From Volume 42, Issue 3, April 2015 | Pages 215-218
This paper explores the implications of the Francis Report for education of the dental team. It considers selection of candidates for training, issues relating to the curriculum itself, including assessment and the importance of listening to trainees. The overriding importance of the ‘informal’ or ‘hidden’ curriculum, through which students and trainees observe their teachers and develop a sense of the professional and ethical culture within an educational institution, is stressed.
Francis could be said to have laid much of the blame for what happened in Mid-Staffordshire on the failure of ‘systems’ but the action, or lack of it, of individual healthcare professionals did not escape criticism:
‘…clinicians did not pursue management with any vigour with concerns they may have had. Many kept their heads down’.1
With respect to nursing, Francis commented on ‘…a declining professionalism and tolerance of poor standards’.1
It is the role of education and training providers to produce clinicians who are patient-centred, who will act as advocates for high-quality patient care, and who will be resilient enough to maintain the highest professional standards in the most challenging of circumstances. Demanding as these standards of conduct may appear, especially to those unfortunate enough to work in dysfunctional organizations, they are nonetheless a fair summary of what the General Dental Council (GDC), for instance, requires of its registrants.2
Surprisingly, Francis says relatively little about the educational process directly, and what he does say is in relation to nursing:
‘There should be an increased focus on a culture of compassion and caring in nurse recruitment, training and education.’ 1
Whilst the Mid-Staffordshire scandal raised some very specific issues for nursing, the relevance of a ‘culture of compassion and caring’ for all health professions seems obvious and so the question arises as to how this should impact upon the ‘recruitment, training and education’ of dental professionals. This paper will focus on this question and will consider the obligation of providers of education and training (henceforth referred to as ‘providers’) to their students and trainees in light of the Francis Report.
A tool that identified non-cognitive attributes such as caring, compassion and empathy, all highly relevant in the context of Francis, would clearly be of value in selecting students for primary qualification programmes and candidates for further training. The multiple mini interview (MMI) is being used in some medical and dental schools with just this purpose in mind, and has also been used in selecting postgraduate trainees. A recent publication3 suggested that the MMI was the most consistent predictor of success in early medical school assessments when compared with other methods of student selection. However, predicting performance in examinations is not the same as predicting the extent to which students will embody key professional values, and evidence that MMIs, or other tools, are capable of doing this is lacking.4 The contention that providers are capable, should they wish, of selecting candidates with particular non-cognitive attributes must be viewed with caution presently. However, this is a caveat; it is not an argument for continuing with selection methods that are likely to be inherently unreliable or incapable by design of measuring anything other than cognitive skills.
Implications for curricula at all levels can be considered under the following headings:
Of the 290 recommendations in the Francis Report, relatively few are directly relevant to the educational objectives of primary qualification and training programmes for dental professionals; and these are largely concerned with aspects of Professionalism, Management and Leadership. The GDC has placed increased emphasis on precisely these areas in its latest learning outcomes for the dental team – Preparing for Practice.5 Analysis of the educational implications of the Francis recommendations should therefore begin with consideration of how they align with learning outcomes in Preparing for Practice (PfP), both overarching and domain-specific. In some cases, the alignment is clear (Table 1), in others the alignment is less strong; for instance Francis recommendation 111 states:
| Francis Recommendations | |
|---|---|
| Theme: Putting the patient first | |
| 5. | In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: |
‘Provider organisations must constantly promote to the public their desire to receive and learn from comments and complaints; constant encouragement should be given to patients and other service users, individually and collectively, to share their comments and criticisms with the organisation.’ 1
The equivalent learning outcome in PfP is probably 12.3:
‘Recognise and demonstrate the procedures for handling of complaints as described in the Principles of Complaints Handling.’ 5
This touches on a key message of the Francis Report, which is the importance of openness, transparency and candour, but whilst the Francis recommendation implies a proactive state of welcoming and encouraging comments and criticisms, the PfP outcome, by contrast, appears reactive. It is important to remember that the GDC anticipates that education providers will elaborate on the PfP outcomes, with more detailed supporting outcomes that relate to their own curricula. Thus, we suggest the first task for education providers will be to review their learning outcomes, confirm that they encompass the relevant Francis recommendations, and amend them where they do not. The second task will be to consider how their programmes support student learning in relation to these outcomes. Space constraints do not permit a full consideration of constructive alignment in this regard, but there is one facet of learning that is profoundly relevant to the curricular implications of Francis, and that is the informal or hidden curriculum.
A comment in Don Berwick's report, ‘A Promise to Learn – A Commitment to Act’,6 alludes to the hidden curriculum:
‘Culture will trump rules, standards and control strategies every time, and achieving a vastly safer NHS will depend far more on cultural change than on a new regulatory regime’.
Students and trainees observe the behaviour of their teachers and trainers and this is an important means by which they develop a sense of the prevailing organizational culture.7 Unfortunately, the outcomes are not always positive and there is evidence from both the UK and USA of medical students witnessing unethical and unsafe behaviour, resulting in erosion of their own principles and adoption of unacceptable standards.8,9 This thorny issue is fundamental, since the informal curriculum is known to be more powerful than the formal for the transmission of professional values.7 Providers need to consider strategies for raising awareness of the importance of the informal curriculum, and role modelling in particular, amongst their teachers and trainers, and for facilitating their development in this regard.
Reflection is a key skill for life-long learning and may provide a useful link between the informal and formal curriculum. Students should be encouraged to learn through reflecting on their clinical experience, including observed ethical conflicts. A method of facilitating reflection within a dental curriculum has been described.10 Clinical teaching staff might also be encouraged to reflect on their status as role models and to consider the cultural messages they are conveying through their own interaction with patients, students and colleagues.
Professional behaviour is not the only component of organizational culture; leadership, management, support services, estate, all play a part. Francis made it clear that education and training must not take place in environments where fundamental standards of quality and safety were not adhered to. In dentistry this is already explicit within the GDC document Standards for Education.11 In recent years, many UK dental schools have developed Outreach clinics to deliver a significant proportion of their students' experiential learning and providers are aware that their obligation for quality assurance extends to these settings.
Successful completion of programmes of education and training should be dependent upon a satisfactory outcome to valid and reliable assessment of the intended learning outcomes. As discussed above, these learning outcomes should encompass skills and attributes relevant to Francis's recommendations, many of which lie in the domain of ‘professionalism’, where assessment is problematic. For the purposes of assessment, professionalism can be considered in terms of its component elements and these, in turn, can be blueprinted against appropriate assessment methods.12 Many of the methods available measure behaviour and ‘Behavioural assessments are proxy measures, resting on the assumption that observed behaviours are reflective of underlying dimensions. Research shows that this assumption is not always accurate’.4
A holistic assessment of professionalism requires triangulation of outcomes from a number of different assessment methods, involving multiple assessors, in a range of contexts and over a period of time.4,12,13
Regardless of the difficulties associated with summative assessment of professionalism, the benefits of assessment for learning should not be overlooked. This implies the need for effective feedback and a self-regulated approach to learning.14
Finally, in this section, assessment of Professionalism, particularly the identification of unprofessional behaviour, needs to be linked to ‘Fitness to Practise’ procedures. Providers of pre-registration programmes are well aware of their obligations in this regard.15 Less clear are the threshold behaviours that would indicate the need to apply these procedures. Unfortunately, there is little published evidence to guide such decisions. On the one hand, application for low level concerns could allow early intervention and remedial action;16 on the other, it could inhibit the potential for learning in response to minor and infrequent professional lapses.
The Francis Report referred to trainees as ‘valuable eyes and ears’ in a hospital setting. Students and trainees are often acutely aware of unprofessional behaviour and poor standards of care/safety within their learning environments. Francis recommends both, that providers should utilize student/trainee feedback as part of their internal quality assurance, and that regulators should obtain information directly from trainees during inspections,1 as does the GDC. This can be regarded positively and students/trainees should be considered as partners in facilitating change.
The Francis Report, and its ramifications, has implications for the education and training of dental professionals. Education and training providers will need to consider these implications carefully but we would wish to emphasize the following points:
