Learning Professionalism on the Touch-Line: Pedagogical Challenges and Recommendations

Traditional Approaches to Learning Professionalism

Within the broader health care literature, the influence of role models, including educators and clinicians encountered by students, has been suggested to have the most significant impact on informing professionalism.¹² In reality, such role models may have both positive and negative impacts on the development of student understanding and awareness of professionalism. Positive characteristics of role models are demonstrated in the domains of clinical competency (including good clinical reasoning skills, strong communication), teaching skills (including making time for teaching, respecting student needs, providing timely feedback), and personal qualities (including demonstrating honesty and integrity, being collegial).¹⁵ Note that “role modeling consciousness” has been described by doctors who are perceived to be excellent role models; that is, they specifically think about and are aware of being role models when interacting with learners.¹⁶ A synthesis of studies on role modeling in medicine indicated that students identified a range of attributes they seek in role models that included enthusiasm, compassion, openness, integrity, and good relationships with patients.¹⁷ However, these authors also noted that students tend to be drawn to senior figures as role models, owing to their status and levels of responsibility, and that some senior doctors displayed poor attitudes and unethical behavior. This can be problematic, given that students are at the lower end of the “professional power spectrum” and consequently have a tendency to conform to, rather than challenge, behaviors.⁸ The notion of observed behaviors remaining unchallenged by students gains more significance when considering the increased influence of clinicians encountered during work-environment opportunities compared with that of the educator in the classroom.¹⁸ Modeling of poor attitudes and behaviors, predominantly in the clinical setting, has been described as the biggest threat to the development of appropriate levels of professionalism.⁹

The spheres of influence in the multidimensional learning environment are the formal curriculum (the stated, intended, and formally offered curriculum; ie, what is listed, intended, and endorsed in curricula and session documentation); the informal curriculum (the unintentional, and often ad hoc, teaching and learning that takes place, frequently through interpersonal interactions between students and faculty); the “hidden curriculum” (cultural or organizational/subcultural influences on learning, including commonly held understandings or “taken for granted” ideas, behaviors, or habits).¹⁹ The hidden curriculum has been further described as the difference between the values taught in the formal classroom setting and the behaviors encountered during real-life, work-based learning opportunities,²⁰ the aspects of a profession that are not formally taught²¹ and that are often implicit in nature.²² The key relevance of the hidden curriculum in the context of this article is in the influence of culture (of a workplace, organization, professional group, etc) on learning and enculturation to the profession of athletic therapies; traditionally, the concept of professionalism within health care education has been described as being part of this hidden curriculum.^19,23 Conflicting views on the value of the hidden curriculum have been proposed: Its importance has been recognized in the transformation of the student to being a professional²⁴ through providing the links between education and practice.²¹ Some educators believe the hidden curriculum to be “the mortar that binds the bricks of formal learning,”^25(p280) facilitating the socialization of professional values and practices.²⁶ In an exploration of the potential of the hidden curriculum in athletic training programs,²⁷ head athletic trainers and program directors identified truth/honesty, integrity, respect, accountability, and caring as important values for athletic training. This suggests that a set of values that are congruent with the values of the National Athletic Trainers' Association Code of Ethics (https://www.nata.org/membership/about-membership/member-resources/code-of-ethics) are likely to be implicitly conveyed by educators in athletic training and present a potential positive influence of the hidden curriculum in athletic training. However, Stephenson et al⁹ argue that the hidden curriculum may negate the formal teaching of professionalism, where the clear links to codes of professional standards and behaviors are obstructed by the specific challenges presented by real-life situations experienced within work environment opportunities.²⁸ It is worrisome that what is learned by students through socialization and the hidden curriculum is considered sticky knowledge,²⁹ which can be more memorable than the explicit formal curriculum and can thus have greater impact upon professionalism development.

Challenges for Professionalism in the Sporting Environment

In professional identity formation, the significant influence of the environment and interaction with others cannot be ignored²⁸ because these aspects can affect a professional's behavior and adherence to codes of conduct more than the professional's underlying attitudes and beliefs.¹ Students of athletic therapies experience learning in a variety of working environments (through mandated clinical placement or attachment opportunities), a significant proportion of which takes place on the “touch-line” or sideline. These sporting environments can include all levels of amateur and professional sport in sports team or educational settings that expose students to variable hidden curricula. Such variation can cause conflict in the development of professionalism, with some values and behaviors being enhanced while others are ignored or deterred.³⁰ A simple example of discrepancies between formal teaching and sports-related work practices relates to gaining consent: In the educational environment, the professional and legal requirement to obtain clear informed consent before touching a person presenting for treatment is emphasized throughout teaching and practical examinations. However, this message is often negated for many students on placement in the sporting environment who experience consent being implied by the action of the injured player simply attending for treatment.

On a sociocultural level, sociologists in the both the United States and the United Kingdom have identified how subcultures exist in sport (at all levels), within which health care professionals can become constrained or influenced to act outside of normal professional expectations and boundaries.^31–34 The particular culture of a sports club or team is likely to be set by the manager or coach, and medical teams, as employees of the team, may become involved in the methods used by the (nonmedical) manager to stigmatize injured players.³² Like managerial culture, the relationship between clinician and coach/manager varies greatly from team to team and in some cases can be strained. In the United Kingdom, some football (ie, soccer) managers were suggested by physiotherapists and club doctors to have restricted their clinical autonomy in the treatment of players, overruling physiotherapist decisions and conducting fitness tests to return to play without reference to the physiotherapist.³³ Malcolm and Scott³⁵ have discussed the pressures experienced by clinicians working in elite team sport regarding the multiple professional obligations encountered (to the athlete [patient], other health care professionals, the manager, the team) and how these affect the management of patient confidentiality. Indeed, conflicts of interest can arise for health care professionals working in professional sport because they have an ethical obligation to advocate for the athlete but also an obligation toward the team if they are paid employees.³⁶

It is logical to assume that exposure of a student to such unpredictable environments with such variable working practices has the potential to become a source of conflict in professionalism learning and professional identity development. The sports culture and the associated accepted and expected working practices just described have great potential for forming a hidden curriculum for students of the athletic therapies. The professional enculturation that takes place within this environment has potential to undermine the professional values identified by Peer and Schlabach²⁷ and to resonate with definitions of professionalism in health care. This is exacerbated further for students in the United Kingdom who do not routinely gain clinical experience within institutions such as the National Health Service (unlike traditional health care professionals such as doctors, nurses, and physiotherapists) where processes and systems are relatively consistent compared with the sports environment. The potential larger variation in experience of athletic therapies students compared with peers from other health care professions may be counterproductive in cementing conformity³⁷ because the different environments encountered bring with them different pressures and contextual influences. This may create further conflict between the formal and hidden curriculum, widening the gap between what is taught in the academic setting and what is experienced in the working environment. However, to counter this argument, it could also be proposed that the range of experiences and contexts to which students are exposed could positively challenge and facilitate their development of professional identity.³⁸ This would be a worthy area of research for the athletic therapies.

Professionalism as a Threshold Concept

The complexities and challenges of learning something as nebulous yet as important as professionalism mean that it could be considered a threshold concept.³⁹ Originally explored in the context of economics undergraduate education in the United Kingdom, Meyer's notion of a threshold concept was grounded in differentiating a core concept or disciplinary learning outcome that involves “seeing things in a new way”^39(p1) from one that does not. For students of athletic therapies, professionalism is a fundamental aspect of the discipline that is a metaphorical gateway or threshold through which a student must pass in order to progress in their discipline. It is a transformative step that allows them to access other ways of understanding, interpreting, viewing, or thinking.^39–42

There are five key characteristics of a threshold concept: it is transformative, irreversible, integrative, bounded, and troublesome. Threshold concepts are transformative, given that once a student has understood the threshold concept, its potential effect on student learning and behavior not only leads to a significant shift in the perception of a subject, but to the student's ontology.³⁹ The new understandings integrate with the students' biography and become a part of who they are and how they view the world.⁴³ Threshold concepts transform student perspectives permanently and cannot be forgotten or unlearned³⁹; in that way they are irreversible. They are integrative: Understanding a threshold concept allows students to identify and make clear connections to other areas or phenomena that previously appeared unrelated.⁴³ Threshold concepts may be bounded; that is, outside of the discipline, they may not be considered threshold concepts.⁴³ Finally, a threshold concept being troublesome relates well with what Perkins⁴⁴ calls “troublesome knowledge”; that is, knowledge that feels alien and counterintuitive. Meyer and Land³⁹ contend that the powerful, transformative effect of threshold concepts, coupled with their troublesome nature, can prove difficult for students to understand. This can lead to a state of liminality for students: a suspended state in which their understanding approximates to mimicry or is lacking in authenticity.

Crossing the threshold includes both epistemic and ontological transformations.³⁹ For professionalism, this requires individuals to “develop a sense of who they are in terms of professional practice, how they inhabit the professional world and on what terms they interact with others in that world.”^45(p24) This process likely also involves the reworking and adaptation of prior knowledge, particularly when applying that knowledge to the working environment. The ways of being professional have previously been described as a threshold concept within the broader field of health care.²¹ The threshold concept framework has previously been discussed in relation to its usefulness in curriculum structure and design,^46,47 specifically for identifying places where students get stuck or are blocked from moving forward with their understanding and learning. Professionalism as a threshold concept for students of athletic therapies and its implications for teaching and learning are explored further in Table 1.

Table 1.  Key Characteristics of Threshold Concepts in Relation to Teaching and Learning Professionalism for Athletic Therapies

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An Alternative Perspective: The Evolving Professional

At the curriculum level, Tsang^11,21 proposed the concept of an evolving professional for health care education. Principally, the evolving professional concept provides a culture and a context for teaching, learning, professional socialization, and professional development¹¹ via a multilevel framework in which the student is regarded and developed as an evolving professional within a supportive environment. Within this context, students and educators work together as professionals to critically reflect, evaluate, and discuss aspects of the particular discipline, helping to uncover and challenge the hidden curriculum. It focuses on three particular areas of student development: students as reflective practitioners, skilled communicators, and collaborative team members. Tsang¹¹ contends that if students can master and internalize these three skills early in their education, along with developing an in-depth knowledge of their field, they will have the necessary skills to develop other fundamental skills, for example, being a self-directed lifelong learner. These skills are highly relevant to students studying athletic therapies, and teaching and learning approaches to developing these skills are proposed in Table 2, with critical reflection explored in more detail here.

Table 2.  Teaching and Learning Activities to Nurture the Evolving Professional in Athletic Therapies

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The Importance of Critical Reflection

A cornerstone of the evolving professional concept is critical reflection upon the actions and/or behaviors of others as well as oneself⁴⁸; reflection contributes to individual learning, development of a professional identity,¹ and the facilitation of explicit knowledge from a more implicit start point.¹² It enables students to make sense of what they experience and encourages them to become active observers who make judgments on what they encounter.² The value of reflection as a key pedagogy for facilitating professionalism is lost if the curriculum and pedagogical approaches do not allow the opportunity and time for the student to share, discuss, and evaluate their experiences and critique their own behavior and the behavior of others.² Evaluating the behaviors of others may aid in the discrimination between positive and negative role models⁹ and counterbalance the lack of direct support for students by educators in the working environment.³⁸ Many students need to initially be taught how to critically reflect, and this can be supported within the evolving professional framework. Initially, reflective models can be useful to provide a structure for reflective writing or discussion, and they prompt students toward deep rather than surface-level reflection; it is beyond the scope of this article to explore reflective models in detail, but adaptation of Brookfield's⁴⁹ lenses from an educational to a health care context (ie, autobiographical lens, patient lens [rather than pupil lens], peer lens, theoretical literature) provides a very useful framework to encourage students to systematically view an incident from multiple perspectives. Reflective journal writing is a well-known approach to developing reflective practitioners and has been suggested as an approach to developing athletic training students' ability to reflect.⁵⁰ A successful example of curriculum-level embedded critical reflection for the evolving professional can be found in oral health,⁵¹ where final-year students were first introduced to reflection and structured reflective writing through two seminars. Students were required to keep a weekly reflective journal through the year of critical incidents that contributed toward their clinical learning. This was augmented by regular semistructured small group discussion in which all students shared a critical incident and one was selected for further discussion by the group, facilitated by a clinical tutor. As a result of this curriculum-level intervention, the authors reported improved awareness of clinical reflection and better critical thinking and reasoning skills among students, and students reported seeing themselves as professionals rather than students. In-class reflective discussions in three cohorts of final-year oral health students also demonstrated positive results,⁵² with students welcoming reflective discussions to support their reflective writing, noting in particular the benefits derived from the interactive, supportive, and multi-perspective nature of reflective group discussions. Evidently in order to be successful, opportunities for face-to-face, open discussions between educators and students need to be explicit and conducted in a supportive environment, as proposed within the evolving professional concept, where aspects of professionalism are challenged by both the educator and the student as equals. Harnessing the skill of reflection at the undergraduate or preregistration stage is an important facet of preparing the student for being a lifelong learner.

In developing professionalism education, the evolving professional and threshold concepts provide a connected, synergistic approach. This is demonstrated in the Figure, which shows an educational framework for professionalism education in the athletic therapies, drawing on evolving professional and threshold concept at the culture, curriculum, and learning activity levels. Through education, a student is transformed across the threshold to being a professional. For some students, transformation may occur early in the educational continuum, whereas others may take longer to cross the threshold.

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