Despite medical organisations around the world highlighting the need for increased emphasis on professionalism in medical education [1], there is no widely accepted definition of professionalism [2] and no unifying theoretical model that guides the integration of professionalism into medical education [3, 4]. There has been growing recognition of the need for theory-based research to understand healthcare professionals’ behaviours, and to inform the design of interventions intended to change these behaviours [5,6,7,8]. Archer and colleagues [4] propose that the Theory of Planned Behaviour (TPB) would be an appropriate model for creating a more unified, theory-driven approach to teaching medical professionalism and that future research should investigate the variables of the TPB, i.e. attitudes, subjective norms and perceived behavioural control, on professionalism. Other authors have also suggested the TPB as a useful framework to evaluate professionalism [9]. However, while the TPB has been proposed as an appropriate theory for integrating professionalism training in medical education, there is a lack of empirical evidence that examines its efficacy. Therefore, this study aims to examine the utility of the TPB for predicting doctors’ professional behaviours: specifically, raising a patient safety concern, carrying out reflective practice, and using the General Medical Council’s (GMC’s, responsible for the regulation of doctors in the UK) guidance on confidentiality.
Systematic reviews examining the Theory of Reasoned Action (TRA) [10] and its extension, the TPB [11], have concluded that the theories are able to predict intentions and behaviours among different groups of clinicians, including doctors [7, 12, 13]. According to the TPB (Fig. 1), intentions are the precursor of behaviours, and the stronger the intention, the more likely the behaviour is to be performed. Intention is determined by three variables: 1) attitudes (overall evaluation of the behaviour), 2) subjective norms (estimation of the social pressure to carry out the behaviour), and 3) perceived behavioural control (the extent to which a person feels able to perform the behaviour). Given the challenges of measuring actual behaviour, intention can be used as a proxy, where a positive relationship between intention and behaviour has been confirmed [14]. This assumption has been supported for behaviours among clinicians [5].
The TPB has been frequently applied to understand clinicians’ behaviours. For example, in a systematic review examining healthcare professionals’ intentions and behaviours using social cognitive theories, Godin and colleagues found that the theory used most frequently was the TRA or TPB, which was able to explain approximately 35% of the variance in behaviours and 59% of the variance in intentions [7]. However, the behaviours were mainly performed within a clinical context (e.g., prescribing or adhering to clinical guidelines). While the TPB has also been used to study other type of behaviours, such as ethical decision making (reporting a medical error) [15], there is a paucity of studies using the TPB to examine doctors’ professionalism. Understanding the factors that influence doctors’ intentions to raise a patient safety issue, reflect on their practice, and use professional guidance is critical to improving patient safety [16].
Professionalism in this paper is defined as consisting of three professional behaviours: raising a patient safety concern, engaging in reflective practice, and using confidentiality guidance. Doctors have a professional duty to act if they have a concern about patient safety [17], to regularly reflect on their standards of practice, and to abide by guidance in confidentiality [18]. However, in real world practice, all three behaviours can be challenging to perform. For example, research has identified multiple barriers to speaking about patient safety concerns, such as organisational culture norms, power dynamics, and fears of damaging relationships [19,20,21,22,23]. Similarly, reflection is a complex construct which does not have a singular agreed definition and comes with its own challenges. The recent case of Dr. Bawa-Gaba, the trainee paediatrician convicted of medical negligence and removed from the UK medical register following the death of a child until winning an appeal, sparked much controversy regarding reflective practice [24]. This led to many doctors feeling they are no longer able to reflect honestly, openly and safely, due to fears of recrimination [25]. Confidentiality is fundamental to doctors’ professionalism and of great importance to patients [26, 27]; while research has shown that doctors’ attitudes to confidentiality guidance is generally positive, organisational norms and a lack of resources can mean confidentiality is unintentionally breached [28].
Consistent with the TPB, we hypothesize that doctors’ attitudes towards the behaviour, subjective norms, and their perceived behavioural control will predict intentions to engage in professional behaviours. It is, however, important to consider differences between groups of doctors. Healthcare provision relies on non-UK graduates (non-UKGs) [29] who account for a significant proportion of the National Health Service (NHS) workforce [30], but who are more likely to face fitness to practise investigation [31]. Studies show that UK and non-UKGs’ attitudes toward professional behaviours, as well as engagement in these behaviours, differ. Non-UKGs were more likely to have referred to GMC guidance over the past 12 months than UKGs (63% vs. 50%), while UKGs were more likely to state they had concerns for patient safety (17% of UKGs; 11% of International Medical Graduates (IMG); 15% European Economic Area (EEA)) [32]. Understanding what factors link to doctors’, especially non-UKGs’, engagement in professional behaviours will help to develop more appropriate interventions targeting this particular group of doctors.
Thus, the aim of this study is (i) to examine whether the TPB has utility for understanding doctors’ professional behaviour in three areas (raising concerns, engaging in reflective practice, and using confidentiality guidance); and (ii) whether there are differences between UK and non-UK graduates.