Australian Occupational Therapy Journal (2015) 62, 150–159

doi: 10.1111/1440-1630.12204

Review Article

Conceptualising professionalism in occupational therapy through a Western lens Chelsea J. Hordichuk,1 Allison J. Robinson2 and Theresa M. Sullivan3 1 Student Support Services, Maple Ridge, BC, 2Health Sciences Centre, Winnipeg, MB, and 3Department of Occupational Therapy, University of Manitoba, Winnipeg, MB, Canada

Introduction: The term professionalism is embedded within curriculum and occupational therapy documents, yet, explicit discussion of the concept is lacking in the literature. This paper strives for a greater understanding of how professionalism is currently conceptualised within Western occupational therapy literature. Methods: A broad literature search was conducted and included international peer-reviewed and grey literature from Western cultures including Australia, Canada, New Zealand, the United Kingdom and the United States. To enrich understanding, some documents from medicine were also included. Findings: Professionalism is widely upheld as a core construct of occupational therapy. However, an evidencebased consensus of the specific elements of professionalism guiding occupational therapy practice is lacking. Currently, understanding of professionalism is largely based on multiple, isolated concepts presented in Western professional association documents. Relevance to Clinical Practice: Acknowledging the multifaceted and multicultural nature of professionalism is essential to begin systematically delineating and conceptualising elements of professionalism specific to occupational therapy. Limitations: This review has been conducted from a solely Western cultural lens.

Chelsea J. Hordichuk BA, MOT, OT Reg. (BC); Occupational Therapist. Allison J. Robinson BSc, MOT, OT Reg. (MB); Occupational Therapist. Theresa M. Sullivan BSc (OT), MA; PhD (Candidate), Associate Professor. This research was primarily conducted at the University of Manitoba (R106-771 McDermot Avenue, Winnipeg, Manitoba, Canada, R3E 0T6) between September 2010 and October 2014. Correspondence: Chelsea J. Hordichuk, Student Support Services, School District No. 42, 23000 116th Avenue, Maple Ridge, BC V2X 0T8. Email: [email protected] Accepted for publication 3 April 2015. © 2015 Occupational Therapy Australia

Recommendations for Further Research: Additional work to highlight differences specific to international contexts, cultures, and societal influences is needed to enrich the understanding of professionalism in occupational therapy practice. KEY WORDS occupational therapy education, occupational therapy process/competency standards, occupational therapy professional attitudes and behaviours.

Introduction The term professionalism is embedded within curriculum and professional documents of various health professions in the Western world, yet recently, the Health Professions Council of the United Kingdom stated that there is ‘very little published research on “professionalism” in the professions we regulate’ (Health Professions Council, 2011, p. 1). An understanding of professionalism is commonly assumed rather than clearly explained (Bryden, Ginsburg, Kurabi & Ahmed, 2010; van Mook, de Grave, et al., 2009) thus, explicit description and examination of this complex concept is often overlooked. Hoff (2000) commented that authors’ discussions of professionalism at an abstract level are reasonable; yet, without further definition and integration, enacting the concept is unachievable, particularly within increasingly complex realities of practice. Increasing globalisation of practice adds to the challenge of understanding professionalism across cultures (Jha, Mclean, Gibbs & Sandars, 2015). Clarifying the language used to describe professionalism is an important starting point for exploring the concept (Bryden et al., 2010). For the purposes of this paper, the term professionalism will be used as a noun, referring to an over-arching concept that encompasses key ideals specific to a profession. The term profession will refer to a particular health occupation (e.g. the occupational therapy profession). Unless otherwise specified, the term professional will be used as an adjective to describe elements

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that comprise and constitute professionalism (Robinson, Tanchuk & Sullivan, 2012). In the Western world, literature on the topic of professionalism in health care professions is growing due to the realisation that this concept must be explicitly taught and fostered within future generations of health care practitioners (Bryden et al., 2010; van Mook, de Grave, et al., 2009). Western health care practitioners are expected to uphold a high level of professionalism (McNair, 2005). Occupational therapists interact with a variety of individuals who occupy different roles, making professionalism a pre-requisite for successful and effective interactions in practice (Aguilar, Stupans, Scutter & King, 2012; Fidler, 1996). Current literature highlights the need for profession-specific understanding of professionalism due to the inherent differences between professions, such as values, legal frameworks, and ethics (Aguilar, Stupans, Scutter & King, 2013; Bryden et al., 2010; McNair, 2005; Robinson et al., 2012). This diversity accounts for a degree of the variability that exists between professions and why professionalism ‘definitions’ may not be transferable, thus, reinforcing the need for explicit discussions of professionalism within the field of occupational therapy (Aguilar, Stupans, Scutter & King, 2014). There is limited occupational therapy literature focused on a profession-specific definition of professionalism (Aguilar et al., 2013; Bossers et al., 1999; Robinson et al., 2012). Similarly, occupational therapy professional association documents do not explicitly define professionalism (American Occupational Therapy Association, 2010; Association of Occupational Therapy Regulatory Organizations, 2011; Canadian Association of Occupational Therapists, 2012; Occupational Therapy Australia, 2010; Occupational Therapy Board of New Zealand, 2004). Occupational therapy students, faculty, and clinicians are expected to exemplify professionalism, without a consensus among the profession of what professionalism means or how it is practiced (Birden et al., 2014). Lack of consensus may be due to the fact that professionalism is a socially constructed concept (Crotty, 1998) thus, understandings and practitioner expectations are influenced by culture(s) and context. Adding to the void in understanding is the fact that almost all of the documents listed above are written solely from a Western world perspective. Ambiguity, limited understanding of professionalism across cultures, and lack of evidencebased literature hinder the ability to educate, evaluate, and support professionalism, especially in circumstances where an individual is said to lack professionalism. The purpose of this paper is to explore and achieve a greater understanding of how the concept of professionalism is currently conceptualised within Western occupational therapy literature. First, we will explore professionalism as a concept using some medical

articles for context, and then move to a discussion of reoccurring elements of professionalism found in existing Western occupational therapy literature including: professional values, and ethics, and professional behaviours. Finally, we will conclude with a discussion of the gaps in the literature and future directions for research.

Methods A literature review on professionalism in occupational therapy and medicine was conducted within PubMed (1995 to 2014), CINAHL (1995 to 2014) and SCOPUS (1995 to 2014) databases using the search terms: occupational therapy, medicine, defining, definition, understanding, components, professionalism, professional, professional attitudes, behaviour, behavior, social networking, media, practice and values in an assortment of combinations. Proximity operators and title search options in the SCOPUS and CINAHL databases were used as a means of retrieving the most relevant articles. All articles retrieved from searching the named databases and reference lists were hand-sorted to include only relevant articles. Consensus between the authors was obtained using pre-determined exclusion and inclusion criteria. Articles pertaining to professionalisation, professional socialisation, professional development, inter-professionalism, and the occupational therapy profession that did not discuss elements of professionalism were excluded. Articles included met the following criteria: (i) were published in English and contained named search terms; (ii) had content relating to the conceptualisation and/or discussion of elements of professionalism; (iii) were published in last two decades (since 1995); and (iv) applied to either the profession of occupational therapy or medicine (Note: For the purposes of this review, the term medical literature or medical articles will refer to literature from the medical profession). Medical literature was included as it offers a number of high quality, definition-focussed studies examining the concept of professionalism, providing valuable insights and potential directions for the field of occupational therapy. Inter-professional articles that included the medical or occupational therapy professions were also included in order to enrich contexts and discussions. Other professions were excluded in order to maintain focus on the occupational therapy profession. To expand the scope of our exploration, documents published by national occupational therapy professional associations discussing professional expectations, standards, ethics and essential abilities relating to professionalism were also included. Inclusion was dependent on the rights and public access of the individual documents. For this review, we limited inclusion to five countries: Australia, Canada, New Zealand, United Kingdom and the United States. © 2015 Occupational Therapy Australia

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Findings

Professionalism in occupational therapy

Professionalism as a concept

In Western societies, occupational therapy is an ‘autonomous, self-regulated [profession]’ (Canadian Association of Occupational Therapists, 2012, p. 3), consequently, occupational therapists are expected to demonstrate a high level of professionalism. Though the importance of professionalism in occupational therapy is not disputed, literature focusing primarily on exploring the concept of professionalism is limited. Rather, fragments of professionalism elements are present throughout occupational therapy documents and literature – requiring the reader to analyse, interpret and link various professionalism elements to try to gain an understanding of the concept as a whole (Aguilar et al., 2013; Robinson et al., 2012). Few articles related to the overall conceptualisation of professionalism exist in occupational therapy. Among them, one article by Bossers et al. (1999) conceptualised professionalism for Canadian occupational therapists. The researchers in this study developed a schemata outlining three primary elements of professionalism – professional parameters, professional behaviours, and professional responsibilities. Similar studies could be conducted to validate the schemata and expand upon study findings, particularly with different stakeholders, cultural groups and in a variety of geographic regions. Americans Kasar and Muscari (2000) offered their opinion of professional behaviours as overt demonstrations of one’s values and attitudes. Another American, Wood (2004), suggested elements of professionalism share symbolic relevance to the heart, mind and soul of the profession – alluding to the intrinsic nature of professionalism. These authors have begun the analysis of professionalism specific to occupational therapy. However, they do not offer consistent opinions or empirical evidence supporting the concepts presented. Recently, authors within occupational therapy have begun to conduct studies of professionalism in consideration of societal context, adding evidence-based discourse to existing researcher opinions, and discussions within professional association documents (Aguilar et al., 2012, 2013; Mackey, 2014; Robinson et al., 2012). Aguilar et al. focussed their work on identifying professional values and behaviours specific to Australian occupational therapists. Mackey examined occupational therapists’ conceptions of professionalism in England, while Robinson et al. (2012) completed a study exploring Canadian occupational therapy students and faculty perceptions of professionalism. Dialogue on topics related to professionalism in occupational therapy can also be found within professional standards and competency documents published by national occupational therapy organisations. These documents serve as evidence of the significance, relevance and value of conceptualising professionalism in both a societal and profession-specific context.

Professionalism has been repeatedly acknowledged within the literature as a challenging concept to define (Bryden et al., 2010; Rogers & Ballantyne, 2010; van Mook, van Luijk, et al., 2009). Jha, Bekker, Duffy and Roberts (2006) found that when asked, medical students, physicians, faculty and allied health workers all struggled to define professionalism. Participants seemed to know what professionalism was, yet they had difficulty articulating the concept. Similarly, Bryden et al.’s (2010) focus group participants discussed the difficulty of defining the abstract idea of professionalism. One participant stated, ‘We don’t have a language to label it [professionalism], we don’t have a clear construct to define it, and therefore we don’t have a good way of measuring it when it’s not working’ (p. 1029). McLachlan (2010) questioned the need to define professionalism because individuals claimed to, ‘know it when they see it,’ or ‘know it when they don’t see it’ (p. 38). A further challenge to understanding the term professionalism is that it is not a static concept (Bryden et al., 2010); rather, it is dynamic, continuous and ever-changing. In addition to the governing profession, society too plays a role in defining professionalism. The unwritten expectations of professionals held by society are constantly evolving, and being re-defined – causing the definition of professionalism to exist in a constant state of flux (Birden et al., 2014; Bryden et al., 2010; Jha et al., 2015; Khalili, Hall & DeLuca, 2014). van Mook, van Luijk, et al. (2009) added that professionalism must be capable of adapting to the influences of society. Mackey (2014) led a study focused on reconstructing notions of professionalism within occupational therapy guided by the view that ‘professionalism is a dynamic, complex process which requires flexibility in adaptation and interpretation (p. 169).’ Occupational therapists interviewed in Mackey’s study struggled to answer what professionalism means in a modernising health care environment. She found that occupational therapists are not only challenged to define professionalism, but also to apply and adapt the notions of professionalism to experiences convoluted by cultural constraints, workplace practices, and discrepancies between individual and organisational definitions. Navigating this process suggests the need for reflexivity and ethical decisionmaking and a ‘professional conversation’ (p. 175). She described this professional conversation as a reflexive dialogue and reasoning process dictating interactions with others based on calculated considerations of the self, experience, and societal expectations. These concepts are parallel to Robinson et al. (2012) discussions, who described professionalism as a ‘dynamic, contextspecific concept requiring experience, awareness, and reasoning to arrive at an understanding’ (p. 281).

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In Australia, Occupational Therapy Australia (OTA) defined professional competence as ‘a complex interaction and integration of knowledge, judgment, higher order reasoning, personal qualities, skills, values and beliefs’ and ‘a construct that is both abstract and tangible’ (2010, p. 4). In other words, professional competence is the continuously changing knowledge and skills expected of a professional (Allen, Oke, McKinstry & Courtney, 2004). These definitions suggest that the themes of professionalism are not mutually exclusive. Rather, there is overlap between professional competencies, professional behaviours and professional values. Kasar and Clark (2000) acknowledged the overlap, conceding that professional behaviours are rooted in professional values and guided by professional standards. In Canada, the document Essential Competencies of Practice for Occupational Therapists in Canada (Association of Occupational Therapy Regulatory Organizations, 2011) discusses professionalism in two of the seven units: Unit 1, ‘Assumes Professional Responsibility’ (p. 23) and Unit 6, ‘Engages in Professional Development’ (p. 35). Unlike behaviours and values, these sections define therapists’ responsibility to know their personal limits and abilities, highlighting the importance of selfawareness and professional accountability. In the Profile of Occupational Therapy Practice in Canada 2012 (Canadian Association of Occupational Therapists, 2012) an occupational therapists’ role as a professional (noun) is explicitly defined and described using key terms and phrases, including: ‘autonomous, self-regulated. . .manage their personal and professional limits, . . .embracing of appropriate attitudes and behaviours. . . integrity,. . . altruism, . . .attention to diversity and injustice,. . .personal well-being, . . .critical inquiry,. . . and the promotion of public good within their domain’ (p. 6). Though this explicit discussion of what ‘professional’ (noun) means to occupational therapy practice is valuable, this document does not provide a definition and/or description of the concept of professionalism.

Elements of professionalism Professional values and ethics Professional values and ethics provide a structure for practitioners to refer to, facilitating trustworthy, competent and equitable practice. Values involve morals and beliefs about what is wrong and what is right (Kanny, 2000). Youngstrom (1998) noted that professional values are the hardest component of professionalism to conceptualise because they are subjective and rooted in ethical connotations. The term ethics ‘is used to describe the understanding of moral issues from a broader perspective’ (Kassberg & Skar, 2008, p. 204). Acknowledging where personal values and ethics align and conflict with occupational therapy professional values and ethics is important to ensure reflective practice (Kanny, 2000; Kassberg & Skar, 2008; Kinsella, Park, Appiagyei, Chang

153 & Chow, 2008). Values and ethical responsibilities (one’s sense of what is important, of what is right and wrong) inform and direct professional behaviours which in turn, affect one’s level of professionalism (Aguilar et al., 2012, 2013). Within occupational therapy literature and national documents, core values of the profession are outlined: client-centred practice, meaningful occupation, occupational performance, respect for cultural values, environment, personal capabilities and health (Canadian Association of Occupational Therapists, 2012; Holmes & Scaffa, 2009; Occupational Therapy Australia, 2010; Peloquin, 2005). These professional values inherently link to personal values of occupational therapy practitioners, affecting daily practice (attitudes, decisions, reasoning and attitudes), and contributing to one’s professional identity (Drolet, 2014). Codes of ethics documents reflect similar ethical principles: autonomy, beneficence, non-maleficence, and justice (American Occupational Therapy Association, 2006, 2010; Occupational Therapy Australia, 2010). Some authors suggest the values and ethics that a person holds both personally and professionally provide a foundation for their personal and professional behaviour (Aguilar et al., 2012; Drolet, 2014; Kanny, 2000; Kinsella et al., 2008). In the Guidelines to the Occupational Therapy Code of Ethics (American Occupational Therapy Association, 2006), professional behaviours are tied to specific ethical standards, outlining their cooperative interplay. Therefore, reflecting on one’s own values is critical to understanding and ensuring professional behaviour (Aguilar et al., 2012, 2013; Kanny, 2000; Kasar & Muscari, 2000; Robinson et al., 2012). Aguilar et al. (2012) acknowledged the need for explicit discussion of values related to professionalism in occupational therapy. Their research found three value categories: ‘The client and client-therapist partnership’ (p. 211); ‘Occupational therapy knowledge, skills and practice’ (p. 212); and ‘Selfless values’ (p. 214). Aguilar et al.’s study is an important step forward in providing a current, explicit examination of an acknowledged element (professional values) of professionalism in occupational therapy. These same authors published another study (2013) using the Delphi technique to begin to define professionalism specific to Australian occupational therapy practice. Sixty-one values were identified by study participants that related to four areas: ethical practice, client-centred practice, contemporary practice and the foundational beliefs of the profession. These authors have consistently highlighted the significant role values play in occupational therapy professionalism. Recently, Drolet (2014) conducted a qualitative review of value statements within existing occupational therapy literature and professional documents, finding that there is conceptual confusion about what constitutes a ‘value’. Drolet’s discussion provides clarity, explaining how val© 2015 Occupational Therapy Australia

154 ues differ from commonly confused terminology such as beliefs, attitudes, principles, social norms or non-evaluative concepts. She defined a value as ‘an abstract, evaluative concept that serves to determine the ethical validity of an attitude, action, or situation’ (p. 7). Drolet also noted that there is significant variety and inconsistency among the values named and identified within occupational therapy literature. Despite this inconsistency, the majority of literature she examined identified the value of occupational participation. Professional integrity is a value commonly discussed in occupational therapy literature and national association documents, implying its importance to professionalism (Bossers et al., 1999; Canadian Association of Occupational Therapists, 2012; College of Occupational Therapists of the United Kingdom, 2010 [COTUK]; Kassberg & Skar, 2008; Kinsella et al., 2008). The OTA Code of Ethics (2001) document outlines professional integrity as one of four main statements; the subsections of the professional integrity statement include discussion of how one’s personal values are intertwined with their professional integrity through the provision of examples such as discrimination, and abuse of drugs or alcohol. Similar to the Australian document, the COTUK dedicated a section of their Code of Ethics and Professional Conduct document to ‘Personal/Professional Integrity’ (p. 20), suggesting different types of integrity exist. Under ‘Personal Integrity’ (p. 20), ‘criminal/ unlawful behavior’ (p. 20) and ‘relationships with service users’ (p. 21) are discussed. Included under ‘Professional Integrity’ (p. 23), are subjects such as ‘fitness to practice’ (p. 24), ‘substance misuse’ (p. 24), ‘personal profit or gain’ (p. 25), and ‘information and representation’ (p. 25). Although literature and professional documents provide some information about how an occupational therapist should and should not act in order to demonstrate professional integrity, more extensive discussion and exploration of this element would be beneficial, including whether integrity is solely a value or if it also encompasses behaviours. Some occupational therapy literature regarding ethical dilemmas suggests that integrity is a balancing act between professional values and situational expectations (Kassberg & Skar, 2008; Kinsella et al., 2008). Kinsella et al. examined students’ experiences of ethical tensions during fieldwork placements. Professional integrity was reported to be challenged when values of the profession conflicted with values of a practice setting. However, a description of professional integrity was not offered. Kinsella et al. call for a sound understanding of expected professional and personal integrity to enable occupational therapy students and practitioners to better respond to ethical conflicts. Mackey’s (2014) findings echo these sentiments, describing occupational therapists’ experienced tensions between negotiating expectations of their workplace while maintaining internal professional values. Occupational therapists felt © 2015 Occupational Therapy Australia

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pressure to transform to conflicting values in order to succeed, consequently causing confusion and ambiguity regarding their professional values (i.e. to whom they are accountable – their client or their workplace manager). Other noted themes of important ethical standards in occupational therapy are: reflection, professional development, and commitment to lifelong learning (Association of Occupational Therapy Regulatory Organizations, 2011; Canadian Association of Occupational Therapists, 2012; College of Occupational Therapists of the United Kingdom, 2010; Occupational Therapy Australia, 2010; Occupational Therapy Board of New Zealand, 2004; Schultz-Krohn, 2009). These themes will not be explored further as part of this review; readers are referred to the above cited authors/documents for further elaboration.

Professional behaviours Seemingly the most frequently mentioned element of professionalism in the occupational therapy literature are professional behaviours (Aguilar et al., 2012, 2013; Association of Occupational Therapy Regulatory Organizations, 2011; Bossers et al., 1999; Canadian Association of Occupational Therapists, 2012; College of Occupational Therapists of the United Kingdom, 2010; Hubbard, Beck, Stutz-Tanenbaum & Battaglia, 2007; Kasar & Clark, 2000; Kasar & Muscari, 2000; Occupational Therapy Australia, 2010; Occupational Therapy Board of New Zealand, 2004; Randolph, 2003). However, few authors clearly describe what is meant by ‘professional behaviour’, nor offer a consistent outline of what behaviours are critical. In Aguilar et al.’s study (2013) there was a ‘clear disparity in participant’s opinions’ (p. 206) of what constitutes essential professional behaviour. The lack of a consistent operationalised definition of professional behaviour in the literature demonstrates the complexity and the dynamic meanings of this element of professionalism. Professional behaviours are often considered the most crucial learning outcome for occupational therapy students (Fidler, 1996; Randolph, 2003; Scheerer, 2003), and are essential to make a successful transition from the classroom to a clinical setting (Koenig, Johnson, Morano & Ducette, 2003). Carroll et al. (2002) recognise that the lack of a consistent definition of professional behaviour poses challenges when developing a curriculum for occupational therapy students.

Professional image, communication, and collaboration Some authors have sought to identify the professional behaviours required of occupational therapists and students (Aguilar et al., 2013; Bossers et al., 1999; Fidler, 1996; Kasar & Muscari, 2000; Koenig et al., 2003; Randolph, 2003). When examining literature and professional association documents, professional image, communication, and collaboration are commonly mentioned professional behaviours (Association of Occupa-

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tional Therapy Regulatory Organizations, 2011; Canadian Association of Occupational Therapists, 2012; College of Occupational Therapists of the United Kingdom, 2010; Kasar & Clark, 2000; Occupational Therapy Australia, 2010; Occupational Therapy Board of New Zealand, 2004). Though these terms are often mentioned as required professional behaviours, they are rarely explicitly described or defined. Kasar and Muscari (2000), Larkey (2000) and Davys, Pope and Taylor (2006) have suggested that professional image affects other’s interpretation of a practitioner’s competence. Davys et al. debated notions of personal choice versus the importance of meeting professional expectations in occupational therapy and society. This opinion piece is ‘based on a lunchtime discussion between three occupational therapy lecturers’ (p. 339) and offers interesting dialogue regarding professional image. However, it lacks in-depth critical analysis and evidence of this topic. Bossers et al. (1999) also noted presentation as a component of professional behaviour, specifically outlining aspects such as image and dress/ grooming. However, there was no further elaboration. Robinson et al. (2012) led a study comparing second year master of occupational therapy students and faculty members’ perspectives of professionalism. Students identified professional image as a key component to one’s professionalism, expressed confidence in their ability to demonstrate this component, and explained that putting forward a professional image helped them compensate for their lack of professional experience. However, the Robinson et al. study also had limitations due to use of a convenience sample drawn from a narrow geographical area and inclusion of a limited variety of stakeholders. Communication is a frequently mentioned professional behaviour, yet it also lacks explicit discussion (American Occupational Therapy Association, 2006; Bossers et al., 1999; Canadian Association of Occupational Therapists, 2012; College of Occupational Therapists of the United Kingdom, 2010, 2011; Fidler, 1996; Occupational Therapy Australia, 2010; Occupational Therapy Board of New Zealand, 2004). The Occupational Therapy Board of New Zealand (2004) outlined communication as one of seven competencies for registration as an occupational therapist. Verbal and written communication is discussed within the performance criteria (or behaviours) that demonstrate competent communication. Similar to the New Zealand document, the Profile of Occupational Therapy Practice in Canada 2012 (Canadian Association of Occupational Therapists, 2012) included ‘communicator’ as one of seven roles essential to occupational therapy practice. These roles are outlined with enabling competencies, or example behaviours of what a competent and proficient occupational therapist should demonstrate. Second-year occupational therapy students also identified communication as a key component to professionalism (Robinson et al., 2012).

Findings of this study revealed some of the specific attributes of communication that were perceived to be important for professionalism, providing insight and clarity to how this component relates to professionalism from a student perspective. Fidler (1996) and Kasar and Muscari (2000) discussed the importance of collaboration in occupational therapy. Canadian Association of Occupational Therapists (2012) also outlined ‘collaborator’ as one of seven essential roles. Similarly, the COTUK’s Code of Ethics and Professional Conduct document (2010) outlined collaborative working as a key component to professional practice. Though this document did not outline collaborative working overtly as a professional behaviour, the document explained how an occupational therapy practitioner should act to exercise this component of practice. Interestingly, in Aguilar et al.’s study (2013), practicing therapists did not reach consensus that ‘works and communicates effectively with other team members’ (p. 214) is an essential professional behaviour, highlighting the need for additional research in this area.

Relevance to clinical practice Existing Western literature suggests that professionalism is vast and multidimensional, yet lacks a thorough exploration that comprehensively operationalises its’ elements (Aguilar et al., 2013; Birden et al., 2014; Bossers et al., 1999; Health Professions Council, 2011; Jha et al., 2006; Kasar & Clark, 2000; Robinson et al., 2012; van de Camp, Vernooij-Dassen, Grol & Bottema, 2004; van Mook, de Grave, et al., 2009; van Mook, van Luijk, et al., 2009). The lack of high quality evidence that currently exists within the literature and the limited Western scope of this paper precludes the ability to firmly name elements of professionalism. As such, this review reveals the need for further evidence-based occupational therapy study findings in order to identify elements of professionalism and work towards a more comprehensive understanding of professionalism in Western occupational therapy practice. Within the literature, professionalism has been discussed from multiple approaches including: concrete and conceptual components (Robinson et al., 2012), reflexive dialogue requiring reasoning processes to navigate internal and external contextual pressures (Kinsella et al., 2008; Mackey, 2014; Robinson et al., 2012), a dynamic concept influenced by society (Bryden et al., 2010; Khalili et al., 2014; van Mook, de Grave, et al., 2009), and the listing of specific elements and attributes (Aguilar et al., 2013, 2014; Bossers et al., 1999; Bryden et al., 2010; Canadian Association of Occupational Therapists, 2012; Holmes & Scaffa, 2009; Kasar & Muscari, 2000; Occupational Therapy Australia, 2010; Peloquin, 2005; Robinson et al., 2012; van de Camp et al., 2004). Given the importance of cultural values and understandings on perspectives and worldviews, it is critical © 2015 Occupational Therapy Australia

156 that we begin to acknowledge that professionalism is influenced by both micro (organisational), meso (ethnic, racial and/or gender) and macro (larger societal) cultures (Khalili et al., 2014; Morrow, Rothwell, Burford & Illing, 2013; Pan, Norris, Liang, Li & Ho, 2013). Culture influences both the professional and personal values which shape practice, so awareness of differing therapist-client values is necessary to provide culturally safe care (Aguilar et al., 2012). International clinicians or students may also require mentorship to adapt to practice in different countries (Dix & Baptiste, 2012), and may unjustly be perceived as unprofessional due to valid differences in cultural norms or socially constructed views of the world. Bryden et al. (2010) caution that despite the growing dialogue on professionalism, a gap still exists between findings presented in the literature and the medical profession’s ability to teach and evaluate the concept among students. Without a comprehensive understanding of professionalism, what a student, educator and/or clinician consider to be professional is subjective, and therefore open to debate. Explicit examination and discussion of what professionalism means, specific to occupational therapy practice is needed in order to promote, teach, and evaluate this important concept. Robinson et al. (2012) found that second-year occupational therapy students were uncertain about professionalism expectations and identified the need for explicit discussion of professionalism expectations among students, faculty, and preceptors to foster the development of professionalism within occupational therapy education programs (p. 283). Sullivan and Thiessen (in press) encourage occupational therapy educators to make professionalism overt within educational programs and to include learning opportunities that will help students explore the complexity and nuances of the concept. Robinson et al. (2012) recommended strategies to apply within curriculum including small group discussions to explicitly discuss and debrief experiences of professionalism, and promotion of self-reflection, as means of fostering professionalism among occupational therapy students. Occupational therapy faculty need also consider whether understandings of professionalism are currently limited to a Western world perspective and what should be known and taught in educational programs (Merriam & Kim, 2008) in the context of increasingly culturally diverse client and student populations.

Limitations Ten professional association documents were included in this review and are traditionally considered low level evidence (Law & MacDermid, 2013). Although the predominance of articles included in this paper were peer-reviewed, inclusion of professional association documents may have impacted recommendations and readers are cautioned to interpret findings with this lim© 2015 Occupational Therapy Australia

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itation in mind. In addition, grouping perspectives into one ‘Western’ category may have resulted in limited understanding of the nuances between different Western cultures and societies. This review was not exhaustive and is limited to a discussion and interpretation of professionalism from a Western lens and does not represent professionalism perspectives held among other global cultures.

Recommendations for further research Though research regarding professionalism poses challenges, it is necessary to begin examining the elements of professionalism while striving to ultimately construct a comprehensive understanding of professionalism in occupational therapy. The conceptualisation of professionalism requires investigating the language used by the profession, and how key stakeholders (i.e. students, faculty, clinicians and clients) perceive its meaning. Evidence-based results could provide clarity by shifting discussion away from subjective elements to evidence-informed elements of professionalism. This evidence could be furthered explored and used to inform occupational therapy education and clinical practice. These results could also enable practitioners to navigate professionalism tensions, and uphold standards of professionalism within their occupational therapy practice. Rodger, Clark, Banks, O’Brien and Martinez (2009) acknowledged that competencies identified by the profession can influence the design of occupational therapy curriculums. International agreement of what professionalism means in occupational therapy is lacking. However, this is reasonable considering how context and society influence the understanding of professionalism (Aguilar et al., 2012, 2013; Jha et al., 2015). The number of documents used to inform occupational therapy practice, and differences between countries, create challenges for student and novice practitioners trying to understand and access appropriate information and guidance. That said, occupational therapy associations could begin by providing an explicit discussion of professionalism, or professionalism elements, in documents where this concept is included. Studies examining these documents could explore whether common professionalism elements exist, regardless of the country of practice, as a means of comprehending shared meaning(s) of professionalism within occupational therapy. In our review of numerous professional association documents, we found that most did not fully describe the participants and/or the methodology used in the document’s development. It was encouraging to see the inclusion of this important information in more recent documents (Canadian Association of Occupational Therapists, 2012), or publication of a separate methodology document (Glover Takahashi, Beggs & Herold, 2011).

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We encourage other professional associations to also make this information public to allow occupational therapists to fully consider the document’s context, credibility and transferability. Bryden et al. (2010) raised the critical notion that the definition of professionalism is constantly evolving and must be capable of adapting to current societal factors. An emerging area for professionalism research in Western cultures is the use of social media (Antheunis, Tates & Nieboer, 2013; Bernhardt, Alber & Gold, 2014; Chan, 2012; Farnan et al., 2013; Lehavot, Ben-Zeev & Neville, 2012). This social media use by professionals may not be as prevalent in other global cultures. Identifying and highlighting unique differences specific to various international or regional contexts would further our knowledge of cultural, political and societal influences on our understanding(s) of professionalism. Recently, in the field of medicine, Jha et al. (2015) presented the need for further attention and exploration of ‘global professionalism’, emphasising the impact cultural and regional perspectives have on the interpretation of professionalism. Similarly, the lack of written information about other cultural and societal viewpoints on professionalism in occupational therapy results in a void of understanding different perspectives. Hammell (2011) posited that philosophical and conceptual consensus can be exclusionary and give prevalence to predominantly Western ideas. She cautioned the occupational therapy profession to resist theoretical imperialism in order to be inclusive of a variety of cultural perspectives. Thus, it is imperative that we start to discuss and share different viewpoints so that occupational therapists can embrace diversity and practice in a client-centred, culturally safe manner (Beagan, 2015; Gerlach, 2012). We hope that our paper will be a catalyst to begin this dialogue about professionalism, and we encourage the presentation of international occupational therapist views that thus far have not been evident in the literature.

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