducted by HB. The learning taxonomy selected to act as a frame to analyse statements was Bloom's taxonomy,5,6 as this is the most widely used, applied and understood taxonomy within higher education. Bloom's taxonomy is a hierarchical taxonomy with three domains of learning: cognitive (knowledge-based); affective (attitudes, emotions, feelings); and psychomotor (skills-based). An example of the cognitive domain at the lowest end of the hierarchy might be the ability to 'list' items or 'define' something. Higher level within the cognitive domain may include the ability to 'synthesise' information and perform a 'critique'.

Using documentary analysis techniques,20 each GDC professionalism 'outcome' was reviewed to assess whether it met the criteria of a functional learning outcome: its clarity of meaning, explicit reference to a level of cognitive, psychomotor or affective attainment and its compatibility with existing assessment processes. In addition, the outcomes were considered in relation to the practical challenges of demonstrating an overt and behavioural manifestation of achievement within an undergraduate degree programme.

Outcomes were analysed in terms of how tangible (ability to be applied) they were, this included the presence of a clear endpoint, indication of scope of breadth and depth of content, and direction on how assessment could be conducted. The action verb component of each 'outcome' was considered, both in terms of Bloom's taxonomy domains and levels. An Excel spreadsheet format was used to record these data.

Production of summary documentation

When essential components for 'learning outcomes' were absent, other classifications were considered for the professionalism statements. These included, from the abstract to more concrete: principle, standard; objective and outcome, which was further divided into outcomes with challenges with regards to feasibility and also function. The descriptors for each of these classifications are shown in Table 1. The use of the term 'competencies' was not included in this study as these are associated with completion of specific actions and tasks, so were not included on the continuum of education goals.

Table 1 Descriptors developed in this study for identification of educational goal 'style' in statement presentation
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Revision, final analysis of document and validation

Consideration was given to the practical challenges of implementing each 'outcome' and consideration given to whether the learner, working under supervision in a learning environment, has the opportunity to demonstrate the traits and skills, as stipulated within the outcome. Statements were critically reviewed and annotated, making notes regarding whether the 'gold standard' for the above features were met by the descriptors, also drawing on the collective experience of the authors as clinical educators to consider the practicalities of demonstrating attainment in the context of a learner in a supervised environment.

The analysis findings were critically reviewed by all researchers in a validation process, revisiting initial classification and annotations to confirm the approach as described below.

Assurance of analytic rigour

The rigour of the analytic process was supported by recursive analysis21 and using memoing22 to record analytical choices. Transparency of coding allowed decisions to be overt and open to scrutiny by other researchers (Table 1).

In terms of reflexivity,23,24 each member of the research team brought different experiences, skills and perspectives in the scrutiny of the data. These included experience of curriculum mapping and assessment blueprinting as well as experience in the practicalities of design and implementation of assessments for the undergraduate curriculum. Open discussion and exploration of each other's opinions enabled a non-biased conclusion to be achieved through a reflexive approach.

Peer review22 was crucial to the rigour of the analysis as it allowed crystallisation25 of the approach rationale and justification of the classification made in the analysis. When there was disagreement between researchers, the group reviewed the rationale, descriptors and their application, before reaching consensus. Following this, remaining outcomes were re-reviewed to ensure any modifications in analysis were applied consistently.

Results

Twenty outcomes formed the professionalism domain of the 'Preparing for practice' document. The analysis of each 'outcome' is shown in Table 2. Issues identified had two main foci, firstly on why they fail as outcomes and secondly, why these outcomes present challenges if ensuring attainment of 'professionalism'. These are summarised in Box 1 and illustrative examples are described below.

Table 2 Analysis of 'outcomes' in 'Preparing for Practice'1 by elements of style, ability to assess, and consideration of the learning environment
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Illustrative examples of findings

The action verb in some outcomes was readily identifiable, making assignment of a Bloom's taxonomy learning domain and level within that domain straightforward. An example of this is GDC outcome 8.3, which has the action verb 'explain' and is therefore part of the cognitive domain, at the level of 'understanding':

GDC 8.3 'Explain the contribution that team members and effective team working makes to the delivery of safe and effective high quality care.'1

However, in some instances, the identification of the action verb proved challenging (both the domain and level) with no specific behaviour stated but instead a statement of instruction, suggesting an objective rather than an outcome:

GDC 8.2 'Ensure that any team you are involved in works together to provide appropriate dental care for patients.'1

When considering the above example, ensuring a 'team' is working together may contain affective components, cognitive elements of knowing how and why teams may work more effectively, and could include practical task application. It is also relevant to acknowledge that, within an undergraduate dental programme, students are not operating as independent practitioners. This raises questions for some statements whether there is the ability to truly demonstrate achievement independently in a supervised environment, or whether it should be considered as aspirational.

In assigning a 'level', to fulfil Bloom's taxonomy, challenges also arose when the verb within the statement was not specifically listed in the taxonomy. On these occasions, a judgement was made based on clinician/clinical educator experience of what was being asked for in the outcome, and the necessary skills to achieve this. For example:

GDC 7.1 'Be familiar with and act within the GDC's standards and within other professionally relevant laws, ethical guidance and systems.'1

This example includes phrases that would normally be avoided when writing learning outcomes. Although 'be familiar with' suggests a cognitive process that could be assessable, it does not articulate or allude to how 'familiarity' will be demonstrated by behaviours and to what level of expertise it will be practised. The 'act' within the outcome is more difficult to tangibly assess, but this could be considered 'achieved' if there had been an absence of concerns raised; that is, no reports of concern where the student has not achieved the specified components of an outcome. The 'outcome' also has a broad scope and multiple component elements. The range of laws, ethical guidance and systems is extensive, so would not be assessed in single assessment episode. 'Familiarity' could be assessed at a point in time, however, 'acting within' implies a more longitudinal activity.

While the style of some outcomes conformed to the expectations detailed in the descriptor of an 'outcome' (Table 1.), others were styled with elements of a standard. For example:

GDC 6.2 'Be honest and act with integrity.'1

In terms of assessment opportunities, some of the 'outcomes' did not identify an obvious quantifiable opportunity for assessment:

GDC 6.5 'Recognise and respect the patient's perspective and expectations of dental care and the role of the dental team taking into account current equality and diversity legislation, noting that this may differ in England, Scotland, Wales and Northern Ireland.'1

There are elements of both the cognitive domain, possibly at the 'remembering' level if 'recognise' is taken as the action verb, but also an affective component in terms of 'respect' which may indicate a 'value' level within the affective domain. 'Respect' is technically an outcome as it is in Bloom's taxonomy affective domain (at different levels), but is difficult to measure as it relies on an ability to assess such attitudes. It is, therefore, difficult to design an assessment by which an education provider could tangibly and consistently assess the way in which a student has 'respect' for patients' expectations. Two further examples of similar challenges in application and representativeness of 'professionalism' are:

GDC 6.3 'Respect patients' dignity and choices.'1

GDC 7.3 'Act without discrimination and show respect for patients, colleagues and peers and the general public.'1

In these a student's behaviour could be 'assessed' at a moment in time, and for a given scenario, but this may not represent specific attitudes or give the longitudinal maintenance of attributes which are key to the consideration of complex phenomena such as professionalism.

Discussion

Given that the purpose of the GDC document 'Preparing for practice' is to support quality assurance across all dental education providers, this study identifies a risk that the quality of the learning outcomes could themselves result in differing interpretations. By being unclear, the outcomes are likely to defeat the purpose of having a standardised document for all providers of dental education. The complexity of the 'style' may, however, not be the 'fault' of the writers of the document, but rather that attempting to describe a complex phenomenon such as professionalism in this format of educational goals just does not work.

This study demonstrates that very few of the outcomes in the professionalism domain of 'Preparing for practice', when taken in their entirety, are written as outcomes from the perspective of their application in an education environment. This situation has implications for education providers from a local governance perspective when designing curricula and assessments and when mapping and preparing blueprints. The challenges of providing broad outcomes has been described in the literature and includes how they are interpreted by both students and education providers, and how they are mapped to other requirements.26 When outcome statements include subsections within them, how providers interpret a partially attained outcome creates an element of uncertainty and potentially inconsistency across providers. Differing interpretation of attainment, from what might be described as 'woolly', and inaccurately articulated 'outcomes' has the potential to undermine the apparent purpose of having universal outcomes from regulators. Similar challenges arise when outcomes are so broad in terms of scope and content that it becomes difficult to determine exactly what assessments would be needed to judge attainment.

In terms of assessment opportunities, some outcomes did not identify an obvious quantifiable opportunity for assessment. In many of these cases, recognising an absence of the described attributes may provide a possible attainment indication of the desired outcome. Successful attainment may, therefore, require an approach of identifying those who are not demonstrating the outcome. Challenges also existed when there was no established assessment tool which was reproducible, valid and reliable. Currently, there are no accepted robust tools to consider the assessment of attitudes and beliefs, with reliance on observable behaviours. This approach has weaknesses and, from a practical perspective, demonstration of attainment presents challenges.16,17,27 From the perspective of compliance with regulatory requirements, the key consequences of an absence of obvious assessment tools is that training providers can demonstrate successful attainment, irrespective of differing interpretations between providers, and may not support regulator confidence in consistent attainment.

More complex and difficult to resolve, our findings suggest that articulating complex social processes as 'learning outcomes' is likely to be flawed. By utilising a format that in itself is quite prescriptive and mechanistic, there is a risk of losing the richness of complex phenomena such as professionalism; reducing it to the denominators or surrogates which can be described and assessed. However, with learning outcomes so widely adopted and integrated into how educational attainment is expressed, it may be difficult to have alternate formats recognised and adopted. Therefore, by presenting the professionalism requirements of the regulator as outcomes which themselves do not conform to an established educational format, there is a risk of compounding the challenges education providers have in demonstrating the attainment of 'professionalism' and also undermining the educational role and benefit of true, well-designed learning outcomes.

The challenges identified in this manuscript associated with working to regulator specified outcome documents are not specific to dentistry and these challenges are amplified by focusing the inquiry on the 'professionalism' domain of this GDC document. Issues which have become evident also relate to more ideological and philosophical questions about accurately articulating the attainment of complex phenomena. Moving forward, it will be critical to consider these concepts to better understand and then have confidence in what professionalism is, and how it can be demonstrated and maintained throughout a professional's life. Careful and fair consideration by stakeholders including the public, patients, regulators, professionals and those who support the development of professionals is needed, to develop both an informed and deliverable perspective.

Conclusion

Critical review of the utility of the GDC's prescribed list of 'professionalism' learning outcomes identified attainment challenges from the perspective of the education provider. There is justification to reopen the debate about the complexity of judging professionalism and address the current mismatch of managing complex phenomena with educational goals.