gms | German Medical Science

Health Professions often invoke the long tradition of self-regulation and the autonomous elaboration of their curricula. For a long time, distance to the standardised education system was their hallmark. This may be the result of a professionalisation in which a liberal form of professional praxis, delimitation and distinction, and the non-proliferation of knowledge to outsiders was more important than the mission deriving from health policy.

In Switzerland, this autonomy decreased gradually over the past decades. New regulations were introduced which aimed to control the therapists, to maintain the industrial workforce and the armed forces healthy, to protect the citizens against fraud and injury. These regulations were complemented by rules intending to achieve better health benefits and effectiveness, to obtain comparable competencies among care providers, to plan supply, and - when necessary - to regulate and restrict practice. The relationship between health professionals and the state has changed significantly since the year 2000. Nowadays, a constitutional amendment and the bilateral agreements with the EU require a nationally-harmonised education system and give article 95 of the Swiss Constitution concerning economic freedom a new meaning. Hence, state interventions regarding education and practice in the health sector are given a stronger legitimation [1], [2], [3]. With this shift, it is now the responsibility of the federal government to control the quality of study programmes and to grant diplomas – and this not only for academic medical professions. The federal diplomas ensure - since 1874 - freedom of movement between the cantons and entitle to practice within all of Switzerland (and now also in the EU). The new balance of power also created space to introduce health policy considerations in the form of overarching strategic goals and management requirements.

Since the mid-nineties, it has become common sense that, in the health sector, study programmes should not focus exclusively on professional expertise, but also on collaboration with other health professions. Moreover, the interface-management in care giving processes is a critical success factor. Health professionals need to see themselves as being part of a system which goes far beyond the treatment in face-to-face interactions with the patient. They work in a highly regulated, complex, and progressively more expensive health care system. Processes are becoming increasingly multi-sectoral and rampant costs account for a strong public interest in the effectiveness of professional practice.

These fundamental changes require a system- and process-based approach. Healing and relief from suffering no longer depend on the intervention of a single person. Effects and patient benefit are the result of a process. To be able to ensure quality of care and patient safety does not mean to cure only pathologies and to dispose of expertise in the therapeutic profession. An optimal collaboration of several categories of professionals with different skills – suppliers as well as enablers – is a necessary prerequisite for the achievement of preventive, diagnostic, therapeutic, rehabilitative or palliative goals and measures. The outcome is more and more a result of teamwork.

Disagreements about the direction and quality of professional standards, evolving from long lasting debates on profession specific traditions, dominated the development of the federal law on medical professions [4]. Nevertheless, in June 2006, the law was approved by the parliament as it was proposed by the government. The subsequent regulation on nursing, physiotherapy, midwifery, occupational therapy, nutrition counselling, and technicians in medical radiology opened up the opportunity to bridge existing gaps and to make an important step towards the harmonisation of all regulated professions in the health sector.

The law on medical professions serves as a model. It was therefore important to take into account the result from the parliamentary debates as well as the experiences made during the implementation process when developing the Swiss competencies framework for the other health professions. Besides, it was necessary to systematically close several gaps concerning health and education policy, particularly regarding the general competencies.

In Switzerland, since 2006 professions such as physiotherapy, occupational therapy, midwifery, and nutritional counselling are trained exclusively at universities of applied science. Legally, the universities of applied science are equivalent to universities (“equal but different”). Nurses and technicians in medical radiology can study at universities of applied science or at higher vocational schools [5]. Since 2005, the health departments of the universities of applied science are under regulation of the federal government. The Federal Office for Professional Education and Technology (OPET) is in charge to guarantee uniform requirements throughout Switzerland and to ensure that these requirements are reviewed in the accreditation process.

The programmes at the universities of applied sciences last three years, involve 180 ECTS, and are completed with the federally recognised diploma “Bachelor of Science” (BSc) in one of the six disciplines. Prerequisite is an upper secondary leaving certificate. Several programmes have introduced additional aptitude tests. The first Bachelor-diplomas were awarded in fall 2009. They provide access to Master’s degree studies which usually last one and a half or two years and involve 90 ECTS. Currently, only Master-programmes in nursing and physiotherapy have been approved [6]. At the six universities of applied science in 2010, about 1’200 Bachelor-diplomas were awarded, nursing with 735 and physiotherapy with 260 diplomas being by far the largest domains [7].

Health professions are regulated professions. The regulation is derived from overarching legal norms (constitution, laws) and is in the service of patient safety and effectiveness of professional practice. Besides, the above-mentioned motives evolving from health policy play a significant role.

The traditional canon of subjects to teach does not provide an adequate response to today’s challenges. Modern conceptions of education are therefore based on normative goals concerning learning outcomes. This view is not completely new and can already for some time be found in the documents specifying educational objectives. However, the implementation took its time. In the training of academic medical professions, it was only in the context of the experimental regulations, adopted in 1999, that innovative medical faculties began to replace the traditional canon of subjects by new forms such as skills labs, OSCE and problem-based learning (PBL) [8]. In the vocational colleges, it was only with the start of the new millennium that PBL began to gain currency.

Based on the conception which focuses on learning outcomes, in the drafts to the law on medical professions, three levels of objectives were identified: general competencies, profession-specific learning outcomes and learning outcomes to be implemented in the universities.

• General competencies: The general competencies apply to all regulated health professions and are based on constitutional requirements concerning health protection. In essence, they contain the sovereign expectations which are being addressed to all health professionals as a prerequisite for professional practice.
• Profession-specific learning outcomes: For each professional profile, requirements were established, taking into account internationally established standards. They define skills, knowledge, and attitudes which are to be acquired at the end of Bachelor’s and Master’s level studies and thus determine basically the scope of professional practice.
• Learning objectives: Derived from the objectives of the two levels above, the educational institutions are in charge to train health professionals who meet actual demands and who are fit for future challenges. The study programmes are coordinated and controlled by means of learning objectives with a nationally mandatory catalogue of learning objectives including the taxonomic level to be achieved. The catalogue is approved by the government and is one of the instruments considered in the accreditation.

The general competencies are an original work of the Swiss project „Learning Outcomes for Health Professionals at Universities of Applied Sciences“. They are based on a grid of objectives, as stipulated in the law on medical professions. Furthermore, they include elements from the parliamentary debate and experiences made during the implementation process.

The general competencies are composed of four dimensions and apply to all health professionals. They are based on the conviction that not only professional expertise is needed, but also an understanding of legal bases and health policies.

Upon graduation, health professionals must possess the following general competencies:

A. Orientation knowledge about health policy

1.

They know the legal bases, the priorities, the form of regulation and the limits of the Swiss health care and social security system

2.

They are able to align their professional practice according to political references and to evaluate continually the effectiveness, efficiency, quality and appropriateness of the services rendered and initiated

B. Professional expertise and methodological skills

1.

They dispose of the scientific knowledge which is required for preventive, diagnostic, therapeutic, palliative and rehabilitative measures

2.

They are familiar with the methods of scientific research in the health sector and with evidence based practice

3.

They know health-maintaining and health-promoting factors having influence on individuals and populations, and they are able to initiate measures improving the quality of life

4.

They perform well in clinical reasoning and are able to develop and implement measures which can be integrated systemically into treatment and care

5.

They are capable of providing high quality care in accordance with the best practice of their profession

C. Professionalism and responsibility

1.

They accept responsibility for their actions and recognise and respect their limits

2.

They act with commitment and according to ethical principles; they assume the responsibility for individuals, society and environment, and they adhere to the right of self-determination of their patients

3.

They are able to act innovatively and to advance their professional practice by implementing new scientific knowledge, and to continually reflect and update their skills and abilities in a process of lifelong learning

4.

They are able to participate in research projects and to incorporate relevant findings into professional practice

5.

They act autonomously and on the basis of a professional assessment

D. Skills regarding communication, interaction, and documentation

1.

They actively seek inter-professional collaboration with other health professions and stakeholders within the health care system

2.

They are able to establish professional relations with patients and relatives which are adapted to circumstances, and to give them appropriate advice

3.

They can present and document their own actions in a meaningful and comprehensible way and they know how to use e-health-instruments in patient and health care management

The profession specific learning outcomes in the Swiss framework are based on the CanMEDS role model for physician competence. In 1996, the Royal College of Physicians and Surgeons of Canada developed an innovative competencies based framework for describing the core knowledge, skills, and abilities for postgraduate medical education. After a broad opinion-making process, the framework was updated and revised in 2005, and it has since become a popular standard for medical education at undergraduate and post-graduate levels [9], [10]. The framework was adapted for use for occupational therapists in Canada [11], and has made an essential contribution to medical education around the world. However, the systematic transposition of the role and competency-based profiles to six health professions, as it was done in Switzerland, is a novelty.

In the CanMEDS framework, competencies are defined as a process of identifying the core abilities involved translating the available evidence on effective practice into educationally useful elements [9]. Knowledge, skills, and attitudes are condensed into meta-competencies which in turn are divided into seven roles which represent professional practice.

In addition to the CanMEDS model, the definition of competencies in the Swiss framework is also shaped by the terminology of the Copenhagen process (EU project on enhanced European cooperation in vocational education and training) and by the law on medical professions mentioned above. In the Copenhagen process, competencies are defined as the ability to apply skills and knowledge and they are composed of know-how, professional expertise and attitudes appropriate to the context [12]. In the statement by the Federal Council on the law on medical professions “competency based” means a comprehensive preparation to subject-specific, human, ethical, technical, and economic professional requirements as well as a focus on evidence which allows to apply the most effective, efficient and safe methods in a given context [3].

The methodology used for the development and definition of the profession-specific learning outcomes was particularly instructive. The six so-called professional conferences, consisting of representative of the study programmes at the universities of applied sciences, were asked to circumscribe content and taxonomy of the respective fields of competence while taking into account national and international standards and references. During the six-month process, two phases were fixed to discuss the interim results with professional organisations and the universities of applied sciences. The project management directed the process by fixing milestones and by predetermining indicators and exemplary formulations concerning the level of abstraction. The interim results were reviewed by the project management in two steps. They were presented in synoptic tables for further discussion and each professional conference received an evaluation with comments, recommendations, and specifications. The iterative process led to a strong identification with the results and to a reference document in which all study programmes are presented according to the same criteria and with comparable statements.

The profession-specific learning outcomes in the seven roles focus on professional practice: expert in…, communicator, collaborator, manager, health advocate, scholar, and professional. They define capabilities, skills and knowledge that must be acquired at the end of the Bachelor’s and Master’s degree programmes.

Unlike the traditional conception of education focusing on profession-specific expertise and methodological skills, a modern conception is calling for a comprehensive repertoire of competencies. The patterns of activity associated with the different roles respond to the above mentioned challenges.

In the Swiss framework, the profession-specific learning outcomes for the Bachelor’s and Master’s degree programmes in nursing, physiotherapy, occupational therapy, midwifery, nutrition counselling, and technicians in medical radiology were outlined with 3 to 5 indicators each (the complete catalogue for the six study programmes and the two levels comprises about 70 pages and is available under http://www.formative-works.ch). Concerning the definition of the profession-specific learning outcomes in Switzerland, the CanMEDS role concept has been adapted.

The major difference to the Canadian model is an autonomous understanding of the role of the expert. While in the CanMEDS framework the role of the expert is understood as an integration of (or the resulting performance in) all the other roles, in our case, we describe it with profession-specific characteristics composed of indicators and objectives (see Figure 1 [Fig. 1]).

After graduation a physiotherapist, for example, will be „expert in physiotherapy”. In the CanMEDS framework, the term “expert in…” is based on professional knowledge and skills acquired during formal education. It enables him to act professionally and autonomously in his professional practice and in specific situations. The role of the expert is specific to each profession and it allows reflecting the function and role as well as the positioning of the specific profession in a given societal and health policy context. One can be called “expert in…” when the professional knowledge allows making an independent assessment in a specific field of expertise. The depth and the width of knowledge and skills vary depending on the profession, but they are always present and comply with the requirements for professional qualification. This conception legitimates the granting of a federal diploma which entitles to practice in the given profession.

Using the CanMEDS framework as a model allows differentiating the competence profiles for each profession in accordance with individual talents and inclinations. Moreover, it allows employing the workforce more effectively. Besides, there is a substantial profit for education and health policy as all graduates are considered full-fledged professionals instead of long-time learners who remain in subordinate positions and in need of supervision and guidance.

The general competencies and the profession-specific learning outcomes are a coherent, coordinated set of standards which can be applied to all health professions and which represent the objectives of Bachelor’s and Master’s degree programmes in a differentiated way. It is set up in the same way as the standards for the academic medical professions and thus promotes inter-professional collaboration.

Even though there hasn’t been any feedback from the educational institutions going in that direction, it is conceivable that some content or learning steps cannot always be assigned clearly to a specific competence. It may in particular not always be possible to draw a straight line between professional expertise and methodological skills as mentioned as part of the general competencies and their role as “expert in…”. However, the division into three levels of objectives is required by the legislature. Besides, the key innovation does not consist in the detailed classification of the different competencies, but in the development of a comprehensive set of meaningful indicators. The conception of the learning outcomes demonstrates that sound diagnostic and therapeutic knowledge and skills are a necessary but not a sufficient condition for effective professional practice. Professionalism, in the sense of “more of the same” – namely more professional expertise – cannot be seen as sustainable. Competence-based education and practice requires learning experiences which prepare for profession-specific, human, ethnical, technical and economic requirements needed for professional practice. In addition, the professionals need to assume responsibility as well as educational and managerial functions. While respecting their own limits and weaknesses, they need to collaborate with other professions, they need to adapt and integrate, invest and assert themselves. Last but not least, ethical judgment is needed when making cost-benefit analysis and when working with limited resources.

As a consequence, this means a shift of power in the definition of curricula. The professionals – in particular those teaching and researching at universities – define the narrow confines of professionals and methodological expertise. Overall, however, they are subordinate to health policy intentions and requirements.

The author declares that he has no competing interests.