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Research report

Preventing smallproblems frombecoming bigproblems inhealth and care

Foreword 1

Acknowledgements 2

Executive summary 3

1 Broadening the discourse ofcompetence 4

1.1 Introduction 4

1.2 Evolution from education toregulation 4

1.3 Questions and critiques 6

1.4 An evolving discourse 7

1.5 Emerging discourses 8

1.6 Conclusions 14

1.7 References 14

2 Engagement anddisengagement in health andcare professionals 20

2.1 Introduction 20

2.2 Project aims 20

2.3 Method 20

2.4 Results 23

2.5 Interviews with registrants whohad been the subject of acomplaint 28

2.6 Analysis of patients, service usersand public focus groups 28

2.7 Analysis of health and careprofessionals focus groups 32

2.8 Factors that affect competency 34

2.9 Views on engagement 37

2.10 How to prevent small problemsfrom becoming big problems inhealth and care 39

2.11 Analysis of stakeholderinterviews 39

2.12 Discussion 44

2.13 Methodological limitations 45

2.14 Conclusions 45

2.15 References 46

Appendix 1 – Case reviewsummary 47

Appendix 2 – Topic guides forfocus groups and interviews 51

Appendix 3 – Raw data givingexamples of the reasons fordisengagement, competency driftand methods of prevention 52

Contents

I am delighted to welcome this monograph inour series on research relating to HCPCregulated professions. As with previous work inthe series, it reflects our commitment tobuilding the evidence base of regulation andbringing new thinking and empirical data to thefield of professional regulation.

Our aim is that this work, like others beforeand after it, will contribute not only to ourunderstanding on regulation, but also to awider audience with an interest in this area.Previous reports have been used to generatedebate and discussion and we hope that thisreport will provide another focus for honestconversations about professional practice.

The study of competence in health and careprofessionals has generated many hundreds ofresearch papers by academics andpractitioners from different disciplines. Perhapsthe only area of agreement amongst themodels and constructs is that competence,like professionalism, is challenging to define.Endeavours to try and capture it in a list ofknowledge, skills and attributes, to produce achecklist which covers all behaviours, are likelyto end in oversimplification. Competence, likeprofessionalism, is more than the sum of itsparts.

Alongside this debate, another importantconstruct, that of engagement, has begun totake hold. The evidence is increasinglysuggesting that failures in care are frequentlyassociated with low levels of staff engagement.The questions posed by practitioners andpolicymakers alike are: Why does this happen?What can be done? As a regulator, the HCPCis also aware that many complaints about theprofessionals we regulate have little to do withtheir technical competence, and much moreabout their conduct and communication.

It is in this context that the HCPC firstcommissioned research on professionalism.This monograph describes the next stage ofour work in this area where we have combined

an independent literature review with empiricalresearch. Both provide new insights into thetriggers of disengagement and the ways inwhich preventive action might beimplemented.

What is clear from this research is that we havea collective responsibility to address thecauses of disengagement. This must involveusers of services, employers, educators,professional bodies, regulators, as well asindividual professionals and teams. I hope thatthis publication will encourage debate andraise awareness, which will help to make adifference to the way health and care isdelivered in the future.

Anna van der Gaag CBEChair

Foreword

Preventing small problems from becoming big problems in health and care 1

Acknowledgements

This research report combines two pieces ofwork on competency and disengagement:

– a literature review by Professor ZubinAustin of the University of Toronto; and

– an empirical study of engagement anddisengagement by Carol Christensen-Moore and Joan Walsh at the PickerInstitute Europe.

The HCPC is grateful to Professor ZubinAustin, and Carol Christensen-Moore and JoanWalsh for their contributions to this initiative.We would also like to thank the patients,service users and professionals, unionrepresentatives, employers and professionalbody representatives, who contributed to thework carried out by the Picker Institute team.

Views expressed in this report are those of theauthors and not the HCPC.

Preventing small problems from becoming big problems in health and care2

This monograph is about engagement anddisengagement and its implications for ourunderstanding of the competence of healthand care professionals. It is the next stage inthe Health and Care Professions Council’s(HCPC) research on professionalism, exploringthe critical role that professionalism plays indelivering safe and effective care to serviceusers and patients.

The first section, from Professor Zubin Austinof the University of Toronto, provides a reviewof the literature, illustrating how competence inhealth and care has many meanings, as wellas many often competing frameworks. Theseinclude traditional frameworks based onknowledge, performance, psychometrics,reflection and outcome-based approaches, allof which have contributed to ourunderstanding of competence.

Austin demonstrates how newer, emergingconstructs around teamwork, emotionalintelligence and engagement may well bethose which enable health and care to shiftcloser to a model that is fit for purpose in thetwenty first century. Zubin suggests thatchecklist approaches may still be necessary,but are not sufficient as the complexity ofhealth and care increases and patients andservice users expect a different relationshipwith professionals.

The review also points to an importantmessage about staff engagement: where staffare engaged, patient and service useroutcomes are better and quality improves.

The second section describes a study ofengagement and disengagement by CarolChristensen-Moore and Joan Walsh at thePicker Institute Europe. This is comprised of aretrospective analysis of a sample of HCPCfitness to practise cases, and group andindividual interviews with service users,patients and professionals.

The study explored perceptions of the triggersfor disengagement in health and careprofessionals, and the ways in which smallproblems may be prevented from escalatinginto complaints in health and care settings.

Amongst participants in the study, there was aperception that it was possible for engagementto impact on competence, and for this to haveconsequences for practise. Disengagementoccurred on many levels, but was seenprimarily as a symptom of underlying issues.The character or personal values of aprofessional as well as a range of personalcircumstances could give rise todisengagement. However, poor levels ofsupport and supervision and workloadpressures were more frequently cited astriggers. Specifically, these included a lack ofsupport for continuing professionaldevelopment, situations where a professional’sskills were being under-utilised or where therewas a lack of autonomy and professionalisolation.

Identifying signs of disengagement early onwas possible in the right circumstances, forexample where a culture of no blame wasencouraged, where professional networkswere strong and where managers wereoffering appropriate support for staff.

Improvements in these external frameworks,together with support for internalisedprocesses such as self awareness andreflection on practise, were seen as key tobetter outcomes for patients, service usersand professionals.

Christensen-Moore and Walsh recommendfurther research into the barriers and enablersto reporting concerns. Like Austin, they pointto the need for better understanding of thecontext in which competency drift occurs andmore focus on preventive methods ofaddressing poor practise.


Executive summary

1 Broadening the discourseof competence

1.1 Introduction

The purpose of this report is to review relevantliterature related to competence in the contextof the health and care professions. Around theworld and in most professions, ‘competence’has become the most commonly used word todescribe the knowledge, skills and attributes ofprofessionals. In most cases however, the wordis used without further elaboration, with theassumption that everyone has the sameunderstanding of its meaning and application.Given the ubiquity of the word itself and thesometimes contradictory ways it has been usedin academic literature, it is essential that thoseusing the term have a clear understanding of itsmultiple meanings and significance.

1.2 Evolution from education toregulation

It is difficult to pinpoint a moment whencompetence became entrenched in theacademic literature, or in the thinking and workof regulators and educators. McGaghie et al(1978) and Carraccio et al (2002) have arguedthat the idea of competencies was a responseof educational institutions, to concernsregarding the perceived inability of graduatesfrom health and care professions to managereal-world problems and effectively deal with theneeds of real-world service users and patients.

Competence-based education was initiallydriven by the need for greater accountability intraining, the desire to demonstrate relevance tosocietal needs, and a desire to providelearners with reassurance that they actuallywere being well-prepared for a valuable role insociety (McAshan, 1979). As such,competence-based education directlychallenged the prevailing mid-twentieth centurystatus quo of higher education thatemphasised theory, knowledge-acquisition anda didacticism that presumed learnersthemselves could translate theory intopractice. This movement emerged within

medical education, but subsequently spreadthroughout other health and care professionssuch as psychology (Rubin et al, 2007) andsocial work (Anema and McCoy, 2010), andhad established itself in other professions suchas engineering (Dainty et al, 2005) and teachertraining (Houston, 1973).

As competence-based education became morecommonplace in the training programmes ofhealth and care professions, accreditation andregulatory bodies became more interested in thismodel. This further accelerated adoption ofcompetence-based education within academicsettings (Sullivan, 2011). In the context of publicconcerns about patient safety, disparities inaccess to care and the struggles of health andcare professionals with increasingly ambiguousand complex practices, competence-basedapproaches focusing on real-world performanceand doing rather than acquiring knowledge,aligned well with regulators’ needs around publicprotection, and their interests in demonstratingsocial responsibility and accountability in theirroles (Hodges and Lingard, 2012).

As dialogue around the notion of competenceevolved between educators, regulators andemployers, a key challenge emerged.Defining competencies as a series of real-world performance expectations and tasks,then using these as a foundation forcurriculum purposes (as educators did),requires a certain level of accuracy,impartiality and validation. Using thesecompetencies (as regulators wished to do) asthe foundation for entry-to-practiceassessment, maintenance-of-competencyevaluation or fitness-to-practice decisionsincreased the stakes considerably. The levelof definitional clarity, validity and defensibilityof what competence actually means andlooks like – the ‘psychometric burden’ – ishigher within a regulatory context, due to thehigh-stakes nature of decisions made byregulators that directly affect the generalpublic (Bleakley et al, 2011). The scrutiny



faced by proponents of competence-basededucation increased significantly as thedialogue shifted to high-stakes evaluationwithin regulatory and accreditation processes.Of importance, this shift towards higherstakes led to a new scrutiny around whatactivities should actually be measured andassessed. The need for defensibility andstandardisation, due to fear of litigation,resulted in greater emphasis on the moreobjective, technical and visible activities ofprofessionals, like physical assessment skillsand a hesitancy to assess subjective or lessvisible activities, such as conflict managementskills or empathy.

As interest in competence evolved fromteaching and learning to assessment andevaluation, it became increasingly clear that nosingle or simple definition of competence couldadequately capture the gestalt ofprofessionals’ work (Malone and Supri, 2010).As a result, the notion of ‘competencyframeworks’ emerged, as a tool for describingand defining the constellation ofinterdependent knowledge, skills, behaviours,values and attitudes necessary for effectivereal-world performance. Competenceframeworks typically eschew specific tasks oractivities, and instead conceptualiseperformance as an interlaced or overlappingseries of roles, each of which is necessary butby itself insufficient for effective real-worldperformance. One of the most widely cited,frequently emulated, and best known modelsis CanMEDS (Frank, 2005). CanMEDS wasone of the first national competencyframeworks developed for medicine, but isnow used in various countries such asAustralia, Canada and the Netherlands(Whitehead, 2013), and increasingly adaptedfor various health professions such as nursing,occupational therapy, pharmacy and physicaltherapy (Verma et al, 2006; Ringsted et al,2006).

CanMEDS Competency Framework (2005)

In the CanMEDS framework, expertise as ahealth or care professional is conceptualised atthe intersection of various other roles, such ascommunicator and collaborator. Role-specificcompetencies are further described, but donot form the actual substance of theframework, in an effort to move away from areductionist, task-centred view of competence.This holistic, integrative, role-centred viewprovides both conceptual clarity and enhancedface validity and has, as a result, become anincreasingly dominant mode for presentingcompetency frameworks across other sectors(Frank, 2005; Whitehead et al, 2011).

In the UK, individual health and careprofessional bodies, including physiotherapists(Chartered Society of Physiotherapy),occupational therapists (Winchcombe andBallinger, 2005) and mental healthprofessionals (Roth et al, 2011), haveproduced bespoke competency frameworks.

Competency frameworks have now becomethe dominant vehicle by which educators,regulators, employers and others communicateperformance expectations with professionals,the public and other stakeholders (Whitehead,2013; Simpson et al, 2002). In distilling complexand nuanced aspects of professional practiceinto visual forms or rubrics, they provide a

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1 Broadening the discourse of competence


common starting point for understanding anddiscussing expectations and requirements ofhealth and care professionals in practice.

1.3 Questions and critiques

Competence frameworks now underpin healthand care professions training, education andregulation in many countries (Simpson et al,2002), leading to greater scrutiny of theirdevelopment and implementation. There are ofcourse positive and productive elements inthese initiatives, around achieving consistencyand transparency in different contexts.However, some have argued that thisapproach is a ‘striving for mediocrity’ (Brawer,2009) that arises when we ‘focus our attentionon minimum requirements only’, ascompetency frameworks tend to do (Bleakleyet al, 2010). When dealing with complex,ambiguous professional work, the whole isgreater than the sum of the parts (Andersonand van der Gaag, 2005). Slavish adherenceto competence as a guiding principle ofteaching and assessment risks atomisingprofessional work, overemphasising routineskills and inculcating a teaching-to-the-testmentality (Huddle and Heudebert, 2007;Malone and Supri, 2010). Frank et al (2010)note that formulaic competency frameworks or‘prescriptions’, may produce a form ofreductionism and utilitarianism, with anemphasis on the lowest-common-denominator, rather than an aspirational visionof professionals, to their best potential, servingthe public good – ‘professionalism’.

Curiously absent from much of thecompetency literature is discussion ofprofessionalism, reflective practice andwillingness to ‘go-the-extra-mile’ for patientsand service users (Lingard, 2009). Anemerging theme in the competency literature,this notion of ‘going the extra mile’, is well-understood by patients, service users andemployers as an important component ofhealth and care professionals’ work. Mann etal (2009) and McGivern and Fischer (2012)

note that health and care professionals’responses to competency frameworks maytend towards reactive compliance. In complexsituations, instead of asking “what does theservice user or patient need me to do?” theymay ask “what am I minimally required to do?”

This inherent tension between ‘prescription’ and‘professionalism’ is perhaps best illustratedthrough the recent experience in the UK. TheFrancis Report (2013) made 290recommendations in response to the systemicfailures at the Mid Staffordshire NHS FoundationTrust, to legally enforce duties of openness,transparency and candour in the NHS. Theserecommendations in turn prompted criticismfrom some academics around the UK. Fischerand Ferlie (2013) argue that “…rules to enforceopenness, transparency and candour amongNHS staff can create an impetus for change, butincreasing micro-regulation of clinicians andmanagers is likely to undermine, rather thansupport high-quality patient care”. They furthernote: “…we are seeing a shift from micro-management to micro-regulation…what isneeded instead is reanimation of the [health andcare] professions…micro-regulation is not goingto bring about [the] culture change needed”.

This tension is also recognised in the Francisrecommendations themselves. “1.75: Thecurrent structure of standards, laid down inregulation, interpreted by categorisation anddevelopment in guidance, and measured bythe judgement of a regulator, is clearly animprovement on what has gone before, but itrequires improvement”.

This finding was further reinforced through theReview of Staff Engagement and Empowermentin the NHS Report (Ham, 2014). The reviewfound evidence connecting high levels of staffengagement, from professionals who arestrongly committed to their work and involved inday-to-day decision making, to better qualitycare and outcomes, including lower mortalityrates, better patient experience and reduced staffabsence and turnover. Importantly, the Report




also connected low levels of staff engagementwith the type of failures demonstrated at the MidStaffordshire NHS Foundation Trust. The Reportcalled for all NHS organisations to prioritise staffengagement, not just competency frameworks,as a vehicle for improving delivery of safe,effective and competent care.

Historically, competence has been understoodas a technical function of a profession, well-aligned to assessment through analyticalchecklists based on in-service performance(Witz, 1992). The mechanism by whichcompetency frameworks and standards haveevolved has been to reduce complexprofessional work to a checklist, then to definecompetencies simply because they are alreadycodified on a checklist, then to test on these atexaminations. Of significance is the notion thatactivities or behaviours that do not lendthemselves to checklists or yes / noobservations do not consequently becomedefined as competencies (Rogers et al, 2005).This has been illustrated recently in the UK bythe Compassion in Practice campaign: a“…new vision for nurses, midwives and care-staff in England” (Department of Health, 2012).The very need to actually define ‘compassionin practice’ and to produce guidance around‘6Cs’ (six areas of action, with accompanyingimplementation plans), points to limitationsinherent in the way in which the discourse ofcompetence has evolved. Words such as‘care’ and ‘compassion’ do not necessarilylend themselves to measurement throughchecklists, and consequently are not easilyincorporated into competency frameworks astraditionally developed.

It is difficult to argue against the notion ofcompetence underpinning our understanding ofsafe and effective practice in health and careprofessions. Competence by itself may be anecessary but insufficient construct to helpshape safe and effective practices. New ways ofseeing and understanding competence areevolving to address this gap.

1.4 An evolving discourse

The term ‘discourse’ has been used todescribe the implicit meanings behind thewords we use, and how these meanings shapeour thoughts and ideas. Hodges (2009) hasdescribed five dominant discourses that haveemerged over time in the health and careprofessions literature related to ‘competence’.

1. Knowledge discourse:Competence is a function of ability torecall facts and basic scientific knowledge.From this perspective, competence isassessed using multiple choice tests orother methods that emphasisememorisation and rote reproduction ofknowledge. As Miller (1990) has noted,this leads to book-smart professionalswho lack interpersonal skills and thepropensity to care is another issue.

2. Performance discourse:Competence is a function of the ability toactually behave or perform in a prescribedmanner in a specified situation. From thisperspective, competence is assessedusing objective structured clinicalexaminations or other in-practiceobservations. We are less concerned withwhat people know and more interested inwhat they do; Norman et al (1996) havenoted that this may lead to mindlessreproduction of practices rather thandeliberative and well-reasoned care. Itmay also lead to an inability to actuallyperform effectively in non-standardised orambiguous situations.

3. Psychometric discourse:Competence is a function of the ability todemonstrate attainment of pro-formastandards and expectations in astatistically defensible manner. From thisperspective, competence is assessedthrough sampling with the objective ofreducing variance and ensuring reliability,validity, generalisability and defensibility

of the assessment. Schuwirth and vander Vleuten (2006) have noted that thisdrive for standardisation negates theactual essence of human-focused care.

4. Reflection discourse:Competence is a function of mindfulnessand self-assessment in practice. From thisperspective, intelligent and well-intentionedindividuals provided with an environmentto safely reflect and self-improve willenhance their own practice. Nelson andPurkis (2004) have noted that anoveremphasis on reflection may result intechnical incompetence being overlooked.

5. Production discourse:As health systems have become morecomplex, filled with ‘cases to bemanaged’ rather than ‘people to becared for’, the imperative of operationalefficiency has grown. There is a strongemphasis on monitoring and a culture ofsurveillance in the name of outcomemeasurement. Questions regarding theobjective of efficiency at the potentialexpense of empathic care are challengesto the production discourse.

Over the past 30 years, these dominantdiscourses have produced a variety of rules,checklists, algorithms and guidelines that aremeant to hold health and care professionalsaccountable to a clear, objective, minimalstandard of practice. To Whitehead (2013),answering the question of ‘accountability’ byproducing checklists and competenceframeworks not only does not address theproblem itself, it paradoxically distorts theessence of professionalism by only promotingminimal expectations. This finding has beenechoed by Fischer and Ferlie (2013):“increasing micro-regulation across the NHS islikely to aggravate tensions between externallyfocused regulation, oriented towardstransparency, accountability and externalscrutiny, and locally important values of

delivering high-quality care. Paradoxically, theFrancis recommendations extend regulation stillfurther as a dominant idea, which is misguided.”

No single existing competence discourseadequately captures the nuanced complexityof contemporary health and care professionals’work. Recognising that each discourse bringswith it a series of assumptions (and in additionblocks or crowds out other assumptions)means that no single discourse by itself trulycaptures the full essence of ‘competence’.

1.5 Emerging discourses

The current system of health and careprofessionals’ education and regulation hasbeen built upon competing and evolvingdiscourses of competence. For some, thisrepresents the triumph of the Productiondiscourse: large, chaotic, complex healthsystems, catering to multiple needs andemploying hundreds of thousands ofindividuals, need systems to ensure theyactually function. Competence discourses thatemphasise processes, utilise checklists, andrely upon centralised leadership andhierarchies, provide a comforting andrecognisable structure that appears business-like and efficient (Mylopoulos, 2013).

A significant critique of existing competencediscourses has emerged. After decades ofwork, and billions of pounds spent developingcompetence frameworks, why do large systemfailures such as Mid Staffordshire still occur?Does this suggest a problem with‘competence’ itself as a safeguardingconcept? How could the Mid Staffordshiretragedy, among others, have occurred giventhe complex, interwoven web of local, nationaland profession-specific competenceframeworks that have existed for many years?Failure on this scale and at that level raisesquestions about the adequacy and sufficiencyof existing frameworks for public protection. AsFrancis himself noted in Patients First andForemost: The initial government response to





the report of the Mid Staffordshire NHSFoundation Trust Public Inquiry (2013), “[t]hesystem as a whole failed in its most essentialduty”, including the existing system ofcompetence frameworks as a safeguardagainst harm.

In this spirit, several scholars have begun topoint out the limits of existing competencydiscourses and have suggested complementarydiscourses of competence to broadenunderstanding of the term itself.

1.5.1 Competence as aninter-relational / collective construct

Care today is provided by teams. Patients witha sore elbow are referred to radiographers;biomedical scientists take blood samples;pharmacists provide medication;physiotherapists and occupational therapistsrestore function etc. The reality of inter-professional care delivery poses centralchallenges to the uni-professional and highlyindividualistic construct of competence ascurrently understood. As Lingard et al (2007)note, teamwork is mostly learned throughsocialisation (eg observation and experience).Below Lingard (2012) notes these realitiesproduce important paradoxes, particularlysince competence is generally seen as aquality or capacity an individual possesses ordoes not possess.

a. Competent individuals can cometogether and still form an incompetentteam.

b. Individuals who perform competently inone team may not in another team.

c. One incompetent member functionallyimpairs some teams but not others.

Lingard suggests these three paradoxes pointto the limitation of current discourses ofcompetence. Real world experience of healthcare today suggests that competence is morethan simply a quality that individuals acquire

and possess, free from context or location.High-profile examples of organisational andinstitutional failures suggest competentpractitioners who find themselves infloundering systems are not as self-containedas the current discourse pre-supposes.Lingard (2012) suggests a collectivistdiscourse to competence must evolve, onepremised on the following notions.

a. Competence is achieved throughparticipation in authentic, real-worldsituations, not contrived academicsettings.

b. It is distributed across a broad networkof persons and artefacts.

c. It is a constantly evolving set of multiple,interconnected behaviours enacted overtime.

Lingard’s work examining the nuancedinterpersonal interactions amongst operatingtheatre staff and surgeons points to the notionof the whole being greater than the sum of theparts. Building on the work of Salas et al(2007) in ‘team cognition’, this collectivist viewof competence emerges at a time when healthis increasingly recognised as a network, not adyadic relationship between a singleprofessional and a patient. Drawing upon theexperience of other industries, notably aviation,the idea of collective competency, whichincludes not only practitioners but theorganisational context within which theypractice, requires alternative methods ofunderstanding and assessment.

Critics of this approach note the logisticaldifficulty of developing and implementingteam-competency assessment models.However, as Lurie et al (2009) have noted, thiscriticism presumes that current competenceassessment systems are indeed robust andactually do what they purport to do well, whenin fact, with the exception of the medicalknowledge domain, few competence


assessment tools are actually simultaneouslyreliable, valid, generalisable and feasible.

Broadening the discourse of competence torecognise the centrality of collaboration,interdependence and teamwork in today’shealth system is necessary. Many systemproblems and errors characterised as‘communication failures’ are not the result ofsubstandard or incompetent communicationskills. Instead they reflect failures to recognisethat teams are the true unit of care delivery inmost systems today and further work isnecessary to articulate and constructdiscourses that recognise this reality. AsBerwick observed, “[h]ealth and careprofessionals… want to offer safe care: inspite of that, patients get injured because ofdefects in the care system. Blame andaccusations are not the answers. Teamworkand improvement are the answers.Commercial air travel did not get safer byexhorting pilots to please not crash. It gotsafer by designing planes and air travelsystems that support everyone to succeed ina very, very complex environment. We can dothat in healthcare too.” (Berwick, 2013).

1.5.2 Competence as an emotionalconstruct

McNaughton and LeBlanc (2012) note that,“…within the health professions, emotion sitsuneasily at the intersection between objectivescientific fact and subjective humanistic value”.From early on health and care professionalsare taught and encouraged to separate theirprofessional and personal selves, theimplication being that human emotions cloudjudgement and professional effectiveness.Increasingly, there is recognition that thistraditional approach may be counterproductiveto the objective of safe and effective healthcare delivery.

Williams (2001) has noted the long-heldambivalence towards emotion within the healthprofessions education literature. He notes that

emotion is traditionally viewed as ‘theopposite’ of reason, and consequently seen asuncontrollable and something that needs to betranscended. Increasingly, psychologists havegrown to understand that emotion and reasonare not isolated processes but interconnecteddualities: without emotion, there cannot bereason and vice-versa. Kensinger (2009) hasnoted that emotion plays a critical role inmemory function: the emotional contextfundamentally shapes the way in whichmemory is formed and recalled. Raghunathanand Pham (1999) argue that emotion has aformidable influence in decision making.Phelps (2006) and Damasio (1994) note thatemotion can influence a wide range ofcognitive functions, including perception,attention, memory and decision making.

Competence as an emotional construct hasbeen popularised through the work of Goleman(1996). His model combines skills, abilities andpersonality traits, and formulates a commandfunction of ‘emotional management’. Theliterature applying emotional intelligence (EI) tohealth and care professions education is broadand extensive. EI principles are now utilised inadmissions interviewing (Libbrecht et al, 2014;Humphrey-Murto et al, 2014), clinical skillsassessment (Stratton et al, 2005; Cherry et al,2013; Romanelli et al, 2006) and clinicalteaching (Allen et al, 2012) in health and careprofessions such as nursing, physiotherapy,speech and language therapy, pharmacy,medicine, midwifery and psychology.

A consensus from this literature is emerging,that empathy is the core of health and careprofessional practice, significantly challenginghistorical assumptions of the centrality oftechnical or cognitive skills (McNaughton andLeblanc, 2012). From this perspective,discourses of competence that focus on thetechnical or cognitive domains actually missthe mark. Superior technical and cognitiveskills with limited empathy and emotionalintelligence give rise to poor care (McNaughton




and Leblanc, 2012). This insight reinforces thework of McGivern and Fischer (2012) who notethat “…rules-based regulation tends to erodevalues-based self-regulation, producingprofessional defensiveness and contradictionswhich undermine, rather than support, goodpatient care”.

Human factors in patient safety are currently ofsignificant research interest. There is a criticalneed to understand the distinction between‘knowing’ and actually ‘wanting to do’ the rightthing in a complex environment, particularlywhen doing the right thing requires the healthor care professional to go beyond what mightbe normally expected or to overcome a systembarrier (Feldman, 2001).

This link between competence and emotionalintelligence has been underdeveloped, in partdue to the psychometric emphasis of much ofthe contemporary competence literature. EIresists reduction in the form of a checklist thathas historically been the approach taken incompetency-based systems (Carrothers et al,2000). Framing competence as a form ofemotional intelligence or ‘emotional regulation’(Phelps, 2006) is challenging due to thedifficulties associated in measuring it usingstandard statistical tests such as reliability,validity or generalisability.

How can recent insights into emotionalintelligence be integrated into a broadeneddiscourse of competence? At a psychometriclevel, increased reliance on global or holisticforms of assessment may be one alternative.Conceptualising competence as a gestalt,rather than as a checklist aligns with the notionthat emotion and reason are as indivisible as adancer and a dance: change one and out ofnecessity the other changes. Current attemptsto translate competence discourses intoassessment tools suffer from an overly-rationalist bias, the belief being thatmeasurement is quantitative, behaviour isobservable and performance can be

subdivided into constituent components.Competence discourses that emphasiseemotional intelligence at the core would resistthese biases and instead examine ways inwhich the link between emotion and reason,clinical decision making and empathy, andprofessionalism and ethics are more explicitlyacknowledged.

1.5.3 Competence as a psychologicalengagement construct

The work of Csikszentmihalyi (1990) andGardner et al (2001) with respect to thepsychology of positive experience provides aunique insight into the connection betweenmotivation and performance. This modelsuggests that human beings are at their bestwhen environmental challenges andopportunities align with personal skills andinterests. Csikszentmihalyi (1990) coined theterm ‘flow’ to describe a state of absorption inan activity: “…your whole being is involved andyou’re using your skills to the utmost”.

Csikzentmihalyi’s description of flow echoes thework of Schon (1983), who coined the term‘reflective practitioner’ to describe the uniquefeature of professional work: cognitive ambiguity.If professional practice were straightforward andformulaic, it would easily be performed bymachines. What makes professional workunique, and valuable to society, is that decisionsmust be made when information is imperfectand answers are not clear. At these times,professionals must demonstrate a psychologicalflexibility that allows them to recognise there maynot actually be a right answer, only so-calledleast worst alternatives.

The work of Schon and Csikzentmihalyi raisesimportant issues regarding the role ofmotivation in human behaviour. Simply becauseindividuals can do something does notnecessarily mean that, in a given circumstance,they will do it, especially when barriers includinginertia, complexity, organisational culture ortime constraints exist. The psychological


energy necessary to transcend routine,bureaucracy, standard operating procedures orany other form of resistance, requires ‘flow’(Csikzentmihalyi, 1990).

There has been increasing interest in the notionthat competency frameworks may actually beantagonistic towards ‘flow’ and thepsychological / motivational needs of healthand care professionals. As Bereiter andScardamalia (1993) note in SurpassingOurselves, rules-based systems, includingchecklists and competency frameworks,generally do not create the type ofenvironment, or produce the psychologicalinterest and energy, required by most people touse their skills and knowledge to their fullestabilities.

The work of McGivern and Fischer (2012) andFischer and Ferlie (2013) have illustrated howrules-based regulation of health and careprofessionals erodes values-based self-regulation. They have raised concerns that anyattempt to regulate or prescribe the work ofprofessionals will compromise motivation andengagement, fundamentally changing thenature of professional work.

The need to create a psychologically engagedworkforce has been identified by experts in theUK. Proposals for staff-led health and careservices, with devolved decision-making havebeen described as a vehicle that will improvepatient care. West et al (2012) have argued thatdevelopment of engaged, collective leadershipfor health care is critical: individuals mustassume responsibility for the success of theirorganisation, not just their own jobs. Campling(2013) presents the notion of intelligentkindness: behaviours not found in any jobdescription, specification or competencyframework, but ones that actually “…capturethe essence of kind practice”. This kindpractice, she argues, builds a virtuous circleproducing better outcomes which “…could beuseful in our quest following the Francis Inquiryto transform the culture of healthcare”.

This emphasis on cultural transformation isechoed by West and Dawson (2012) who notethat “[i]t has long been recognised thatengagement of employees with their work andorganisation is a factor in their jobperformance.” In their report EmployeeEngagement and NHS Performance, theyconclude that staff engagement “…is linked toa variety of individual and organisationaloutcome measures, including staffabsenteeism and turnover, patient satisfactionand mortality, and safety measures, includinginfection rates”.

Traditional competence frameworks havefocused on development of individuals’capabilities, which does not necessarily translateinto organisational advancement. As describedin the Review of Staff Engagement andEmpowerment in the NHS (Ham, 2014), suchshifts in culture and organisational administrationproduce the type of psychological engagementnecessary to unleash health and care providers’potential. In their White Paper Delivering aCollective Leadership Strategy for Health Care(2014), Eckert et al highlight the connectionbetween devolved decision making, staffengagement, morale and ultimately improvedhealth care outcomes. Literature on theconnection between staff engagement andoutcomes in the health and care professions isemerging. Prins et al (2010), in a study in theNetherlands, noted that physicians who scoredhigher on professional engagement werestatistically significantly less likely to makemedical, diagnostic or prescribing errors. A largestudy involving over 8,000 hospital nurses byLaschinger and Leiter (2006) noted that thosewho ranked higher in terms of professional andorganisational engagement had better patientsafety outcomes. Boorman (2009), in the NHSStaff Health and Well-Being Report, noted thatstaff absenteeism cost the system over 1.75billion pounds (equating to the loss of 45,000 fulltime staff positions) annually, and thatabsenteeism itself is linked strongly withengagement scores.




Berwick (2013) has emphasised “[t]heworkforce is not the problem…they want tooffer safe care. Good people get trapped intobad systems. [Safety] is not aboutenforcement; it’s about involvement”. As notedby Eckert et al (2014), disengagedprofessionals are disinclined from ‘going theextra mile’ and instead are more likely to doonly that which is minimally required.

Can one be simultaneously competent anddisengaged? Austin et al (2003) have notedthat pharmacists in Ontario, Canada at highestrisk of not meeting competence standards:

– graduated from educational programmesmore than 25 years ago;

– work in sole practitioner arrangements;and

– received their professional educationtraining outside North America.

Austin argues that these risk factors aregeneral symptoms of isolation and professionaldisconnection. Grace et al (2014) identifiedpredictors of physician performance oncompetence assessment and noted similarpersonal characteristics and practice contextfeatures, suggesting professional isolation is arisk factor for competence drift. Wenghofer etal (2014) note that attendance at, andparticipation in, continuing professionaldevelopment activities may serve aninoculating function for those who are at risk ofcompetence drift. Engagement with one’speers and involvement with one’s professionalcommunity provides peer-benchmarkingopportunities that may relate to competency.This literature suggests a connection betweendisengagement and competence drift.

As noted by West et al (2012) “...the morepositive the experiences of staff within an NHStrust, the better the outcomes for thattrust… the more engaged staff members are,the better the outcomes for patients and theorganisation generally”. The language of

engagement has only recently been included indiscussions related to competence, and hasnot yet been incorporated within mostcompetency frameworks. As this discoursematures and evolves, this perspective willcontinue to grow in importance.

1.5.4 Competence as a culturalconstruct

Competence problems are identified in only avery small number of professionals within anycohort (HCPC Fitness to Practise AnnualReport 2012, 2013). In these cases, includingthe system failures at Mid Staffordshire,organisational culture has been identified as animportant potential cause (Francis, 2013). Nomatter how competent each individualpractitioner may be in the practice of his / herprofession, s / he may simply be unable topractise at an optimal level due todysfunctional or suboptimal leadership, linemanagement, supervision or organisationalculture.

As noted by Dixon-Woods et al (2013), withinthe UK NHS there is “…an almost universaldesire to provide the best quality care…”, but“…consistent achievement of high quality carewas challenged by unclear goals, overlappingpriorities that distracted attention and acompliance-oriented bureaucratisedmanagement… [g]ood staff support andmanagement were also highly variable, thoughthey were fundamental to culture and weredirectly related to patient experience, safety,and quality of care.” This raises the question ofwhether the current model of assuringcompetence of each individual health and careprofessional’s competence is adequate andsufficient, or whether a new construct, such asorganisational culture competence, should bedeveloped. A consistent theme from Francis(2013), to Berwick (2013) and Ham (2014) hasbeen the need for culture change in the NHSto prevent future tragedies.


While calls for strategic culture change within theNHS are ubiquitous, specific tactics continue tobe elusive. For example, the National AdvisoryGroup on the Safety of Patients in England, in APromise To Learn – A Commitment to Act (2013)noted that “[w]hen responsibility is diffused, it isnot clearly owned; with too many in charge, noone is”. Simultaneously they call for moreinvolvement to “engage, empower and hearpatients” and “foster whole-heartedly the growthand development of all staff”. The authors ofPatient Centred Leadership: Rediscovering ourPurpose (2014) state: “[i]t is time for the NHS torediscover its purpose” and propose a model ofshared leadership and bottom-up collaborativedecision making focused on patients, which mayproduce conditions of diffused responsibility.Storey and Holti (2013) in Towards a New Modelof Leadership for the NHS describe elementssuch as motivating teams and individuals,creating a positive emotional tone / climate andencouraging staff involvement and engagement,as the most effective evidence-informed tools fororganisational cultural change.

Further research is ongoing to try to betterunderstand what specific tactics to producecultural change within organisations canactually support meaningful improvement.

1.6 Conclusions

Traditional constructs of competence haveemphasised an individual health or careprofessional’s technical and cognitive skill set.As described in this synthesis, this may be anecessary but insufficient way of thinkingabout competence.

Emerging notions of teamwork, emotionalintelligence and engagement representimportant steps in broadening the discourse ofcompetence. The idea that organisational cultureinfluences an individual professional’s ability todemonstrate competence raises importantchallenges and questions. The traditionalchecklist approach to defining and measuringknowledge and skills, while necessary, may not

be sufficient as the complexity of health and careand service delivery increases. Broadening ourunderstanding of competency and recognisingthe limitations of traditional approaches areimportant first steps in ensuring the best, mosteffective health and care possible.

Currently, there is little evidence but somediscussion regarding the issue of competencedrift and the mechanisms by which an individualpractitioner’s knowledge, skills, and attitudesmay deteriorate over time. In particular, andbuilding upon the notion of engagement or ‘flow’,there is interest in further examining whether it ispossible to identify individuals at higher risk ofcompetency drift earlier, and to provide morefocused support and / or remediation in anattempt to prevent larger performance basedproblems from arising. This model of targetedinterventions to address competency drift, beforeit translates into a practice-based issue, raisesimportant potential roles and responsibilities foreducators, regulators and employers. Furtherresearch, however, is required to establish theseconnections and to identify what, if any,interventions may be most useful in this context.

1.7 References

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2 Engagement and disengagement inhealth and care professionals

2.1 Introduction

The Health and Care Professions Council(HCPC) has begun exploring how and whyhealth and care professionals becomedisengaged in their place of work. A range ofbehaviours and circumstances commonlyassociated with disengagement can give rise toconcerns about practise and can lead tocomplaints. In spring 2014, Picker InstituteEurope were commissioned to undertakeresearch into this area, following on from a wideranging review of existing literature by ProfessorZubin Austin at the University of Toronto.

The Austin review provides an analysis of therelationship between competency anddisengagement in a health and care context.Disengagement, it is suggested, can emergefrom a complex interplay between internal andexternal factors. Internally, there are elementssuch as motivation, beliefs and values whichshape the way in which people engage. Thereare also structural, cultural and managementinputs into engagement, which can havesignificant impact, often over long periods oftime.

The study reported is a first step in furthering theHCPC’s evidence base in this area and tocontribute to the ongoing debate about theorigins of complaints and how more can be doneto prevent them from arising in the first place.

2.2 Project aims

The project was designed to begin to exploreideas with registrants, employers, stakeholdersand members of the public, including:

– perceived causes or triggers fordisengagement amongst health and careprofessionals;

– views on to what degree disengagementaffects competency;

– understanding of the competency andaccountability frameworks professionals

hold themselves to, and how applicablethey are to ‘everyday realities’;

– what interventions, if any, might preventhealth and care professionals from beingdisengaged; and

– for those involved in fitness to practiseproceedings, whether they are able toretrospectively identify when and whydisengagement occurred.

2.3 Method

2.3.1 Background and development

The development stage included an overviewof the reports such as the HealthFoundation’s ‘Asymmetry of Influence’ (Biltonand Cayton, 2013) thought paper andAustin’s ‘Continuing the competency debate:reflections on definitions and discourses’(Whitehead, Austin and Hodges, 2011). Thispreparatory work provided crucial context forthe development of the project, particularlytopic guides for both the focus groups andthe individual interviews, which are includedin the appendices.

2.3.2 Gathering information from fitnessto practise case histories – review ofcase notes and interviews

The initial stage of the research was a reviewof fitness to practise case notes. The samplewas drawn from HCPC cases that hadconcluded at final hearing in 2012, 2013 or2014. Cases were selected against criteriarelating to issues of competence andcommunication, ensuring a mix of professionswere covered.

A total of 27 cases were reviewed. Each casewas analysed in depth, and themes wereidentified. The analysis of the cases wereguided by the definitions of engagement fromWest and Dawson (2012) and Boxall et al(2011).



2.3.3 Views from members of the public– focus groups

Three focus groups were held in September2014, two in Leeds and one in London. Twofocus groups were made up of the generalpublic and one comprised people consideredas patients or service users (ie had recentexperience of health or care services). Patientsand service users were included to ensure thatthe project consulted individuals who hadsome experience and understanding of healthand care professionals regulated by the HCPC,and of their roles and responsibilities.

Pre-conditions for engagement (‘Black Box’model) (Boxall, Ang and Bartrum, 2011)

– State of engagement = involvement inone’s work + commitment and positiveattitudes to one’s engagement

– Behaviours = making discretionaryeffort + personal initiative or proactivity+ pro-social behaviour in organisation+ advocacy in favour of organisation

– Intermediate outputs = better staffhealth and lower absence + higher jobsatisfaction / lower turnover + moreefficient use of resources + higherlevels of innovation

– Overall performance = highercustomer satisfaction + higherprofitability + greater resilience + fastergrowth

Engagement: staff involvement in decision-making, or more generally, the openness ofcommunication channels betweenmanagement and staff in organisations(West and Dawson, 2012).

Engagement comprises:

– psychological state (involvement,commitment, attachment or mood);

– performance construct (effort orobservable behaviour); and

– disposition (positive affect).

Engagement is characterised / evidencedby:

– psychological engagement (a positiveand fulfilling work-related state ofmind);

– proactivity;

– enthusiasm and initiative;

– organisational citizenship-behavioursand organisational commitment;

– involvement in decision-making; and

– positive representation of theorganisation to outsiders.

2 Engagement and disengagement in health and care professionals

Table 1 – Service user, patient and public focus groups

Group Location Participants

Members of the public Leeds 9

Members of the public Leeds 9

Service user and patient group London 8

Total 26


The patient and public focus group topic guideis included as Appendix 2.

Participants were recruited using the services of aprofessional recruiter andwere screened to ensurea good demographicmix. Employees of health orcare providers were excluded as participants, even ifnot HCPC registrants. All participants were askedfor their consent to the digital recording of the focusgroups. Participants were assured that what theysaid would be treated as confidential and that anyquotes would be anonymisedwithin this report.Participants were offered a small cash incentive tocompensate for their time and travel expenses.

2.3.4 Views from registrants – focusgroups

Five focus groups were held with HCPCregistered professionals, two in Leeds and three inLondon. A topic guide was developed for thisdiscussion and is included as Appendix 2. It wasdesigned to assess:

– what personal frameworks of competenceand accountability they use to ensure theyare delivering ‘excellent’ care;

– how formal competency frameworksresonate in everyday delivery of care;

– understanding of ‘competency drift’ andengagement;

– to what extent they believe engagement

can affect competency; and

– what, if anything, can employers or theHCPC do to assist them in ‘feelingengaged’ at work?

Participants were recruited through an email sentby the HCPC to a sample of registrants within thegeographic area. All participants were asked fortheir consent to the digital recording of the focusgroups and were assured that what they saidwould be treated as confidential and that anyquotes would be anonymised within this report.Participants were offered a small cash incentive tocompensate for their time and travel expenses.

2.3.5 Views from stakeholders

26 interviews with stakeholders, which includedprofessional bodies, union representatives andemployers (NHS and local authorities) wereconducted. Stakeholder’s experience in fitness topractise proceedings were drawn upon tounderstand their views on disengagement issues.Interview participants were identified by the HCPCand from within Picker Institute Europe’s network.There was a considered effort to haverepresentation from diverse professions, roles andresponsibilities, as well as geography. Allparticipants were asked for their consent to thedigital recording of their interview. Participantswere assured that what they said would betreated as confidential and that quotes would beanonymised within this report.


Group Location Participants

Mixed professionals Leeds 6

Mixed professionals Leeds 3

Mixed professionals London 5



Total 20

Table 2 – HCPC registered professionals groups



Table 3: Stakeholder interviewees byprofile

2.4 Results

2.4.1 Case note review

A number of themes emerged from the analysisof the 27 cases. The documents reviewedincluded final decision bundles, a summarydecision form and the evidence contained inregistrant bundles. It is worth noting the contextwithin which the registrants were responding,which has a bearing on the evidence within theregistrant bundle. Registrants were defendingthemselves against an allegation and as such,the evidence presented tended to be set out inorder to show themselves in the best possiblelight. The review took the form of a qualitativeanalysis and, due to the small sample size,statistics have not been reported.

2.4.2 Dissonance between theindividual and the organisation

There was often a conflict betweenorganisational cultures and individualperceptions of professional codes of practice.Registrants in otherwise compatible culturesreported becoming vulnerable when they feltthey were being asked to agree to compromiseon standards. For example, where a departmentwas under pressure and registrants wereimplicitly or explicitly expected to deviate frompolicies and protocols to maintain output.

Differences appeared to arise from long-standing formal and less-formal working

arrangements between teams, professionsand services, which led to unintendedconsequences. These were typically complexcases. In some, the unintended consequencesappeared to flow from registrants’ decisionsand behaviours. For example, the choice oflanguage used with a patient or service user,or excessive use of short forms in clinicalnotes. In others, there were other, arguablymore influential factors that were entirelybeyond the registrants’ control such asworkload pressures or meeting targets.

The case review pointed to a tension betweenprofessionals’ attitudes and behaviours thatexpressed a desire to ‘keep the show on theroad’ and the decisions and behaviours thatprotect an individual’s registration. That is tosay, registrants reported feeling that in order toachieve organisational objectives and goodservice user care, they were required to adoptbehaviours and approaches which called theirfitness to practise into question.

There was one case in which the registrantcited a poor employee-employer relationship inmitigation for misconduct. The registrant’sresponse described the employingorganisation, its culture, the registrant’smanager, remuneration and terms andconditions of employment very negatively. Inmany cases however, it was difficult to definein any precise way the differences betweenregistrants’ commitment to, and attitudetowards, their employing organisations beforethe event(s) that had brought their fitness topractise into question and later on in thenarrative. Some had clearly not had positiverelationships with their supervisors ormanagers but, taken together, the casesreviewed do not suggest that registrants hadovertly withdrawn from their organisations,before or at the time of the alleged event.

The case review suggests that someregistrants’ engagement with their organisationwas subsequently affected by the way in which

Interviewee profile Number

Professional body representative 20

Local Authority employer 2

NHS employer 3

Union representative 1

Total 26

competence and conduct were investigated bymanagers, employing organisations and theHCPC, and by registrants’ expectations andexperience of being fairly treated andsupported. Some registrants were apparentlyso angered, distressed or disillusioned thatthey disengaged from their profession andemployer completely, by resigning andrequesting voluntary deregistration, andasserting that they never again intended towork in that profession. For one registrant, theprocess seemed a foregone conclusion anddecided they would not respond to theallegation, where another had self-referred forvoluntary removal.

It is however not possible, from these casenotes, to determine whether disengagementby these registrants resulted only from theirexperiences of disciplinary, competence and /or fitness to practise processes. It is possiblethat the investigations were in effect the ‘finalstraw’, rather than the only precipitating factor.Some registrants’ decisions to ‘walk away’may have reflected long-standing, thoughunexpressed, disengagement.

2.4.3 Competence and capability innewly appointed professionals

In West and Dawson’s model of a highlyengaged organisation, the pre-conditions forengagement include the conditions that peopleneed from their roles, teams and managers.These are:

– a sense that work is meaningful andvalued;

– challenges, stimulation and opportunitiesto learn and grow;

– authority, autonomy and influence overenvironment;

– manageable workloads and access toresources;

– clear objectives and well-structuredappraisals;

– effective communication and co-ordination;

– a supportive work community;

– rites and rituals which celebrate successand reinforce good practice;

– managers who welcome staff views andengage their teams in decisions;

– managers who show appreciation ofeffort and contribution;

– managers who support staff in improvinghow they carry out their work andaddressing problems; and

– coaching and mentoring rather thandirective management (West andDawson, 2012).

These conditions certainly characteriseengagement as a two-way street and areperhaps particularly important for recentlyrecruited staff. Registrants who perform wellenough in their roles and teams are offered therole, team and management conditions forengagement. They will also have opportunitiesto engage themselves and to demonstrateengagement attitudes and behaviours.

Equally, employers can withhold or withdrawthese conditions and opportunities, in theprobationary period and subsequently, whereregistrants are not proficient or are nototherwise a good fit in the team.

It is not possible to determine from the casesreviewed whether withholding or withdrawingthe pre-conditions for engagement directlyaffects registrants’ state of engagement. Ifanything, the review suggests that there canbe a two-way short-circuit between the ‘pre-conditions’ and ‘behaviours’ elements of theWest and Dawson model, whereby role, teamand management conditions affected




registrants’ behaviours and vice-versa,without obviously influencing the registrants’internal state of engagement. In fact, someregistrants seemed over-resilient, in that theirsense of themselves as competent andengaged professionals was entirely at oddswith colleagues’ and managers’ evidencedand ongoing concerns about their proficiencyor conduct.

It is perhaps in no-one’s best interests foremployers to invite and encourageengagement from HCPC registrants wherethey are not meeting reasonable expectations.That is to say, expectations of positiveengagement from the employer need to bemanaged until a registrant is proved to becompetent in the role to which they have beenrecruited. Equally, new recruits are entitled toprove themselves and to engage with their roleand organisation. Taken together, the casesreviewed suggest that registrant andsupervisor relationships deteriorated, and / orbecame highly adversarial, when registrantsfelt that supervisors or managers had withheldthe conditions for engagement from the outset,or had withdrawn them prematurely.

2.4.4 Competence and capability

In some cases, registrants apparently did nothave the necessary skills, abilities or personalsuitability to perform well in the role to whichthey had been appointed, and no amount ofmanagement or team support would bringtheir practice up to the required level andconsistency. It was interesting that theseregistrants’ responses, both their own andthird party reports, typically described theregistrant as highly involved in their work andcited engagement behaviours, such as makingdiscretionary effort, taking personal initiativeand attempts to be pro-social, in defence. It ispossible that in many of the cases reviewed,engagement and competency were notstrongly linked, and that improvingengagement would not resolve a competency

impairment to fitness to practise.

In other cases, registrants had apparently beenappointed to roles where, though competentto some extent, they were described by theirsupervisor(s) as “completely out of theirdepth”. In particular, they had been unable towork independently and safely, sometimes inacute settings and with complex patients, assoon as their managers and colleagues hadexpected and needed them to.

The case review suggests that is it important forsupervisors and managers to be aware of themessages that they are sending about engagingwith their organisation, and to get the balanceright. It could be argued that it is misleading,inappropriate and in no-one’s best interests toencourage engagement when the registrant’sfuture in the role or organisation is in the balance.On the other hand, withholding the conditionsfor engagement for new recruits risks isolatingthem. Some of the cases reviewed suggest adownward spiral of evident disappointment frommanagers and team members, and loss ofconfidence and disengaged behaviours andattitudes from the registrant.

Otherwise, in this review, ‘wrong job’ and ‘out ofdepth’ cases raise questions about how theseindividuals were recruited to the roles they werein, how they qualified, and about how trainingand appraisal systems could be developed toensure that registrants are a genuinely good fitfor their preferred role. They also suggest roomfor improvement in employers’ recruitmentcriteria and recruitment processes, if registrantsare not meeting their competencies.

2.4.5 Personal circumstances

A further theme emerged from the case reviewaround the influence of personal circumstances.There were a number of registrants who citedbereavement, acute and chronic illness, or othersignificant problems and pressures (personal,familial, financial and / or professional) asmitigating factors in the case made against them.



The review found nothing to suggest that any ofthese registrants had any awareness that theyhad disengaged from their profession, from theirwork or from their employer. Rather, registrantshad apparently tried to continue to practise asusual but had reached a point where they wereoverwhelmed and something had to give.Professional practice was compromised andthings got worse as registrants continued topractise, but were unable to recover thesituation and ‘get back on track’.

These cases included registrants providingacute, community-based and domiciliaryservices. In all settings, the aspects of practicemost likely to be both compromised andevident to colleagues were record keeping andrecord management. Registrants includedlong-serving and highly-regarded professionalswho had not, or had not appropriately, forexample, made contemporaneous notes,documented telephone conversations, notedall findings, completed forms, recordedconsent or stored records securely.

Some cases suggest that there are structuralissues that make record keeping morecomplicated than it might be, for example alack of standard formats for record keeping insome service settings and clinical specialties.Multi-disciplinary and multi-agency workingarrangements are complex, and there isalways the potential for miscommunicationsand misunderstandings.

It appeared that record keeping andmanagement became problematic, especiallyin cases concerning senior, very experiencedand highly-respected professionals. It may bethat ‘paperwork’ became the lowest prioritywhen there were multiple competing pressuresand priorities, and / or that it was an aspect ofpractice that was relatively invisible tocolleagues until discrepancies came to lightand prompted an investigation. Anotherinterpretation could be that ‘paperwork’ beingsubject to audit, and clinical notes often being

shared between clinicians, was a moreroutinely scrutinised area of their work.

Registrants who were struggling with recordkeeping and management did not, apparently,voluntarily disclose their difficulties and receivesupport from their supervisors. Theseregistrants appeared to conceal rather thancommunicate their difficulties.

2.4.6 Dysfunctional relationships

Deficits in supervision feature, in different ways,in many of the cases reviewed. These includeallegedly inadequate supervision by theregistrant, the registrant apparently not takingresponsibility for ensuring appropriatesupervision, assuming this is an expectation ofHCPC registered professionals and obviouslybroken relationships between registrants andtheir supervisors and managers.

Several registrants’ responses implicitly orexplicitly pointed to difficult relationshipsbetween registrants and supervisors. Acceptingthat cases referred to the HCPC are likely to beatypical, it is notable that few of the registrantshad apparently felt supported by theirsupervisor, or even felt able to approach theirsupervisor to express concerns about their ownpractice. From the case material, even seniorregistrants would not typically have beenconfident of a supportive and constructiveresponse from supervisors or managers if theyhad sought to fulfil their professional duty tomanage their circumstances, change theirpractice or stop practising.

Some of the cases concerned seniorpractitioners who had allegedly failedadequately to supervise the work of morejunior colleagues, and / or to provideappropriate guidance. Again, the review doesnot suggest that these registrants hadabdicated from their supervisory responsibility.Rather, registrants and their supervisors ormanagers had different understandings of theboundary between the supervisors’




responsibilities and accountabilities and thoseof the supervised registrant, as an autonomouspractitioner in their own right. This applied, inparticular, to documentation and otherresponsibilities that were not, strictly speaking,hands-on ‘clinical’ and so very obviouslysubject to the registrants’ supervision.

2.4.7 Disengagement ‘after the event’

Registrants’ responses to allegations ofmisconduct and subsequent investigations varywidely. Some engaged fully, submittingcomprehensive and carefully argued responsesthroughout internal and HCPC processes. Atthe other end of the spectrum, someregistrants appeared to disengage, not replyingto HCPC correspondence, resigning from theirposts, requesting voluntary deregistration andasserting that they never again intend to workin the profession. There is no obvious pattern ofengagement or disengagement as a response;the disengaged group, for example includesregistrants working in hospital, community andsocial care services, more junior or recentlyappointed registrants and senior registrantswith decades of service.

Some of the submissions to the HCPC fromlonger-serving registrants who disengaged afterthe event express clear and long-standingfrustrations with their managers, their employingorganisation more widely and / or with othersystems, organisations and communicationissues in the local health system.

Post-event disengagement could, arguably, beinterpreted as evidence of pre-existingdisengagement, ie that registrants haddisengaged before they behaved in a way thatraised questions about their fitness to practise.

The cases reviewed, however, do not suggestthat registrants had previously disengagedfrom their work role or from their service users.In some cases, registrants’ fitness to practisewas questioned when they had done or notdone things that they argued, sometimes

successfully, had been in the best interests ofthe service user. Furthermore, in some cases,it could be argued that it was certainbehaviours that had put their registration atrisk. For example, ‘going the extra mile’ andworking at the edge of competence insituations that subsequently spiralled out of theregistrants’ and their services’ control.

The case material reviewed in this study overallhas limits as a source of evidence aboutregistrants’ state of engagement. Perhapsinevitably, given that they were referred to theHCPC, most of the cases describe a fitness topractise (rather than ‘truth and reconciliation’)approach to discovering what happened andwho was responsible, with a clear focus oninvestigating impairment. No matter howconciliatory, registrants’ statements and writtenresponses seek to defend them againstallegations and, where registrants remainengaged, to present them in the best possiblelight. Being both retrospective and defensive,case materials may not accurately andcompletely reflect registrants’ state ofengagement with their work or their organisationat the time of the incident(s). Furthermore,HCPC processes often began a long time afterthe incident(s) in question and, with regard to allwitnesses and other participants, there is anobvious risk of recall bias.

Fitness to practise case material set out thefacts and the implications for current fitness topractise, but the case material provided limitedinsight into registrants’ reasoning or motivationsfor past (alleged) misconduct. Some casesprovide a little information, offered in mitigationin respondents’ responses. In a few, therationale is self-evident (for example caseswhere there was a narrative around financialgain). In other cases, however, registrants hadmade inexplicably poor decisions that obviouslycontravened policies or codes of practice, orhad made decisions that were not theirs tomake. Without more (ideally contemporaneous)information about registrants’ thought


processes, it is not possible to drawconclusions about the extent to whichengagement or disengagement contributed. It isperhaps worth noting that in several casesregistrants in acute services were at the verybeginning or end of a shift period.

It was however striking how some registrants’reaction to allegations and investigations wasto make their own situation very much worseby being untruthful or otherwise misleading bytrying to disguise what they had done ornot done. This included asking others to bedishonest about what had happened orwhat they had witnessed. This raisesquestions about registrants’ state of mind anddecision-making processes around the time ofthe incident(s), but may reflect the ‘drift’referred to in Austin’s review.

2.5 Interviews with registrantswho had been the subject of acomplaint

Given the low numbers of participants, thefindings related to this project aim have notbeen reported. Recruiting registrants who hadbeen subject to fitness to practise proceedingsproved difficult given the opt-in methodology.The HCPC sent letters to 23 individuals whereeither a conditions of practice order orsuspension order was imposed at the originalhearing and had subsequently been revoked ata later review hearing. One interview wascompleted and two others contacted theresearchers as they felt not enough time hadpassed since their final panel to comment.

2.6 Analysis of patients, serviceusers and public focus groups

Three focus groups were held with patientsand service users in two locations. There were26 participants across the groups.

2.6.1 Perceptions of a ‘competent’professional

Patients and service users in the sample hadbeen in contact with a variety of HCPCregistered professional groups. Members of thepublic had a more limited interaction with theseprofessionals and typically were withchiropodists / podiatrists, paramedics andphysiotherapists. They did, however, commentgenerally on doctors and nurses. Whererelevant we have included these comments inthe analysis, omitting anything that was clearlyrelated specifically to the medical or nursingprofessions. From prior experience with similargroups, it can be difficult for patients andmembers of the public to comment generally onhealth and care professions, whilst excludingtheir experiences of doctors and nurses.

The groups started by defining what elementswould denote to participants that a health orcare professional was ‘competent’ or that theywere ‘doing a good job’. They focussedprimarily on the way that they interacted withtheir patients or clients. Participants mentioned‘compassion’ and clear, articulate or positivecommunication as denoting competence.

When probed about how communication candenote competence, participants pointed to a‘confidence’ in delivery that let you ‘know whatthey’re doing’. They further mentioned thathaving the ability to reassure, meant that theywere experienced in dealing with patients andservice users. One participant suggested that ifthey understood and were able to follow ahealth or care professional’s advice, and thatresulted in a positive outcome, then they wouldtrust that they ‘knew what they were doing’.

“A personal touch, individual care, a bit moreof a tailored, kind of, approach.”

“Caring and compassion and kindness…she’s very friendly towards me. It’s theinterpersonal skills.”




2.6.2 Consistency

Participants also mentioned the word‘consistency’ as being linked with a competentprofessional. It seemed as though they wereinterpreting consistency as giving ‘good’ or‘sage’ advice and not attempting to resolve aproblem in as many ways as possible, asquickly as possible.

They also mentioned timing as being importantin perceptions of competence. A health or careprofessional who rushed you, or who did notseem to have time to make the process as‘comfortable’ as possible would be less likely tobe a competent professional.

In terms of more ‘technical’ competencies,members of the public and patients and serviceusers found it difficult to define what mightcomprise technical competencies. They didhowever, have a baseline expectation thatprofessionals would keep up to date with theirprofessional requirements and that varioustraining would be expected to be undertaken onan annual or otherwise regular basis. Theylikened it to training within the fields that theyworked, where qualifications were only valid fora year or few years at a time.

2.6.3 Perceptions of factors which mayaffect competency

There was agreement, in general, that theremight be a number of factors within aprofessional’s life, which may affect theircompetency, such as their relationships withtheir supervisors and teams, family difficulties,training and time since qualification. This wasstrongly qualified by participants that it would be‘rare’ or that ‘you hope it wouldn’t’ be a factor.This belief was most often linked to the positionof trust and responsibility that came with beinga health or care professional. Participantsviewed their role as so important that thereseemed an additional burden of competencythat they wouldn’t expect of other professionals.

Family difficulties, such as a bereavement, familybreakup, illness or other personal difficulties,were cited as examples potentially giving rise toissues with competence. In the case of apersonal issue, the sense was that this wouldbe a temporary competence issue, and theirimpression was that it wouldn’t typically besevere or unsafe. There was also a view thatone’s relationship with colleagues could causedifficulties in a similar way to personalrelationships. The stress of a bullying situation,for example, might cause competencyproblems.

There was a disagreement amongst participantson the effect that where one trained would haveon their competence. Patients and the publicwere more likely than professionals to beconvinced that the location of a professional’soriginal training course would have a bearing ontheir competence. Those who thought theircompetence might be affected, cited areasoning of people who go to the bestuniversities will get the best training and be thebest. This was seen from a very ‘UK centric’way. However, many participants believed thatcompetence in a health or care professional isabout more than ‘academics’ and therefore itwas less likely to impact on their competence.

“You don’t want to feel like you’re rushed, anMRI machine is scary, you want someoneto talk to you and… make you feel like aperson and not a thing.”

“They should be up to date with the relevantpractices… They should do relevant trainingevery year, things are changing all of thetime.”

“Explain what they’re doing and why they’redoing it.”

“They make you feel at ease, by talking toyou in a soft voice.”


There was an expectation that if a professionalhad been employed in the UK that theirqualifications had been deemed sufficient toassure competency. That is to say, there was abelief that there is good consistency in terms ofquality across training programmes in the UKand that foreign credentials, if deemed of asimilar quality, should be accepted.

There were those who suggested thatcompetence would be impaired if languageskills made it difficult for patients or serviceusers to understand the professional.Conversely, they wondered if it could impairone’s competency if it was difficult for theprofessional to understand the nuance ofinformation given to them by patients or serviceusers. When thinking about ‘real world’situations one participant laughed, stating thatthe last thing you would be thinking about wheninteracting with a health or care professionalwould be where did you train?

Though the location of people’s work, such ashospital, community or social care setting, didnot appear to relate to concerns about potentialimpacts on competence, there was a concernabout lone working or isolation. A communityworker would be as competent as long as theyworked as part of a team, to keep their practicein check. In the participants’ view, professionalswho they had interacted with in a particularsetting, would have worked with them to thesame standard, even if the setting had changed.

There seemed to be significant value placed onthe ability to confer with colleagues on cases,to reflect on a professional’s practices, thatisolation could make difficult. This interactionwith colleagues was seen as important to thedevelopment of competency and staying up todate. The concern with lone workers was thatthey would become complacent.

Complacency concerns were echoed in thelength of time since a professional hadqualified. Patients and service users were likelyto make assumptions about a health or care

professional’s competency based on thelength of time since someone qualified,whereas members of the public had a morebalanced view. This might be due, in part, totheir interaction with long serving specialistsand consultants, who were viewed aspaternalistic by patients. The impact for thosewho felt there was one, fell into two distinctcamps. Some patients and service usersmentioned that they viewed younger healthand care professionals as more likely to ‘notquite know what they’re doing yet’. Others,however, believed that people who had beenin the profession longer, tended to be morecomplacent, as though they ‘can’t stillimprove’, whereas younger professionals, weremore likely to be interested in innovation ortrying alternative approaches. When asked,participants found it difficult to decide onparticular examples of this, but rather thatthere may be an impact on competency ineither direction.

2.6.4 Views on engagement

When asked what might effect a healthor care professional’s engagement withtheir work, similar themes of difficulties intheir personal life emerged. In addition, however,participants were keen to point to immediatemanagers as a cause of strong (dis)engagement.For most participants they perceived this as astrong link and defined it as a desire to ‘do yourjob well’. When asked how ‘wanting to do yourjob well’ affected competence, participants werenot clear that they were related, rather that healthor care professionals ‘may not go the extra mile’.

Another area where they felt engagement mightbe affected was where a health or careprofessional was unable to exercise all of theirskills, or where they had a particularly difficultpatient or service user workload. They felt that

“Something in their personal life could beaffecting them, maybe their wife has leftthem.”




either the boredom or stress burden in thesecases may change the way that they felt abouttheir work. They felt it possible that, withoutexercising different skills on a regular basis, itmay affect competence.

2.6.5 Financial constraints andworkload pressures

Patients and service users reported noticingthe effects of the financial pressures ontheir appointments times, bookings andcancellations. They could tell that theprofessionals treating them were frustrated bythe constraints they were operating under, andthey thought a sense of continued frustrationmight impact on their engagement with theirwork. They also wondered if this might be anarea where engagement and competencewere linked, because with capacity pressures,‘something’s got to give’. Similarly, there was aview that health and care professionals wereincreasingly spending more time with acutecases, or the ‘worst cases in social care’ andthat they weren’t always able to deliverpreventative care or support. They wondered ifthis caused ‘empathy fatigue’, a sense thatcontinually ‘fighting fires’ might make one lessengaged.

2.6.6 Autonomy

Participants in one group spoke very highly ofparamedics that they had come into contactwith. They had found them to be extremelycompetent and professional. Through thediscussion, they pondered whether the relativeamount of autonomy given to somepractitioners was related to their engagement.There was a sense that in hospital or a caresetting that the targets were more evident andthe audits more burdensome.

Participants described the link betweendisengagement with competency as definitelypossible, but believed that professionals wouldbe conscious of any disengagement and wouldact to rectify the situation. For example, theymight raise their workload pressures withmanagers, or leave a job where they felt bullied.They did not believe that they would be passivein their disengagement to such an extent as tobecome incompetent. However, a number ofthe participants questioned what would youneed to do to be considered incompetent?Examples, such as poor note taking orparamedic vehicle checks, were somethingparticipants thought ‘you might not know howimportant it was until something happened’, butfor the most part they thought a rationalprofessional should be able to think through thepotential negative impacts of not completing allaspects of their role.

2.6.7 Preventing problems

When discussing how to prevent smallproblems from becoming big problems,participants wondered if it wasn’t better to domore to prevent disengagement in the firstplace. They felt that regular team buildingexercises were important and that appropriateperformance evaluation takes place. They

“They’re not working in this one situationnine to five, they’re living a live drama.When you’ve got people coming in like aconveyor belt into a building, that’s whereyou get compassion fatigue.”

“They have more autonomy, because of thenature of the emergencies they see, they usetheir initiative, they’re living a live drama.”

“Need to know they can work their way up,after ten years doing the same thing, theymight get bored.”

“It might get people in a rut, they might getcomplacent. It’s your job, you can’t chooseyour patients.”


believed that employers and colleagues playeda significant role in providing a guidanceprogramme (interpreted as a preceptorship,mentorship or clinical supervision programme).Participants were also keen to suggest ‘spotchecks’ of work, such as clinical review ofcases, or of audits of certain elements ofperformance as an added safeguard to smallproblems becoming big ones.

2.7 Analysis of health and careprofessionals focus groups

Five focus groups were held with health orcare professionals in order to gauge their viewson competency, engagement and factorsaffecting both, as well as whether theybelieved there to be a link between the two.The HCPC invited a random sample ofregistrants who lived within the London orLeeds area where the groups were to takeplace, and an opt-in booking process wasused. A total of 20 registrants participated.Their professions are described in the tablebelow.

Table 4 Participants in focus groups byprofession

2.7.1 Notions of competency for healthand care professionals

HCPC registered professionals’ descriptions ofthe elements that made up competencyindicated a type of ‘fluidity’ to competency,that it meant and required different things atdifferent times. Several participants describedtheir competencies as being not simply aboutthe knowledge or the skill ‘operating in avacuum’, but also the ability to know how,when and why they were applying a particularskill or practice in a given situation. Indeed, theability to choose and set the appropriate skillfor a good outcome for their client group wasconsidered a crucial component ofcompetency. Although that is not to say a pooroutcome necessarily denoted a competencyproblem, rather in order to be competent, onewould expect a professional to adjust anyprocess or treatment that was not resulting ingood outcomes.

Most professionals could describe a particularlist or baseline of skills or tasks which theyshould be able to perform to be a competentprofessional. These skills and tasks wereunderstood as what is learned during pre-registration education. They further explainedthat, depending on any training or specialty aprofessional might hold, they would haveadditional lists of skills, knowledge or abilitiesthat they would need to keep up to date inorder to be considered as competent.

Social workers described a much moreprescribed notion of competency within theirprofession than reported by other participants.Capabilities for social workers, denoted what isexpected of them at varying career levels,whether that was to do with length of serviceor seniority of management within a team.Capabilities were referred to regularly, giving afairly clear picture as to competency for socialworkers in the group.

Similarly, biomedical scientists said that theframework of quality assurance within their

ProfessionNumber ofparticipants

Social worker 5

Physiotherapist 2

Speech and language therapist 1

Radiographer 3

Occupational therapist 4

Biomedical scientist 2

Practitioner psychologist 1

Operating department practitioner 2

Total 20




profession, whether that was proceduresrequired by ISO certification for example,which meant there was little interpretation inwhat constituted competency. That is to say,the procedure was either carried out correctlyor incorrectly. They did however note thatother aspects of competency, includingbehaviour and ethics, were more nuanced.

2.7.2 Autonomy

The notion of autonomous practice was oftenreferred to as an important element ofcompetency, and was often mentioned inrelation to risk. The sense was, to becompetent, a professional must have theconfidence to practise autonomously, or atleast have the confidence to highlight theirweakness in an area rather than putthemselves, or indeed a service user orpatient, at risk.

Competency, like expectations, changed giventhe characteristics of the professional.Competency for a newly-qualified professionalwould not be the same as that for someonewho had been practising for several years, nordid professionals believe they ought to be thesame. As previously mentioned, this appliedfor any additional training or specialitiesacquired by professionals.

Competency frameworks that professionalsworked to varied by profession, but generallyparticipants referred to the HCPC standardsfor registrants, as well as guidelines providedby employers related to particular skills orpractices, or employer competencyframeworks. Professionals were not certainthat employer frameworks were consistentacross the UK, but there was an assumptionthat they would cover similar elements. Socialworkers mentioned they had a certain numberof other influences on competent practiceincluding styles of practice, such as ‘anti-oppressive practice’.

When asked whether competency frameworksinformed their daily practice, professionalsdescribed having them ‘in the back of theirmind’. They also thought that the HCPC bi-annual review of professionals’ CPD hadmeant they reflected on their competencies,training and abilities in a more formal ordocumented way.

“The ability to work autonomously andconfidently, that you’re not hiding any gapsin knowledge, that you’re open.”

“We have the general expectations for CPDfrom the HCPC, the general how youprogress… once you’ve qualified there’snothing else, other than in your departmentyou might have different levels and differenttrainings.”

“It’s in the back of my mind when I’m doinganything: can this count for my CPD, can Ireflect on this area – it governs whichpatients I can treat and what work I can do.”

“We deliver daily, we just do it. It comesnatural. We do the job, but actually its veryrare that a social worker will say ‘I need timeto develop this area’, to have that reflectivethinking. It’s only drawn out when you have[a] formal appraisal or assessment sessions.”

“It’s an application of your knowledge to atask.”

“It’s about the ability to prevent or to solveproblems in your daily practice.”

“You’ve got different types of competencieslike behavioural or skills base, but it’s alsoabout understanding the outcome of any ofyour activities.”

“If the intervention has been successful youcan be reassured that you’re competent, orif it hasn’t, knowing how to reassess yourapproach.”


2.7.3 Reflective practice

Less formal ways of reflecting on competencyalso seemed to be routine amongst theparticipants in the groups. They said that itwas not uncommon to reflect on one’scompetence, sometimes in observing acolleague’s approach to a problem (ie havethey done it differently and would it improve mypractice if I were to adopt their approach).Similarly, professionals also described areflective ‘inner question’ process. They oftenthought ‘would another professional haveacted similarly in this situation’, as a way ofchecking themselves.

2.7.4 No blame culture

One professional found their team’s approachto no error reporting as helpful in ensuringcompetence. Where mistakes were discussedopenly and solutions or preventative measureswere drawn up as a team, everyone was ableto both be aware of how a mistake may haveoccurred, but also understand what goodpractice looked like.

2.7.5 Measuring competence

When asked whether it was possible tomeasure a professional’s competency, therewas consensus that it would be possible tomeasure certain elements of competencyeasily, but that others would require a muchmore in-depth assessment. Themeasurement question also brought up otherthoughts on what constituted competency.For example, would behaviouralcompetencies be weighted more than skillsor vice versa?

Indeed, participants wondered if you coulddevelop a holistic view of competencebecause of the numerous elements that wentinto deeming someone competent. There was

also a sense that the reverse might be easier.One could more clearly deem an action orbehaviour as being incompetent practice.

2.8 Factors that affectcompetency

2.8.1 Organisational influences

The biggest factors which health and careprofessionals believed impacted oncompetency were related to the organisationthat they worked for. Several professionalsreported having a workload issue, or theorganisation having a capacity pressure suchthat expectations could threaten thecompetency of their practice. They often linkedthis to insufficient support, most likely of theirimmediate manager. Professionals emphasisedthe importance of being able to discuss theircompetency and whether their practice wassafe with their managers. Without support, orbelief of support, this could be difficult.

This concern of reporting on one’s owncompetency, could be caused by a fear ofcriticism. The sense that there was a risk todiscussing competency when it came toworkloads because other practitioners on theteam might be coping with the workload. Theimpression given is that managers would notalways be supportive of staff members raisingconcerns about their own competency.

A number of participants mentioned that theirNHS Trusts were no longer filling vacant posts,but there was an expectation that waitingtimes would remain unchanged. Manypractitioners had felt pressure to do more inthe time that they had and felt that they had, insome cases, compromised their practice. They

“Competence is dependent on so manyfactors it’s difficult to put it all together.”

“The quality is measured by the outcomesachieved, but there’s a lot of competencethat requires qualitative measurement.”

“Regular no blame reporting systems so wecan all learn from where things go wrongand that helps.”




did not believe that these constraints hadrendered their practice incompetent. Rather, itwas not what they would promote as goodand competent practice. They also thoughtthat many of the decisions made aboutcapacity and what can be achieved were beingmade by trust leaders or at a political level bypeople who were not practitioners, and theyfelt there was a fight to describe whatconstitutes safe and competent practice.

Professional groups were also asked tocomment on a number of areas they hadn’traised independently and whether thoseelements may impact on a professional’scompetence. These included, time sincequalification, where they trained, personalcircumstances or difficulty and workinglocation or style. Overall, professionals believedthat these elements could impact on aprofessional’s competence but that for themost part, they would expect that professionalto identify the issue with their supervisors.Then to take some time off or make anotheraccommodation, such as requesting specialistsupport, for what they believed to be, in mostcases, a temporary impact on competency.

2.8.2 Time since qualification

Unlike members of the public, professionalswere more likely to see people who had beenin the profession for a long time as thosewhose competency might be affected. Theirknowledge of preceptorship, and theexpectation that newly qualified professionals’competency would increase over time, madethem less concerned about knowledgeaffecting newly qualified professionals’competency. The idea that a professionalcould become stuck in their ways or inflexiblein their practice over time was seen as oneway in which competency might be impacted.

2.8.3 Professional isolation

There was concern about how isolation couldimpact on competency. Participants perceivedisolation as either being the only qualifiedmember of their profession within anorganisation or working privately, or working inthe community without the support of a team.

This concern about isolation was describedin different ways. Firstly, if a professionalbecomes isolated they may not be reflectingon their practice in the same way that teamswould do. Similarly there was a concern thatif a professional was working in an isolatedway it may be difficult for them to accessspecialist support as and when needed inorder to remain competent. Finally, there wasa concern that their competency might notbe monitored in the same way asprofessionals who work in teams. However,

“Is there a fear of reprisal if you do raise yourhand and say this isn’t safe or competentpractice?”

“Because posts aren’t being filled there’s arisk to competency because you’re beingasked to do so much, how can [you] beexpected to achieve that? And you feel likeyou have to say that’s not safe.”

“People make big decisions who aren’tpractitioners, and that can cause aproblem, as they don’t know, necessarilyhow to do so and the impacts they mighthave on quality or competent or safepractice.”

“Where people have been in a role for a longtime and been denied opportunities toprogress… And they’re doing things in aslapdash way… They’re not doing things ina thorough way… not doing the liaison withother professionals… not really engagingenough with that patient in another sense…it’s not being incompetent really, but it’s notdoing it to the full level of your competence.”


there were very few instances thatprofessionals could think of whereprofessionals were very isolated. Indeedmany of the services they worked for hadbeen set up to avoid any member of staffbecoming isolated as a safeguarding processfor both patients and staff.

One participant who had worked in bothcommunity and acute settings, felt as thoughprofessionals were placed in vulnerablesituations by working in the community. Bybeing asked to monitor the risks of a numberof different patients in a number of differentsettings with little ‘back up’, the stress couldpotentially impact on their competence.Though, as the conversation continued, otherswondered if perhaps the stress had madethem hyper-aware, and potentially morecompetent when not relying on a team.

2.8.4 Continuing professionaldevelopment

A number of participants believed there was aminimum amount of continuing professionaldevelopment (CPD) required to maintaincompetence, but that attitudes toward CPDlikely reflected other things such as whatcareer stage they were at, what client loadthey had and the professional’s personalcircumstances. CPD was seen to supplementcompetency and could make a professional‘skilled’, but they did not view ‘skilled’ and‘competent’ as equivalencies.

2.8.5 Professional networks

Professionals believed that their professionalnetworks, on the whole, did a good job ofcommunicating any changes in practice orguidance to the professionals. Staying up todate was seen as part of the job, and they didnot believe that someone could become‘incompetent through ignorance’. However,linked to the question about the length of timesince qualification, participants felt they couldthink of professionals within their professionalnetwork who had perhaps become set in theirways, and did not actively take up new waysof doing things. This may affect competencybut, more likely, they thought it would makethe overall team of professionals lesscompetent as they were working to differentmethods.

2.8.6 Personal circumstances

Participants thought it might be possible thatthe stress of a bereavement or familybreakdown, for example, might ‘take your eyeoff the ball’. But again, the professionalexpectation and belief was that there would bean awareness of this impact. Participantsfurther qualified that a stressful personal lifecould cause someone to make a mistake, butwondered if a one-off mistake would deem a

“At the end of the day we’re all humanbeings and have ups and downs in our livesand part of being professional is knowinghow to cope with that or talking to yourmanager if you need to.”

“I could see how you might make a mistake.Is a one off mistake not being competent?You might make a mistake but not beincompetent.”

“You’re much more vulnerable in thecommunity, and from my experience I thinkthere should be tighter monitoring of yourcompetence and the access to specialistexpertise should be easier – it could be adangerous situation for keeping up yourcompetency in a vulnerable situation.”

“I think it would be really hard to work inisolation because you wouldn’t haveaccess to that expertise that a team has.”

“Competency includes your current practiceand your practice as you move forward, soyes, keeping up to date is part ofcompetency.”




professional incompetent. In discussion, therewas an agreement that there may be somemistakes that would render one incompetentdue to the severity of the mistakes, but manymistakes would be seen as less serious.

2.8.7 Place of qualification

Participants did not think that the place ofqualification would impact on theircompetency. There were some anecdotesabout particular professionals from particularcountries as being very good. Some had feltthat the knowledge base of someprofessionals differed dependent on thelocation of qualification, but that anyinduction, preceptorship or clinicalsupervision would bring them up to speed.Overall, they believed that, as a qualifiedprofessional, as long as someone had metthe requirements of qualification and werekeeping up to date as they needed, thatwould indicate competence. They addedpersonal suitability to the job was much morerelevant than where they trained, whether inthe UK or abroad.

Personal suitability seemed very important forsocial workers in particular. They wereconcerned that there were newly qualifiedsocial workers entering the profession withvery little ‘life experience’, and that this couldcause a shock when they were faced with theproblems, issues and interventions that socialworkers face. They thought this could cause aproblem in competency, because they feltsome social workers with little ‘life experience’were not fully prepared for the role after theirqualification.

2.9 Views on engagement

Engagement to the professional included theirmotivation to do the job, and this was oftenlinked to the enjoyment of their job. Theycommented on reflective and mindful conductof their practice as being engaged; that in

looking for improvements in their own practiceand service, they were engaged.

Others linked it to a personal responsibility towork well with teams and to developprofessionally. Many mentioned keeping up todate with their profession as engaging in theirwork and in their practice. Much of thediscussion focussed on an active form ofengagement, whether it was seekingimprovements or in developing their team skillset. Engagement for some was about ensuringthe quality of the care delivered.

Professionals did see a certain responsibilityand maturity to engagement, in that there wasan expectation that professionals shouldattempt to not become disengaged. Thereseemed to be a view that disengagementmight entail ‘giving up’.

Relationships with managers were seen as animportant influence. If there was a supportiveculture that encouraged learning and teamworking, then professionals found themselvesto be highly engaged. In a similar way, if theirteam functioned well and valued all members’input, and there was a feeling that ‘everyonewas pulling their weight’, then professionalstended to feel they engaged more readily.

“Coming to work and wanting to do my job,rather than waiting for the day to end.”

“Taking responsibility for your professionaldevelopment, about how managementwere working with you.”

“To be valued as part of a team make[s] youfeel more engaged, and if they’re not thereyou can become disengaged.”

“It’s nice to work in an organisation with agood learning culture, you keep developingand becoming a better practitioner and thathelps me to feel engaged.“


2.9.1 Being valued

Being valued was something that wasmentioned in every group. For some, it wasimportant for their patients or service users tovalue their assistance, for others it was thepraise of a direct manager, and others theirteam valuing their input. A small numbermentioned senior managers as valuing theirwork, and that this value could be expressed asinvolving them in decisions about the service.

2.9.2 Financial pressures

Financial pressures were viewed as a potentialsource or trigger for disengagement.Professionals reported that prolonged periodsof stress associated with financial pressureswithin the system had caused some teammembers to disengage. Anxieties aboutputting service users at risk or compromisingstandards were commonly referred to. Further,they felt the focus of their employers wasalways on financial realities. Suggestedimprovements to services would always needto be justified in financial terms, which, on thewhole, participants felt did not play into theirengagement with work. Professionals werelikely to link disengagement with ‘burnout’,often referring to the two interchangeably.

2.9.3 Relationships

Professionals had engaged more when theirsupervisors had been supportive in developingthe professional’s career, or had beenunderstanding about any concerns they mayhave expressed. Professionals had felt less

engaged where their line manager had beenperceived to be weak in managing teams, orhad been relatively unsupportive or absent.

When asked about the relationship betweenengagement and competency, one group ofparticipants thought that there might be caseswhere this could happen, but they believed itwould be rare; again stating the need forprofessionals to be aware of their own fitness topractise. There were often a number of factorscited as leading to a professional’sdisengagement. For example, a combination ofa poor relationship with a manager or teammember as well as a stressful period at work orat home could lead the disengagement toimpact on competency. However, when thediscussion focussed on stressful familycircumstances, participants wondered if theinevitable shift in the focus of attention from workto home life could affect a professional’sengagement. They also wondered whether aprofessional would have the insight to know theircompetency was affected. A minority in thegroup were clear that a professional did not haveto ‘like’ their job in order to do it competently.

Participants believed that engagement forhealth and care professionals could beascribed to different parts of their work. Forsome, engagement seemed to be to theirwork, and in so doing their patient or serviceusers. Others mentioned their engagementwith their team and organisation. Some felt anengagement with their profession, that theywere engaged in being a qualified professional.As a base, most professionals thought thereneeded to be engagement with the people thatthey served, but with others, this seemed to beless important in terms of competency.

“There are some things, external pressureswhich you can’t manage, which might affectyour engagement or your competency.”

“Sometimes if there’s a big, massive waitinglist, for example, [it] can cause problems forengagement because we’re putting patientcare at risk, so financial implications have arole on engagement.”

“They are all overridden by financial realities.If I want them to invest in my service, I needto quantify that.”




2.10 How to prevent smallproblems from becoming bigproblems in health and care

When asked about preventing small problemsfrom escalating, health and care professionalsfelt a number of different people, roles andorganisations played a part. There was a sensethat sometimes small problems might bedifficult to notice, unless it was related to anissue that was regularly under scrutiny, or thatwas audited regularly. A large role wasapportioned to employers. Health and careprofessionals believed that managers shouldhave sufficient structures in place to assess thecompetency of their staff. Further, appraisaland performance management, when donewell should uncover any weaknesses inprofessional dynamics.

Professionals also suggested that there couldbe a team element to noticing the competencyand practice of their team members, either indiscussing and reviewing cases on a regularbasis, assessing where improvements couldbe made or alternate approaches taken.

Indeed, professionals believed that the teamreview of competency, and the learningapproach where all professionals’ cases arereviewed in time, meant that hierarchies couldbe lessened and a more open culture couldbe created.

There was a clear consensus around theresponsibility employers had to assist withengagement or competency issues. Theybelieved that employers had a role inaddressing any capability issues, or to ensurethat they were a good employer creating aworking environment where staff memberswould remain engaged.

Again, professionals were quite clear in theirbelief that health and care professionals, asprofessionals, would have a firm understandingof their own competence and the factorsaffecting it. The self-reflection inherent in their

understanding of competency, would meanthat they believed that professionals wouldeither act to address causes ofdisengagement, or would change wards, units,or employers, rather than remain in a situationthat may impact their competency. It isperhaps worth noting that the focus groupswith professionals were both held withinreasonably urban areas. As such the choice ofemployers were larger. Views of those withinrural areas where there may only be one largehealth or social care provider within the localarea, and a few small private providers, forexample, might differ.

2.11 Analysis of stakeholderinterviews

Twenty six interviews were conducted withrepresentatives of professional bodies, NHSand local authority employers as well as oneunion. In general, stakeholders had goodexperience and understanding of the fitness topractise process. Their views were remarkablysimilar, despite their differing relationships toHCPC registrants.

“Should be picked up through robustsupervision or managerial structures thatshould give guidance of a threshold ofconcern.”

“Structures for the supervision, or forums todiscuss issues and challenge problems…maybe it doesn’t need to be a one to one toprevent that teacher pupil dynamic.”

“There’s an issue where there’s a largehierarchy which prevents people enteringinto dialogue.”

“The employer has to be a good employerand committed to developing their staff….They can only go as far as they aresupported by senior managers.”


Perhaps unsurprisingly these participants hada clear idea of what they believed constitutedcompetency. They readily describedcompetency as having knowledge, skill andbehavioural parameters applied appropriatelydepending on context. Competency wasfurther defined as those elements upon whicha professional’s qualification were based andassessed through their education.

Stakeholders were the only group to describean ethical construct to competency, at leastdirectly. This was of particular importance toprofessional bodies who had often issuedguidance or materials on the codes of ethicsfor their profession.

Stakeholders were also well versed on thevarious codes and frameworks, published orotherwise, which could be referenced as a guideto the competency of health and careprofessionals. These included the HCPCstandards, particular guides or detailed skillframeworks published by professional bodies,trust codes of conduct, or in some cases, thejob descriptions of certain levels of professionals.

2.11.1 Assessing competency of healthand care professionals

Stakeholders were confident that thecompetency of a health or social careprofessional could be readily assessed. Theyfelt that there were some skills or behavioursthat could be more easily measured thanothers. Stakeholders viewed competency

frameworks as a way of signpostingprofessionals to areas of strength or weaknessin their performance. There was also the sensethat evidence-based practice had madeassessing competence more straightforwardthan it had been previously.

Competency required interpretation in thecontext of the environment, the experience ofa professional, the team they worked with andthe complexity of the patient, client or serviceuser that they were interacting with. Oneinterviewee mentioned that there were sharedresponsibilities to assess competency,between managers and peers.

2.11.2 Factors affecting competency

Stakeholders agreed that there were a numberof influences on a professional’s competency,either relating to personal characteristics of aprofessional or to outside influences on theprofessional.

Personal circumstances and workload werereferenced as the main issues affectingcompetency for professionals. Stakeholdersdescribed stress, regardless of the source, asimpacting greatly on competence. Personalityand values shaped competency.

“I think you have to be careful becauseactually measuring competency canbecome too rigid so, you know, you canstifle practice really if you’re measuringcompetency and staying rigidly within aframework. You need the space to be ableto develop and try different things.”

“Evidence based practice has got to be theway forward, so you don’t just do thingsbecause it seems like the right thing to do,you actually check the research evidenceabout what’s an effective intervention at theend of the day, so competent learning,nothing’s ever the same.”

“Competency is made up of a number ofthings including knowledge, skills andbehaviours that the individual needs to haveand be able to call upon and useappropriately in their workplace.”

“The core competencies will have beengained from university.”

“It’s basically whether we are able to do therole that we are employed to do.”




Echoing concerns from the professional focusgroups, interviewees had strong concernsabout professionals working in isolation, or inone, narrow form of practice. Their firstconcern related to the potential for theossification of a professional’s practice or to anoverall deskilling. Their second concern wasthat it would be difficult to assess, review orenable a professional’s competency when theyworked in isolation.

One professional body had a particularconcern which was being raised within theirprofession. A number of their memberpractitioners had dyslexia, and they had foundit difficult to explain how that may impact theirpractice. Though the professional body did notthink it necessarily impacted on competency,many managers had perceived it thus, and sothey felt there could be similar issues whichmay or may not impact and that there could beopposing views on the impact or on whatconstituted competence.

2.11.3 Engagement and disengagement

The interviews with stakeholders generated acomplex view of what engagement looked likein practice. They viewed engagement as ‘notdoing the minimum’ rather than how someonefelt about their role. Involvement in professionalnetworks, engaging in debate, seeking outimprovements to practice and reflecting onthat practice were seen as the ‘signals’ of anengaged professional. Stakeholdersrecognised that a professional may becomepermanently disengaged. Sources ofdisengagement for stakeholders were stress,personal circumstances, workloads and overallcapacity pressures.

Distinct from other views was the notion thatengagement could be both negative and positivein nature. That is to say, a professional could bevery engaged, but in a way, that was perhapsnot productive or positive. Examples of thisnegative engagement came from issues withemployers such as consultations on jobs andservices, where professionals were engagingwith their employers, but in argumentative ways.Another was where media coverage of health orcare professions was particularly negative. Therewas a feeling that this could increaseengagement, but perhaps not to the part of thejob that one wanted professionals to engagewith. This seemed to fit with the view thatengagement was not a ‘state of being’ as such,but rather a symptom of underlying issues.

Professional body participants, interestingly,seemed to find it difficult to comment ondisengagement and its causes, because if aprofessional began to disengage, it would includetheir relationship with the professional body.Occasionally, managers would seek advice fromthem where there were concerns about anindividual apparently becoming disengaged.

“We shouldn’t delude ourselves thatmeasuring competency gives you a fullpicture, everything exists within a context.”

“You have a duty to maintain yourself at alevel where your competency can bemaximised. You need to be in good mentaland psychological and physical health.Family relationships can affect yourperformance, overwork can affect yourperformance and there’s always a balancebetween respecting a person’s exterior lifeand actually expecting them to deliver therequirements of the job… There has to besome give and take on both sides in thatrespect.”

“Reviewing an individual’s competency who’sworking in isolation would prove to be verydifficult.”


2.11.4 Link between engagement andcompetency

These participants were the most likely toarticulate a relationship between(dis)engagement and competency. Theyperceived that an engaged professional wouldbe more likely to undertake the ‘active’elements required of remaining a competentprofessional, such as reflecting on and keepingup to date with their competencies.

Stakeholders did not see disengagement asnecessarily leading to a professional beingincompetent or incapable, rather that it might

raise questions about a professional’scompetency. They were more likely to perceivethat engagement could be related to the ‘type’of professional or person they were. Indeed,professional body respondents were muchmore inclined to point to issues of personalityand personal suitability. There was often aperception that a professional could disengagefrom some areas of the job, while remainingcompetent. However, interviewees did observethat just as engagement reinforced competency,so disengagement could diminish it.

“I think the more engaged you are the morelikely to be competent you are, and themore likely to keep up your competenciesyou are.”

“Well if somebody is disengaged from theirprofession they usually don’t have verymuch insight into how they could bettertheir competency…”

“If they’re not engaged they may notunderstand nor wish to reflect on theirpractice.”

“It’s not an always relationship because Ithink you can be competent anddisengaged. You can be disengagedbecause you’re unhappy but it doesn’tchange your competency level and I thinkthat is often a reflection of the nature of aperson.”

“…they probably are capable, they’re notincapable, or if they were they would begoing through a capability procedure, sothey’re more likely on the edge ofincapability.”

“It’s not just going in and doing the samething on a daily basis, it’s taking an interestoutside of your immediate workenvironment. So what’s the strategicenvironment in which you’re working,what’s new within your profession. Soreading your magazines, the journals, beingaware when new guidance is published,engaging in debate and discussion withyour colleagues, reflecting on your ownpractice and looking to see you know,where you might need to improve. So it’s anumber of different indicators that wouldshow to me that somebody’s engaged.”

“Engagement is a symptom rather than acause. When people disengage it’s a signthat something isn’t working properly, it sortof reinforces itself.”

“We don’t necessarily know about them, wedon’t hear until something goes disastrouslywrong.”

“The only instance we hear about this iswhere an individual becomes disengagedand their managers or their supervisors ringus for advice.”

“If they disengage from their role, they tendto disengage from us.”




2.11.5 Preventing small problems frombecoming big problems

As reflected in the case review, theseparticipants were aware of the challenges ofmanagement and supervision. They were keenthat managers and supervisors were given thetime and space to be able to supervise theirstaff. Supervision was seen as a key componentto catching small problems and being able toaddress them in an appropriate manner.

Good team dynamics and access todevelopment, training and education were seenas key elements to prevent small problems inthe first place. The monitoring of workloads wasalso mentioned, there was a feeling amongstrespondents of the tendency toward a ‘hero’practitioner, carrying on when things got tough.Keeping up to date on workloads and keepingexpectations in check was an important factorin good management.

For some, it was difficult to determine whatcould be considered to be a small problem. Oneoff mistakes could be a small issue and mightnot require preventative action. If competencywas questioned, a small number of participantsthought that usually there was a larger issue atplay which may not be possible to turn around.Usually, they described a person whosepersonal suitability to a role was not wellmatched and that no matter how much supportgiven, they might be the right person in thewrong job.

As observed in the case review, there was asense that where small problems arose, poormanagement structures could exacerbate theissue, or become adversarial very quickly. Themoment a process became formal, it was verydifficult to prevent it from becoming adversarialas additional parties usually became involved.Participants suggested as a first step thatmanagers ought to create an environmentwhere good performance was enabled, andthat any interventions into a professional’spractice should be communicated as such.

Several participants mentioned values-basedrecruitment as a method of preventing smallproblems from occurring. They linked this totheir belief that often where competency issuesarose, it was due to ‘the wrong person, in thewrong role’. The more that could be done tomatch the skills of the professional to the caseload or care environment the fewer mismatchesin competency would occur.

The environment for reporting concerns wasalso considered crucial. If an environment ormanagement structure was such that thereporting of concerns about a professional’sown, or a colleague’s, competency, would bemet with a heavy hand, then small problemscould quickly become big problems. Implicit inthe professionals need to be aware of impacts oftheir competency, was that employers supportthem in operating within their competency.‘Open’ or ‘no-blame’ cultures, where mistakescould be deconstructed as learning experiences,were seen as a good way of using smallproblems positively to improve the whole teamor department’s working practices.

“I think the managers of the Trust need toenable the line managers to have enoughtime to supervise, so if there is an early signthat somebody is not achieving what theyshould be doing, then you actually have togo in there and spend a lot of time withthem.”

“Well yes, if becoming demoralised, notperforming as well as they could do, notresponding as well to supervision as theyought to do, failing to keep up withprofessional knowledge as it comesthrough. So disengagement in a sense hasa negative effect of engagement and all thethings that we’ve talked about can beweakened or diminished.”


2.12 Discussion

This study represents an initial exploration intothe complex interplay between competenceand disengagement in a health and social carecontext. It aimed to look at the causes ortriggers for disengagement, and whatinterventions, if any, might prevent health andcare professionals from becoming disengaged.It also explored participants understanding ofcompetency and accountability, and therelationships between competency and theconcept of engagement.

Perhaps surprisingly, there was considerableconsensus across the three groups ofstakeholders who contributed. Table 5provides a summary of the key themesemerging on the triggers for disengagementand Table 6 highlights the consensus views onpossible ways of preventing problems beforethey escalate towards a complaint.

The triggers for disengagement include arange of organisational and psychologicaldimensions. What came across was a sensethat, where working relationships andorganisational support were not adequate,professionals were more likely to becomedisengaged. Although the case review datawas less clear cut, the themes arounddissonance, capability issues and

dysfunctional relationships were evident heretoo. The impact of changes in personalcircumstances, and the lack of insight thatcould accompany these, was also recognisedacross the groups.

Table 5 Consensus triggers fordisengagement

The groups generated a wide discussion on themechanisms that might prevent problems fromdeveloping further. Early identification,intervention, conversation, challenge and supportwere all put forward. Some suggestions wereabout improvements in external frameworks,such as regular supervision, appraisal, buddyingand mentoring schemes and team buildingwhere appropriate. Others were more focusedon encouraging internalised processes such asself-awareness and reflection on practise.Creating a culture of ‘no blame’, one whichencouraged openness and honesty was alsoidentified as an important preventive mechanism.

Triggers for disengagement

• Workload pressures

• Operating outside scope of practice

• Under-utilising skills

• Professional isolation

• Lack of autonomy

• Lack of support for CPD

• Poor or infrequent supervision

• Poor management

• Dysfunctional relationships

• Personal circumstances(bereavement, divorce, financialpressures)

• Blame culture

• Working patterns

“In my experience it was the fact that therewas always a big issue but we were hopingit would get better.”

“The right people performing the right roles,it’s a question of leadership and thatdoesn’t necessarily mean management, butleadership at every level.”

“Recognising the impact of hierarchies,because responsibility exists at each level…

“Forgiveness is a powerful behaviour… notblame, but accountability.”




Table 6 Consensus views on ways ofpreventing problems

Overall, this study has provided new insightsinto the nature and context for disengagementin health and care professions regulated by theHCPC. One of the constraints may have arisenfrom participants differing understanding of theterms ‘competence’ and ‘engagement.’ Giventhat this field of inquiry is very much in itsinfancy in empirical terms, this work should beviewed as a first step towards greaterillumination.

2.13 Methodological limitations

It was disappointing that the interviews withregistrants who had been the subject of acomplaint proved problematic. 23 werecontacted, one interview was completed andtwo contacted the researcher to decline,

stating they felt not enough time had passedsince their final fitness to practise hearing tocontribute to the study. It may be that a longertime lapse between contact and the year inwhich the complaint occurred should havebeen set. Without these first hand reflections,which might have revealed insights intoregistrants’ thought processes, the casereview analysis was only able to provide someinitial observations of some of the links whichwere being explored in the study.

2.14 Conclusions

The data generated clear consensus aroundseveral themes, which could usefully be takenforward into further investigation. Amongst allparticipants in the study, there was aperception that it was possible for engagementto impact on competence and for this to haveconsequences for practice. The character,nature or personal values of a professional, aswell as the support, supervision and workloadpressures could all have an impact. Identifyingtriggers for disengagement early on waspossible in the right circumstances, forexample where a culture of no blame wasencouraged, where professional networkswere strong and where managers wereoffering support for staff.

In attempting to uncover the causes of smallproblems becoming bigger problems in heatlhand care settings, the following areas mayprovide a useful focus for future work anddiscussion, either for the HCPC or for otherswith an interest in this area.

1. The importance of appropriatesupervision

Due to the reported difficulty inaccessing supervision, both due toemployer constraints on time, and theirsupport of the practice, there may be arole for the HCPC in setting moredetailed guidance for supervision ofhealth and care professionals.

Possible ways of preventing problems

• Being valued

• Good team dynamics

• Good supervision

• Regular appraisal and performancemanagement

• Buddying schemes

• Mentoring

• Preceptorship

• Team building exercises

• Professional networks

• Reflective practice

• Self-awareness

• Keeping up to date

• No blame culture


2. Preventive work

a. We suggest conducting furtherresearch into thresholds of concerns,barriers and enablers to reportingsmall problems of health and careprofessionals, to better understandthe conditions under which smallproblems could be prevented frombecoming big problems.

b. Guidance for professionals and theirmanagers could be developed toassist managers in addressing issuesof fitness to practise that have beenself-referred. This should assist thoseexperiencing a crisis to be givenappropriate support.

c. Employers should consider additionalsupport systems for employees toraise concerns and access support,guidance or advice without triggeringdisciplinary processes.

3. Building better relationshipsbetween managers and thosemanaged

There is a widespread concern aboutcapability procedures quickly becomingdefensive and adversarial. A betterunderstanding of supportive methods ofaddressing poor practice should bedeveloped. A complementaryunderstanding of all the factors whichmake the process alienating should beestablished, including:

a. points where the process stoppedbeing supportive; and

b. other factors in disengagement, suchas alienation from colleagues lookingnot to be ‘tarnished by association’.

4. The importance of professionalnetworks

Nearly all participants reiterated theimportance of informal, professionalnetworks in retaining competency and inimproving practice. These networksshould be encouraged and fostered.

2.15 References

Bilton, D, Cayton, H. 2013, Asymmetry ofInfluence: the role of regulators in patientsafety. The Health Foundation.

Boxall, P, Ang, S, Bartram, T. 2011 ‘Analysingthe “Black Box” of HRM: uncovering HR goals,mediators and outcomes in a standardisedservice environment’. Journal of ManagementStudies 48(7):1504-32.

West, M, Dawson, J. 2012, EmployeeEngagement and NHS Performance, TheKing’s Fund, available at:http://www.kingsfund.org.uk/sites/files/kf/employee-engagement-nhs-performance-west-dawson-leadership-review2012-paper.pdf

Whitehead, CR, Austin, Z, Hodges, BD. 2013.Continuing the competency debate: reflectionson definitions and discourses. Advances inHealth Science Education: Theory Practice.2013 Vol18 (1) pp. 123-7



Appendix 1 – Case review summary

Profession Yearregisteredwith HCPC

Complainanttype

Incidentemploymentstatus

Detailsof case

Outcome

Paramedic 2000 Employer Employedwithin NHS

Failed to effectivelysupervise traineeparamedic.Dishonest bycolluding person atemployer to providefalse report.

Struck off

Occupationaltherapist

2003 Employer Employedwithin NHS

Failed todemonstrateappropriateknowledge andmanage time.

Removed byconsent

Biomedicalscientist

2007 Employer Other Inadequateknowledge andskills for role, mademalicious complaintagainst colleague.

Struck off


In possession of anEntonox cylinder atambulance stationwhilst signed offsick. AbusedEntonox or hadintended to do so.

Conditions ofpractice

Speech andlanguagetherapist


Failed to reachsatisfactory level ofcompetencies withassessments andtreatment planning.


Hearing aiddispenser

2010 Employer Employed inprivatepractice

Inadequate recordkeeping and clinicalskills. Over chargingservice users andretaining the money.

Struck off




Complainanttype


Detailsof case

Outcome

Physiotherapist Date notavailable

***

Employer Employed inprivatepractice

Inappropriatetreatment of patientduring treatment.

Struck off

Occupationaltherapist


Failed to maintainrecords,assessments andcommunicateeffectively withpatients andcolleagues.

Removed byconsent

Dietitian 1984 Employer Employedwithin NHS

Misuse ofemployer'smobile phone.

Struck off

Paramedic 2005 Article 22(6)* Employedwithin NHS

Inappropriatelanguage used todispatcher on thephone. Left juniorcolleague to carefor patientunsupervised.

No furtheraction

Radiographer 1977 Employer Employedwithin NHS

Failed to maintainadequate recordsand falsifyingrecords.

Struck off

Speech andlanguagetherapist

2000** Employer Employedwithin NHS

Inadequaterecording keeping,communication andclinical skills.

Caution

Hearing aiddispenser

2010 Employer Not recorded Failed to maintainpatient records andprovide adequateclinical care.

Suspension




Complainanttype


Detailsof case

Outcome

Paramedic 2000 Self-referral Not recorded Inadequate patientand clinical care.

Removed byconsent

Dietitian 1992 Employer Not recorded Shared personalinformation withpatients onFacebook.Inadequate patientcare and recordkeeping.


Biomedicalscientist

2006 Employer Not recorded Failed benchcompetency test,plagiarisedcolleague’s work inwritten evidencesubmitted.



Failed to maintainsatisfactorytimekeeping.Attending worksmelling of alcohol.

Suspension

Radiographer 2010 Employer Not recorded Failed to meet levelof competence.

Suspension

Practitionerpsychologist

2010 Employer Not recorded Inadequate recordkeeping and clinicalskills.

Suspension

Radiographer 2001 Employer Not recorded Lack ofcompetence onclinical procedures.

Struck off

Paramedic 2004 Employer Other Failed to provideappropriate care forpatient and identifyseriousness ofpatients condition.

Struck off

Paramedic 2000 Employer Not recorded Failure to respond toemergency call, gavefalse information,attempted toinfluence witness toprovide falseevidence.

Struck off


*Article 22(6) of the Health and Social Work Professions Order 2001 enables the HCPC toinvestigate a matter where a concern has not been raised in the normal way (for example inresponse to a media report or where information has been provided by someone who does notwant to raise a concern formally).

** date of transfer to HCPC

*** registered by the Council for Professions Supplementary to Medicine, date not available



Complainanttype


Detailsof case

Outcome

Operatingdepartmentpractitioner

2005 Employer Not recorded Self-administeredTramadol whilst onduty. Cared forpatients whilstunder the influenceof this drug.

Struck off

Practitionerpsychologist

2009 Employer Not recorded Rude / insulting toservice user duringassessment, usedinappropriatelanguage in reports.

Caution

Social worker 2012** Professionalbody

Not recorded Failed tocommunicate withextended family toprovide alternativecare for child.Falsified date onletter sent to family.

Struck off

Social worker 2012** Employer Not recorded Displayed poorprofessionaljudgement anddecision making.Inadequaterecording keeping.

Removed byconsent

Social worker 2012** Employer Localauthority

Cautioned forcommon assault bybeating serviceuser.

Suspension


Appendix 2 – Topic guides for focusgroups and interviews

Guides for members of the public,professionals and stakeholders were adaptedto each group.

What constitutes ‘good’ or ‘competent’for HCPC registered professions?

– Perception of skills / ability to help

– Way they communicate about condition/ issue

– Presentation, how professional theyappear

– Knowledge of issues discussed

– Whether they worked in a ‘person-centred’ way

– Assessment guidelines from training orspecific guidance from professionalbodies

– Employer or other frameworks such asjob descriptions or codes of conduct

– Other personal moral frameworks

Topics tested for impact on competency

– Commitment to continuing professionaldevelopment

– When and where completed qualification

– Isolation / sole practitioner

– Working in the community or in a healthor social care facility

– Work-life balance (ie if facing stressfulsituations outside of work)

Topics covered in reference toengagement at work

– Media coverage of health sector

– Perception of how work is recognised /valued

– How involved they are in their team ordecisions about their work

– The priorities of the organisation(financial, care, etc)

– Relationship with line manager (good /bad)

– Patient or case load

– Variety of work or ability to use all theirskills

– Possibility of development / progression

– Your development within the profession

– Access to training

– How an organisation acts on patient andservice user concerns

– How an organisation acts on theirconcerns

– Managing work-life balance

– Perception of senior managers

– Interaction with professional body and /or HCPC

What role do you think engagementplays in how well a health or careprofessional does their job?

– Can engagement mean different things(patients / profession / organisation /team)?

– Does it matter which you are engagedto, are some more important thanothers?

– Do you think a loss of engagement from(patients / profession / organisation / team)could have an impact on competency?What might those impacts be?

Topics covered with reference topreventing small problems

– Informal support, finding out the root ofthe problem

– Performance improvement /management plans

– Training and other support

– Guidance from others in their professionin the organisation

Reasons behind disengagementand competency drift

Workload pressures

Because posts aren’t being filled there’s a riskto competency because you’re being asked todo so much. How can [we] be expected toachieve that? And you feel like you have to say,‘that’s not safe’. (registrant, focus group)

I think…[there] isn’t a focus on constancy, as Isaid before, but a focus on having morepeople for less money. But also looking at howmany patients you can see, rather than thequality of that provision. (stakeholder, interview)

As a result of a restructuring and cuts processin that area… they were left with some veryhigh activity expectations that were difficult tomeet and it made it very hard for them really tothink about their work and to make time foranything else other than face-to-face clinicalwork. (stakeholder, interview)

I was stupid to undertake this amount of workwithout a break but did not wish to let anyonedown. (registrant evidence, case review)

It’s almost a perfect storm of not feelingvalued… the refusal of a pay rise, increasingpressure, members of the public expectingmore, increasing expectations both in qualityand quantity of what you do. All of thattogether is becoming obviously quiteoverwhelming and is leading to somedisengagement. (stakeholder, interview)

I certainly think when you look at what’shappening to ambulance service paramedics,they’re coming under greater time pressure.The Health Service as a body is creaking at theedges for unscheduled care. (stakeholder,interview)

Certainly in the arenas of mental health that’sone of the most difficult areas that we work inand the difference to where you’re going torefer someone, that can often be challengingand requires you to have a very clear head…when you’re working under stress that’s notalways there. (stakeholder, interview)

Working Patterns

The beginning of a night shift is also a busytime for fielding queries from staff finishing theirshifts and also for dealing with vehicle, drug orequipment issues that have arisen in thepreceding twelve hour shift. In other words,there would more often than not, be manycompeting factors for my attention that wouldrequire me to prioritise, and as emphasis wasplaced on maintaining shift cover for thestation, this would inevitably be the chief forme, to the relative exclusion of less immediateconsiderations. (registrant statement, casereview)

Operating outside the scope of practise

There were other occasions when she wouldcontact people in the evening and onweekends about [clinical] issues which she didnot need to do... The out of hours contactappeared to be mostly by email and textmessage rather than by telephone. Again, Ithink this related to time management.(witness statement, case review)

I mean it may be that they don’t have theconfidence to, you know, speak up and say,actually that’s not within my competence so…they kind of have a go if you like and try to dowhatever it is they’ve been asked to do.(stakeholder, interview)

I think [record keeping] is probably the firstthing that goes [when someone becomes

Appendix 3 – Raw data giving examplesof the reasons for disengagement,competency drift and methods ofprevention



Appendix 3 – Raw data giving examples of the reasons fordisengagement, competency drift and methods of prevention

disengaged] and maybe the other thing thatcould happen is people stepping outside oftheir competency so… they’re actually doingthings that they shouldn’t really be doing.(registrant, focus group)

Underutilising skills

It may be that [the practitioner] comes in and justtreat[s] that corn that the patient has come in forbut because they’re disengaged they haven’ttaken into account “Well actually hang on, thatperson’s circulation isn’t as good” or “Why is thatcorn coming?” (stakeholder, interview)

If you have somebody who’s focussing onmanagement then they would do less and lessclinical work and then there will be a tippingpoint over which they’re not doing enoughclinical work to keep up their competency.(stakeholder, interview)

Professional isolation

The concern has been where it’s not just beenindividuals, but maybe whole services havedisengaged from the rest of the profession andbecome like isolated little islands, and that’shad quite an impact. (stakeholder, interview)

Sometimes individuals are just left, they maybe employed in a different bit of anorganisation, they’re isolated in that way andthey’re not necessarily brought in to thedepartment as such, that’s going to becomemore difficult. (stakeholder, interview)

Often she was left on the ward working alonesimply because no one else was available orthey were caring for other patients. Thedetrimental effect of this isolation wascompounded by the fact that [she] was notinvited to attend multi-disciplinary teammeetings for the patients she was caring for.(witness evidence, case review)

One of the issues that we had when theambulance service started putting more andmore people into single responder vehicles and

also that they were closing down ambulancestations and having people waiting for calls justsitting in their vehicles. We were saying thatthey’re underestimating the value of peoplebeing able to chew the fat as it were anddiscuss work issues with colleagues becauseclearly sharing things and sharing experience,you know, it’s one way to enhance yourcompetency. (stakeholder, interview)

The only times [slips in competence] might notbe picked up is when someone is reallyworking in isolation with no kind of monitoring.(stakeholder, interview)

Now audit and review generally has becomemuch more robust across the wholeprofession, but I think there are single-handedpractitioners who now may or may not do thecompetency review of themselves, or get acolleague to do it. (registrant, focus group)

Lack of autonomy

I think the laissez-faire manager actuallyenables people to think independently andenables people to actually... feel in charge oftheir own progression. (stakeholder, interview)

Putting a structure of deciding in advancewhen you’re going to end the treatment meansthat you can’t allow space for the unexpectedto come up and it’s imposing a kind ofconstraint on the therapy that’s going to limitits effectiveness, and various other things likethat. (stakeholder, interview)

You’re not able to take patients through to theiroptimum response if you like. And while thatwas ever there it’s got much worse, so thatactually is quite frustrating for a lot of physios.(registrant, focus group)

Lack of support for CPD

In prosthetics and orthotics sometimes thereisn’t the same opportunity for CPD time, a lot ofemployees would be committed to bespending between 90 and 100 per cent of their


time on a clinical basis without any sort of timeset aside by their employer for their ownpersonal development. (stakeholder, interview)

What we’re very aware of, though, and veryconcerned about, is what we’re hearing as aresult of austerity, is that more and more of ourmembers are being told they’re not allowed togo to CPD opportunities even if they’re free.(stakeholder, interview)

I think access in terms of personaldevelopment in the private sector is purelydown to money, because obviously if you’re ona course you [will] not only have to pay for thecourse, but you lose a day’s pay. So it’s adouble whammy. (stakeholder, interview)

Poor or infrequent supervision

I can think of a situation this year wheresomeone has basically had a sort of abreakdown at work and caused an issue witha patient, it was a very minor thing …but she’dbeen obviously… upset for quite a number ofmonths before that and they hadn’t really gonethrough occupational health with her… If theyhad done and put more processes in place tosupport her then her critical issues wouldn’treally have ever occurred. (stakeholder,interview)

She was on a steep learning curve as far asthese complex patients were concerned andmatters were not helped by the sporadic,confused and unfocused nature of the supportand supervision which she received from theTrust. (registrant evidence, case review)

What will often happen is people will beallowed to make mistake after mistake aftermistake and nothing will be done about it.Nobody will engage with them and say, holdon here. You know, it will be overlooked sowhen it becomes suddenly a huge mistake…(stakeholder, interview)

Yeah, I think early identification of small issues,and certainly quite often small things are

unrecognised by the individual until theybecome big and that’s where the airline havethe use of checklists, the use of proceduresand so on down to an absolute T… Isometimes think that lacks a little bit in theparamedic profession. (stakeholder, interview)

Poor management

I was always open and honest about thestresses at home but aware that there wasnothing we could really do about them. At notime however did my manager sit down withme to review my workload or ask me if I wascoping with my work given the pressure theyknew I was under at home. (registrantevidence, case review)

No concerns were raised by my managerswhenever I requested leave and I just tried tocope with everything, as I felt sympathy waslacking by this point. (registrant evidence, casereview)

If you’re in a team and there’s bullying… [ or a]management style that isn’t supportive, [which]is more …suppressive of innovation, then thatwill make people feel undervalued. (registrant,focus group)

I think you can have weak managers in thesame way you can have weak clinicians, thatget focused on an objective and actually losesight of what’s happening day-to-day.(stakeholder, interview)

Yeah, there are certainly occasions where[practitioners are disciplined too soon], nowsometimes it’s a personality issue or there’s abreakdown in relationships, but sometimes it’sjust there isn’t somebody in post who canthink of a different way of managing a situation.(stakeholder, interview)

Dysfunctional relationships (at work)

Is there a fear of reprisal if you do raise yourhand and say this isn’t safe or competentpractice? (registrant, focus group)




There’s a lot of restructuring within health andsocial care and I’m just thinking of someexamples we’ve had recently where there issort of a temporary disengagement especiallywith the employer where people’s terms andconditions of work are either threatened orchanged, and it’s as if they, it’s as if, I supposethey’re still engaged, but they’re engagedantagonistically or they’re engaged in terms ofthey feel hurt because something that theyhad, that they were secure within has beenchanged or shifted. (stakeholder, interview)

We tend to hear of situations like bullying orwhen somebody is disruptive within a team sotherefore the team dynamics are unhealthy shallwe say and inevitably then that does affectsomebody’s work. (stakeholder, interview)

If you had a poor relationship with yourcolleagues then again that could createisolation… within your department that youwork and it may limit that sharing of skills[and] knowledge between the team.(stakeholder, interview)

Staff were completely used to doing what theywanted… they were a team that were used togetting their own way and didn’t like to bechallenged. (registrant, focus group)

Personal circumstances (bereavement,divorce or financial pressures)

I was also under stress due to personalcircumstances at that time. My ex-husbandcame round to tell me I had to sell the maritalhome… It was very stressful having buyersround, looking at other houses andcontemplating moving into rentedaccommodation. (registrant evidence,case review)

She had an accident at work... It was a nearfatal accident and she suffered from post-traumatic anxiety disorder and that’s during theperiod where she is having to complete thisportfolio… (witness evidence, case review)

At that particular time I was under a lot ofpressure from three simultaneous major lifeevents: partner being diagnosed with cancer,being treated and informed that [the] cancerwas terminal; moving house and location aswell as starting a new job. (registrant evidence,case review)

I think we often find when people are strugglingat work… there are often elements elsewherethat are affecting their struggle at work, so itmay be that there’s issues at home, it may bethat there’s health issue and inevitably whenthere are too many stresses then performancegoes downhill. (stakeholder, interview)

Poor support from head office and myworsening health all contributed to the eventsthat followed. My need to support my childwho had just been diagnosed with [acondition] was paramount and led to my focusbeing on little else. Nothing else seemedimportant. (registrant evidence, case review)

Blame culture

Well there can be quite a large blame culture ofcertain employers which is, you know, they’reimmediately thinking of… are we going to getsued for that, are we going to get sued forthat, do we need to discipline them and makean example of them and I think, you know,sometimes that’s justified, but sometimespeople are treated in a punitive way wherereally, you know, there needs to be a bit moreof a constructive approach particularly takenearly on. (stakeholder, interview)

The bullying type of management culture in theNHS… stops people being as open andhonest as we would want them to be, and Isuppose if we wanted to have an aspiration itwould be to be like the airline where they havea culture of open, honesty and putting theircomplaints on the table. It’s not like a no blameculture because you can never really have a noblame culture. If you’ve done something wrongyou need to take the blame for that, but they


worked really hard to get themselves on thatopenness. (stakeholder, interview)

Preventing problems in healthand care

Being valued

If your work’s not valued or you feel that… yourwork’s not valued then it could, you could feelnot as supported as others. It could bedemoralising. (stakeholder, interview)

On the professional side of things you need tofeel that you’re valued or that you’re recognisedin your work, and again that could be down torewards from your employer or based on just adiscussion from your line manager or yourpersonal development review that you’reactually meeting your goals and targets you setout to achieve. (stakeholder interview)

I mean a lot of [being engaged] is about feelingvalued… and that’s from your employer butalso the people that you’re delivering a serviceto. (stakeholder, interview)

It will also be whether they feel valued in whatthey’re doing, both by the patients and howthey respond to them but also by theiremployer. (stakeholder, interview)

I think that’s very important, and I don’t thinkthat always happens... I don’t think there’salways a culture of positive reinforcement,positive acknowledgement of the value andworth of somebody who is doing a very skilledjob…and if that isn’t heard then they could feeldisengaged. (stakeholder, interview)

Good team dynamics

Engagement is likely to happen when peoplehave got clarity of their own objectives andunderstand what the organisation is trying toachieve, a good team setting and goodmanagement and leadership. So all of thosethings will support engagement. (stakeholder,interview)

If there’s a team you’re asked “How do youthink this treatment is going to help patients orhow shall we implement this service?” And theyfeel part of the process rather than being turnedround and told “Right from now on you’re justgoing to treat in this way and you’ve got novoice in the matter. (stakeholder, interview)

I think if you feel that the manager has at leastlistened to you and your colleagues’ point ofview and have taken that into account thenagain you feel more engaged with work andwith how you’re being treated at work and thenI think you reflect that then within the way youwork. (stakeholder, interview)

[Engagement is] also working as part of awider team to say, “Well, if we’re all in ittogether, how do we actually make this workas a team?”, because, you know, theworkforce is beyond just the speech therapyprofession. (stakeholder, interview)

One of the things it’s important to underpin [in]your competency is decision support and it’svery much about trying to say that we’re partof the health team you know, paramedics thatwork in GP surgeries are very well supportedon their decision making and they can referback to someone when something is out withtheir experience. (registrant, focus group)

Good supervision

For example we do have a principle socialworker for adult services and she has acompetency framework and managers canchoose to use that in supervision if they wish.(stakeholder, interview)

So if there’s a proper management orsupervision arrangement in place then thesethings should be picked up sooner rather thanlater. And one of the objectives of goodmanagement and supervision is to identifyearly issues and… stop them getting worse.(stakeholder, interview)




We also push for professional support in someway, supervision is very strong withinoccupational therapy and especially wheresomebody is a relatively new practitioner goinginto perhaps a diverse role or a lone workingsituation we will encourage them to seekprofessional support. (stakeholder, interview)

I think support structures and havinginfrastructure where they know they can go tofor different types of supervision, whetherthat’s clinical, [or] whether that’s peer supportand mentoring. (stakeholder, interview)

I mean that’s part of what clinical supervision isfor, and management supervision is for too, soyou would hope you might be able to pick[slips in competence] up through either or bothof those. (registrant, focus group)

I think it’s vital, if you’ve got support from yourline manager then you’re going to feelconfident about going out and doing your job,and there is a huge variety in the competencelevel of line managers across the NHS.(registrant, focus group)

Regular appraisal and performancemanagement

I think the professional planning for your PDRhelps to motivate professionals to achievemore or improve their skills and knowledge.(stakeholder, interview)

They should begin to pick up on issues [thatmight suggest a slip in competence] if they’redoing proper robust professional developmentreviews. (stakeholder, interview)

Line managers should undertake regularsupervision which would discuss clinicalperformance, again, that is very patchy interms of it actually happening and so it varies.(registrant, interview)

Without [competency frameworks] you haven’tgot benchmarks and you haven’t got aconsistent standard that you apply to all of

your staff. So for me it’s about consistency ofstandards, consistency of expectations, andfair treatment of staff, because they’re alljudged against the same backgroundframework. (stakeholder, interview)

Buddying schemes, mentoring andpreceptorship

I think they need support in their decisionmaking. They need to have a culture where theycan walk in and talk to a mentor or someone togo, “I’m struggling a bit”, and they need to knowthat when action is taken on that where they’restruggling, that is supportive and beneficialrather than punitive. (stakeholder, interview)

I think there’s two types in my experience,there’s formal mentoring which students andso on have, but there’s also an informal typethat goes on where they’ll be people on yourstation or in the area where you work who arenatural mentors, naturally experienced in youknow, help and support. Paramedics are reallygood at supporting each other and the messroom culture is really quite important in that.(stakeholder, interview)

[When a mistake has been made] sendingsomeone on a course is not necessarily thebest thing for that person, it may be that theyneed to do some sort of shadowing ormentoring. (witness statement, case review)

Mentoring, partnering, practice supervisionbetween individuals, there’s one or two placeswhere a few maybe getting together to providecareer structure and to work together onparticular projects you know, so there’sdifferent things [freelance practitioner groupsare] putting in place. (stakeholder, interview)

I think peer support networks are reallysuccessful in making that type of thing happen,and I think the professional body has a role insetting up some networks that will provide thatlevel of support. (stakeholder, interview)


Team building exercises

Having team building exercises every so oftencould help [with engagement], withindepartments or across the departments.(stakeholder, interview)

Professional networks

Now what we always suggest is that loneworkers find some kind of link into otherseither in their field or in their region, in thelocality. It’s something we push very much for.(stakeholder, interview)

By interacting with other professionals it offersan opportunity to share certain new skills andknowledge between professionals. (registrant,focus group)

We’re trying to strengthen those professionalnetworks and engagements as far as wepossibly can. (stakeholder interview)

Reflective practice

I wouldn’t necessarily want to see someonehaving to be tested all the time, but you couldget them to do a reflective log. They should beshowing [their continued competency].(stakeholder, interview)

Well, [competence is] understanding how theirknowledge, skills and experience links to thejob that they are doing and their scope ofpractice, and being self-reflective and aware ofif they have gaps in any of that. (stakeholder,interview)

Self-awareness

We expect employers to support us inachieving our CPD, but it’s our responsibility tomake sure that we identify our needs.(registrant, focus group)

Because competency requires you to becontinually learning, and it requires you to bealert to where the gaps might be and wherethe new things to learn might be. Engagement

is about being awake to those things.(stakeholder, interview)

Because jobs are very difficult to get in theNHS, and I think it’s certainly... since 2006 ithas been, [we’ve] had a lot of newly qualifiedliterally going into setting up their own practiceand taking whatever patients walked throughthe door, with not necessarily understandingtheir own personal scope of work.(stakeholder, interview)

Keeping up to date

It’s not just going in and doing the same thingon a daily basis. It’s taking an interest outsideof your immediate work environment. Sowhat’s the strategic environment in whichyou’re working, what’s new within yourprofession. So reading your magazines, thejournals, being aware when new guidance ispublished, engaging in debate and discussionwith your colleagues, reflecting on your ownpractice and looking to see, you know, whereyou might need to improve. So it’s a number ofdifferent indicators that would show to me thatsomebody’s engaged. (stakeholder, interview)

People who work independently oforganisations tend to take their professionaldevelopment and updated knowledge muchmore seriously because of the risk ofbecoming disengaged from mainstreampractice. (stakeholder interviews)

It’s no good just going on a course, doing thecourse or… getting qualified and then thinkingthat’s it, that’s the end of the process, becauseyou soon forget what they’ve taught you on acourse unless you’re doing it all the time… Soyou still need to have that further engagementwith either other people or reading around… tothen keep on top of that information andreminding yourself why you’re doing it andwhat you’re doing it for, to keep that learninggoing and those competencies going.(stakeholder, interview)




No blame culture

I mean, again having no-blame... The messageneeds to get out to people that, you know,everybody makes mistakes… We allsometimes have off days… and encouragingpeople to be open about that [because]people’s registration becomes more at risk, notbecause of the actual incident, but because ofhow they’ve behaved after it… If you’ve got anemployer that is a very punitive… and peopleare afraid to admit to something they mighthave done wrong, then they’re going to try andbury it, and that’s going to cause moreproblems. So I think you’ve got to have aculture of openness and move away from thesort of blame game that a lot of employers liketo play. (stakeholder, interview)


Notes

This document is available in alternativeformats and Welsh on request.Call 020 7840 9806or email [email protected]

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