ABSTRACT
Background
Systems‐based practice is crucial for health professionals. Our study aimed to explore systems‐based practice within health professions competency standards in Australia, Canada and the United Kingdom.
Methods
We employed conceptual content analysis to review the extent to which systems‐based practice is articulated within competency standards documents across 14 different health professions. Systems‐based practice key word searches were undertaken across 38 documents, with frequency of terms counted and compared across professions and countries. The text surrounding the key word was analysed and categorised based on a systems‐based practice framework into either knowledge (structural competencies), skills (structural action) or attitudes (social responsibility). Categories across professions were summarised and synthesised across professions for each of knowledge, skills and attitudes.
Results
The most common terms used across the professions and countries were ‘quality' and ‘system' with most phrases surrounding quality related to safe and effective patient care with only some references to improving care or quality improvement. Text surrounding the term ‘system' mainly referred to health professions being able to navigate the systems in which they interact to provide care, with some standards describing competencies to affect systems that affect health, including bias, determinants of health, and access to care. The competency statements mostly focused on knowledge and skills with only some attitudinal capabilities described across the standards. All professions included systems‐based practice competencies with some emphasising health system practice (paramedicine, midwifery, medicine, paramedicine, pharmacy, podiatry, radiography) and others including broader social systems (dietetics, nursing, physiotherapy, psychology, sonography, speech pathology, social work).
Conclusions
Systems‐based practice is as a key competency for health professionals across Australia, Canada and the United Kingdom with a focus on health care systems and limited focus on competencies that challenge broader systems and prepare graduates to address the determinants of health.
Keywords: conceptual content analysis, health professions, professional standards, systems science, systems thinking
Summary
Competency standards provide the architecture for health workforce preparation and should articulate systems‐based practice which is a crucial capability for health professionals.
Content analysis of 14 different health professions competency standards across Australia, UK and Canada, on the extent to which systems‐based practice is articulated was conducted.
All professions included systems‐based practice competencies with the majority emphasising health system practice and navigating care within the health system, and some including broader social systems.
Competency statements mostly focused on knowledge and skills with only some attitudinal capabilities described across the standards.
Developing systems‐based practice competency standards across professions may advance the practice of future health professionals.
1. Introduction
Health professionals work in an increasingly complex health care system and must therefore foster health practice that utilises systems thinking and recognises and addresses the factors influencing individuals' health [1, 2]. Systems‐thinking has been defined as the ‘ability to recognise and synthesise patterns, interactions, and interdependencies in a set of activities’ [3, p. 2314] Systems‐based practice, identifies these determinants and works to addresses them to improve health outcomes [4, 5]. Systems‐based practice is a key skill or ‘foundational competency’ for health professionals facing current and emerging complex health challenges [6], yet systems‐based practice remains poorly understood by practising health professionals [4, 7, 8]. Professional competency or practice standards are the key regulatory instruments to guide health professions practice. Despite descriptions of systems‐based practice and clearly defined competencies for systems‐based practice described in medicine [9], there has been no examination of how other health professions articulate the requirements for this practice in their professional standards. Having systems‐based practice clearly described in competency standards is a prerequisite for embedding systems thinking and systems science more broadly into health professions education and practice.
Systems‐based practice addresses the larger context, determinants of health, and system of health care to improve health outcomes. Systems‐based practice facilitates improvement and addresses inequities, interprofessional practice and quality improvement [4]. Systems‐based practice uses systems thinking and health systems science, which studies the features of complex, interconnected systems of society and health systems [4], to consider complex systems and the roles of health professions in these systems including collaborative care and continuous quality improvement [10]. Systems‐based practice is interprofessional, cross‐disciplinary and involves multiple organisations acknowledging the complexity of systems influencing health and addresses health equity [4]. Learning systems‐based practice helps build professionalism and interprofessional practice [11]. Ensuring health profession ‘graduates bring a systems science mindset to all aspects of their work’ [1], p.357 is an important goal of health professions education.
Competency standards provide the architecture for health workforce preparation [12]. Having systems‐based practice clearly described in competency standards is a prerequisite for embedding systems thinking and systems science more broadly into health professions education and practice. Competency standards are a key regulatory framework that guides health professions education. Embedding systems‐based practice into health professions competency standards is one way to support workforce preparedness [12]. Systems‐based practice has been recognised as critical to pre‐registration and graduate medical education for many years [4]. Public health and nursing have also articulated competencies for system‐based practice [11]. The role of systems thinking in the practice of public health dietitians has also been recognised [13]. How well systems‐based practice is articulated across other health professions and standards is unknown.
While competency standards have been described for some health professions, systems‐based practice remains poorly understood by practising health professionals [4, 7, 8]. Developing systems‐based practice skills in pre‐registration health professionals is challenging and requires strong relationships among universities, partner institutions, and health systems [14]. The complexity of systems‐based practice requires education approaches that span classrooms‐based curriculum, through to community or practice‐based learning, and assessment [2, 8]. Much of the literature that guides how best to develop this key skill focuses on graduate medical education and medical students, and describes systems‐based practice curricula, with some literature in nursing, public health and nutrition and dietetics [11, 13]. The dominance of teaching and learning about the social determinants of health is also focused on in medicine with increasing attention over more recent years in the peer‐reviewed literature [2, 8]. Learning about systems‐based practice may not be prioritised over clinical competencies, and there is a lack of role models demonstrating systems thinking in their practice [1, 15]. Barriers to integrating systems‐based practice into the curriculum include conceptual difficulty, faculty capability, overcrowded curriculum, and a lack of documented assessment methods [2, 9]. When integrated into the curriculum, learning is didactic and focused on knowledge, and capability is self‐assessed [2, 9]. Assessment of systems‐based practice is best assessed via direct observation of interprofessional performance in the work place [11], yet this is challenging because systems‐based practice does not easily translate into observable actions or behaviours [15]. Curriculum integration may be further compounded by a lack of clearly articulated systems‐based practice skills, knowledge and behaviours in professional practice or competency standards [15]. Exploring how systems‐based practice is articulated in health professions professional standards may assist in understanding how best to design education to prepare health professionals for systems‐based practice.
Systems‐based practice capability has been criticised for being health care focused which prevents health professionals developing skills to address the determinants of health outside the health system [10]. A way forward has been proposed to articulate systems‐based competencies as including knowledge (structural competency or understanding structures and systems), skills (structural action) and attitudes (social responsibility) [10]. This description supports understanding of structural inequities for example, interventions that address determinants of health, improving others practice, and advocacy for changes to practices and systems that manifest inequities [10]. This model may provide a framework better defining the competencies required for systems‐based practice; however, it has not been tested. Understanding how health professional standards articulate systems‐based practice using this framework may inform health professions education in new ways.
Our study aimed to explore systems‐based practice within health professions competency standards in Australia, Canada and the United Kingdom (UK). More specifically, we sought to answer the following research questions: (1) Where is systems‐based practice included within the competency standards? (2) How is systems‐based practice espoused within competency standards? (3) How is systems‐based practice framed in relation to the proposed domains of knowledge (structural competency), skills (structural action) and attitudes (social responsibility)? (4) Are there differences in systems‐based practice competency across different health professions and countries?
2. Method
We employed an interpretivist approach recognising as researchers, we brought our experiences into the interpretation of language used to describe systems‐based practice in the standards. We employed a conceptual content analysis for our document analysis as it provides a systematic approach to describing and counting patterns in data, especially documents, to support interpretation of these data [16, 17]. Content analysis allowed for the examination of word use and frequency within documents of interest and through the surrounding text related to the terms of interest. We reviewed the extent to which systems‐based practice is articulated within competency standards across a variety of health professions within Australia, Canada and the UK. These countries were chosen as a sample of comparable English‐speaking Western education systems, where the use of practice or competency standards typically drives the preparation of health professions for practice. Ethics approval was not required as the study involved analysis of publicly available documents.
Professional standards documents for each of the included professions were identified via internet searches. Our study focused on 14 professions. The professions were purposefully selected as a sample of diversity across the Australian government‐regulated health professions (midwifery, medicine, nursing, occupational therapy, paramedicine, physiotherapy, psychology, pharmacy, podiatry, radiography) [18] plus four self‐regulated professions (dietetics, sonography, speech pathology and social work). These included professions were reflective of those prepared for practice by the sponsoring institution and provided adequate depth and breadth to answer our research questions in line with purposive sampling approaches [17]. The governing body for each profession of interest was identified, and then from that website, the most recently published respective competency, practice, or professional standards were identified. Only standards of practice that were publicly available, and currently in use for the profession were included. The standards or competency statements together with any supporting introductory or Supporting material were included in the analysis. Due to the provincial nature of healthcare regulation in Canada, only standards that had jurisdiction over all provinces were included. This resulted in some Canadian professions not being included. For the remaining professions, all had a single national set of standards, except for social work, where only standards from England were available. In total, 38 documents were included in the analysis (Table 1).
Table 1.
Competency standard documents included in analysis.
| Profession | Australia | UK | Canada |
|---|---|---|---|
| Dietetics | 1 | 1 | 1 |
| Midwifery | 1 | 1 | 1 |
| Medicine | 1 | 1 | 1 |
| Nursing | 1 | 1 | 1 |
| Occupational therapy | 1 | 1 | |
| Paramedicine | 1 | 1 | 1 |
| Physiotherapy | 1 | 1 | 1 |
| Psychology | 1 | 1 | |
| Pharmacy | 1 | 1 | 1 |
| Podiatry | 1 | 1 | |
| Radiography | 1 | 1 | 1 |
| Sonography | 1 | 1 | 1 |
| Speech Pathology | 1 | 1 | 1 |
| Social Work | 1 | 1 (England only) |
All documents that met the inclusion criteria were imported into NVivo qualitative analysis software (QSR, international, 2026, version 15.4.0). A word search for the terms shown in Table 2 was undertaken within the standards documents in all sections by one author (D.V.). Given the breadth within the definition of systems‐based practice, the first author identified terms used to describe systems‐based practice from key commentary, perspectives and review papers in the health professions education literature [1, 5, 9, 10, 11, 19]. A draft list of terms that were key terms or terms used in definitions of systems‐based practice was presented to the research team and refined through consensus discussion based on the teams' expertise in public health (C.P.), interprofessional education (S.M.) and quality improvement (V.M.). The exact word, with associated stems, within the text depicting the competency statement was reviewed and only terms and the surrounding text of the standard that described the context of systems‐based practice, as per the definition above, were then coded under the term. For example, ‘Participates in collaborative decision making, shared responsibility, and shared vision within teams at an individual, organisational and systems level’ was included, and ‘Align imaging system to demonstrate required anatomical structure(s)’ was excluded from analysis. Any terms that were found in the surrounding text that were unclear as to whether they were related to systems‐based practice were discussed and resolved between the two authors (D.V. and C.P.). One set of standards was read and analyzed line by line by one author (C.P.) and systems concepts were highlighted. This was a comparison of the word search findings, which were comparable.
Table 2.
Terms used for word and standard search within each of the standards documents.
| Clinical governance |
| Collaborative care; Interprofessional; Multidisciplinary |
| Ecological; Socio‐ecological |
| Improvement |
| Patient safety; Safety science |
| Quality improvement; Quality; Quality of care; Service improvement |
| Social determinants |
| Systems‐based practice; System/s; Systems thinking; Systems performance; Systems science |
The frequency of terms used across the different professions and countries were analysed using an interpretive lens noting dominance and types of terms across the standards. In addition, where in the standards this term was located, for example, the standards themselves (domain, indicator) or Supporting text (e.g., introduction, glossary) was noted. Conceptual content analysis was undertaken to categorise the competency statements with these terms into either knowledge (structural competencies), skills (structural action) or attitudes (social responsibility). Extracted text surrounding the key terms were reviewed and coded profession by profession into one of these three categories by one author (D.V.). This categorisation involved two steps, first an initial read of the text noting dominant aspects, an initial impression of whether it was knowledge, skill or attitude and then a second review of the categorisation verified or changed. At this stage this author made an independent judgement in line with our interpretive approach on whether the competency statement reflected knowledge, skill or attitude. This initial categorisation was cross checked by either V.M., or C.P. who drew on their collective 40+ years of higher education experience and learning, leaning on cognitive (knowledge), psychomotor (skills) and affective (attitudes) domains of learning [20] (see example Box 1). C.P. and D.V. then prepared synthesis of the competency statements under each of the knowledge, skill or attitude by profession summarising the dominant codes under each category. This involved initial synthesis by profession and then synthesised across professions for each of knowledge, skill or attitude (Table 2).
Box 1. Example of categorisation of knowledge, skills attitude statements from the National Competency Standards for Dietitians in Australia, 2021.
| Knowledge | Skills | Attitudes |
|---|---|---|
| Acknowledges, reflects on and understands own culture, values, beliefs, attitudes, biases, assumptions, privilege and power at the individual and systems level, and their influence on practice. | Influences food systems to improve the nutritional status of clients. | Acknowledges colonisation and systemic racism, social, cultural, behavioural, and economic factors which impact Aboriginal and Torres Strait Islander peoples' health outcomes, and how this might influence dietetic practice and outcomes. |
3. Results
RQ1: Where is systems‐based practice embedded within competency standards?
Systems‐based practice was embedded or espoused most clearly within the competency standards of the documents themselves, with terms rarely included in the introductions or glossaries across all health professions. ‘Quality' was included in the introduction across some health professions in relation to quality of practice or service provision, quality of life, or quality standards. ‘System or systems' related to health professionals' roles in the broader health system or systemic services, or within glossary definitions of health systems.
RQ2: How is systems‐based practice espoused within competency standards?
The most common terms used across the professions and countries were ‘quality' and ‘system' (Table 3). The majority of phrases surrounding quality related to safe and effective patient care with only some references to systems‐based approach to improving care or quality improvement. Text surrounding the term ‘system' mainly referred to health professions being able to navigate the systems in which they interact to provide care, with some text described competencies to affect systems that affect health, including bias, determinants of health, and access to care.
Table 3.
Frequency of systems‐based practice key words across the health professions standards and countries.
| Term with example | Dietetics | Nursing | Midwifery | Medicine | OT | PT | Psych | Pharm | Pod‐iatry | Radio‐ graphy | Sono‐graphy | SP | Social Work | Paramed‐icine |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
Clinical governance Participate in quality management, including quality control, quality assurance, clinical governance and the use of appropriate outcome measures. (Dietetics, UK) |
1 UK = 1 |
3 UK = 3 |
1 UK = 1 |
1 UK = 1 |
1 UK = 1 |
16 Aus=16 |
2 Aus=1 UK = 1 |
1 UK = 1 |
6 UK = 6 |
2 Aus=1 UK = 1 |
1 UK = 1 |
|||
|
Ecological/Socio‐ecological Applies a socio‐ecological approach to the development of strategies to improve nutrition and health. (Dietetics, Aust) |
3 Aus = 3 |
1 Aus=1 |
||||||||||||
|
Inter‐professional or Multi‐disciplinary or Collaborative care Uses effective collaborative, multidisciplinary and interprofessional approaches for decision‐making and planning. (OT, Aust) |
10 Aus = 3 UK = 1 Can = 6 |
3 Aus = 2 UK = 1 |
4 Aus = 2 UK = 1 Can = 1 |
14 Aus = 11 Can = 3 |
6 Aus = 5 UK = 1 |
13 Aus = 7 UK = 1 Can = 5 |
1 UK = 1 |
16 Aus = 15 Can = 1 |
3 Aus = 2 UK = 1 |
6 Aus = 1 UK = 1 Can = 4 |
8 Aus = 6 UK = 1 Can = 1 |
6 Aus=3 UK = 1 Can = 2 |
2 Aus= 1 UK = 1 |
|
|
Patient safety Recognize, intervene, and report near misses, no harm incidents, and harmful incidents in their practice environments, where patient safety and well‐being are potentially or actually at risk. (Paramedicine, Canada) |
1 UK = 1 |
28 UK = 12 Can = 16 |
1 Can = 1 |
5 Can = 5 |
3 Aus = 3 |
3 Aus = 2 Can = 1 |
5 UK = 3 Can = 2 |
2 Aus= 1 Can= 1 |
||||||
|
Quality Recognize, intervene, and report near misses, no harm incidents, and harmful incidents in their practice environments, where patient safety and well‐being are potentially or actually at risk. (Medicine, Australia) |
29 Aus = 15 UK = 10 Can = 4 |
28 Aus = 9 UK = 19 |
39 Aus = 12 UK = 19 Can = 8 |
29 Aus = 8 UK = 4 Can = 17 |
14 Aus = 6 UK = 8 |
41 Aus = 27 UK = 8 Can = 6 |
13 Aus = 5 UK = 8 |
85 Aus = 64 UK = 4 Can = 17 |
22 Aus = 14 UK = 8 |
68 Aus = 22 UK = 13 Can = 33 |
63 Aus = 17 UK = 27 Can = 19 |
19 Aus = 9 UK = 8 Can = 2 |
7 Aus= 4 UK = 3 |
13 Aus= 7 UK = 4 Can= 2 |
|
Quality Improvement or Improvement or Service improvement Demonstrate a commitment to patient/client safety and quality improvement. (Sonography, Australia) Uses a feedback system that facilitates exchanges with patients/clients and promotes service improvement. (Pharmacy, Australia) |
12 Aus = 7 UK = 3 Can = 2 |
13 Aus = 2 UK = 11 |
20 Aus = 4 UK = 9 Can = 7 |
34 Aus = 13 UK = 2 Can = 19 |
5 Aus = 2 UK = 3 |
33 Aus = 23 UK = 3 Can = 7 |
4 Aus = 1 UK = 3 |
56 Aus = 43 UK = 1 Can = 12 |
11 Aus = 8 UK = 3 |
11 UK = 6 Can = 5 |
18 Aus = 9 UK = 3 Can = 6 |
7 Aus = 2 UK = 3 Can = 2 |
6 Aus= 2 UK = 3 Can= 1 |
|
|
Quality of care Demonstrate the ability to identify and manage risks and take proactive measures to improve the quality of care and services when needed. (Nursing, UK) |
11 UK = 11 |
16 Aus = 2 UK = 10 Can = 4 |
6 Aus = 4 Can = 2 |
1 Aus = 1 |
8 Aus = 7 Can = 1 |
11 UK = 4 Can = 7 |
8 Aus = 2 Can = 6 |
2 Aus = 2 |
2 Aus = 2 |
|||||
|
Safety/Safety science The midwife supports women's wellbeing by providing safe, quality midwifery health care using the best available evidence and resources, with the principles of primary health care and cultural safety as foundations for practice. (Midwifery, Australia) |
8 Aus = 2 UK = 1 Can = 5 |
9 Aus = 1 UK = 8 |
13 Aus = 3 UK = 6 Can = 4 |
32 Aus = 16 UK = 8 Can = 8 |
4 Aus = 1 UK = 3 |
18 Aus = 10 UK = 3 Can = 5 |
5 Aus = 2 UK = 3 |
14 Aus = 7 UK = 3 Can = 4 |
8 Aus = 5 UK = 3 |
18 Aus = 7 UK = 2 Can = 9 |
15 Aus = 9 UK = 6 |
5 Aus = 2 UK = 3 |
16 Aus = 10 UK = 3 Can = 3 |
|
|
Social determinants Understand and evaluate social determinants of health, including inequality and factors contributing to the needs of different social groups, and the factors that influence an individual in health and illness. (Paramedicine, UK) |
1 UK = 1 |
|||||||||||||
|
System or Systems‐based practice or Systems thinking or Systems performance or Systems science demonstrate knowledge and understanding of the health and social care system and of different settings for midwifery and maternity care, and the impact of these on women, newborn infants, partners and families (Midwifery, UK) |
48 Aus = 30 UK = 3 Can = 15 |
2 Aus = 2 |
34 Aus = 2 UK = 3 Can = 29 |
36 Aus = 11 UK = 5 Can = 20 |
3 UK = 3 |
26 Aus = 16 UK = 5 Can = 5 |
17 Aus = 9 UK = 8 |
68 Aus = 61 UK = 2 Can = 5 |
12 Aus = 12 |
19 Aus = 10 UK = 3 Can = 6 |
4 Aus = 3 Can= 1 |
16 Aus = 10 UK = 2 Can = 4 |
5 Aus = 2 UK = 3 |
4 Aus = 1 UK = 1 Can = 2 |
Abbreviations: OT = occupational therapy; Pharm = pharmacy; Psych = psychology, PT = physiotherapy; SP = speech pathology.
The terms ‘clinical governance', ‘system' and ‘quality' across the professions were used to describe health professions engaging quality management and assurance and outcomes. Text referencing ‘quality improvement' related to research and quality improvement processes improving practice through new learning. Collaborative practice terms text related to providing care in partnership with other health professionals, patients, their carers or families and within teams.
RQ3: How is systems‐based practice framed in relation to the proposed domains of knowledge (structural competency), skills (structural action) and attitudes (social responsibility)?
In relation to structural competency or knowledge, across countries and professions, the standards described key knowledge required as being understanding of the health care system, the factors influencing a person's ability to improve their health, including health system factors, the role of evidence‐based practice, quality improvement, and the value of reflective practice. For some professions knowledge of other systems impacting patient outcomes were described, for example food services (dietetics), and disability (occupational therapy) (Table 4).
Table 4.
Content analysis of health professions standards by competency area‐knowledge, skills or attitudes.
| Knowledge (structural competencies) | Skills (structural action) | Attitudes (social responsibility) |
|---|---|---|
Understanding of:
|
|
|
In relation to structural action (skills), across countries and professions, the content analysis identified health professions needing skills to practice cultural safety, recognise biases and act to prevent these from impacting practice, exhibit leadership, work in collaboration with others, comply with relevant legislation and risk management protocols, policies and procedure. In addition, the skills described across professions included critical thinking, consideration of the determinants of health, assisting patients navigate the health system, improving quality of the service and systems, and engaging in continuous quality improvement (Table 4). Competency statements that described capabilities around social responsibility (attitudes) were less common across the professions. Key attitudes and behaviours described include advocacy for change to services and systems and policies, taking a human rights approach to address inequities, and taking leadership to address biases (Table 4).
3.1. Are There Differences in Systems‐Based Practice Competency Across Different Health Professions and Countries?
All professions and countries included systems‐based practice competencies with some emphasising health system practice (paramedicine, midwifery, medicine, paramedicine, pharmacy, podiatry, radiography) and others including competencies related to practice in broader social systems (dietetics, nursing, physiotherapy, psychology, sonography, speech pathology, social work). Physiotherapy and medicine were the only professions to mention systems thinking, and midwifery was the only profession to mention system performance. There was limited reference to ‘ecological' with only social work and dietetics using this term to describe the capability of taking a socio‐ecological approach to practice, and this was only in Australia. The Australian Pharmacy standards described capabilities relating to working inter‐professionally to improve protocols. Across countries, the UK competencies had a greater presence of clinical governance, while quality improvement was dominant across all countries and professions.
4. Discussion
Our study aimed to explore systems‐based practice within health professions competency standards in Australia, the UK and Canada. We found that across professions and countries, there were requirements for health professions to recognise and navigate the systems in which they work to improve care and ensure the quality of care they provide to patients and in the health system through review and improvement. Most competency statements related to systems‐based practice focused on knowledge and skills with only some attitudinal capabilities described across the standards, and these were predominately related to the care of patients. There was limited attention to addressing services or systems and in working collaboratively to affect change.
Our findings support existing dialogue that systems‐based practice is health care focused which prevents health professionals developing skills to address the determinants of health outside the health system [10]. This narrow view and expectation of systems‐based practice may be leading to a health system where inequities and existing injustice prevail. Our study also found that the profession of dietetics stands out as one that expects practitioners to influence multiple systems outside health as well as address the determinants of health. The competency standards for dietitians may be a starting point to support other professions conceptualise new competencies for systems‐based practice. A common set of competency standards for the incorporation of systems‐based practice into all health professions standards, which includes both health services and systems together with the socio‐ecological determinants of health may be a way forward.
Our research was the first to test the utility of the knowledge (structural competency or understanding structures and systems), skills (structural action) and attitudes (social responsibility) framework [10]. Our findings show that this framework can effectively categorise standard statements helping to define the competencies required for systems‐based practice. This framework assisted us to highlight the focus on health services and system improvement across knowledge, skills and attitudes and where understanding of structural inequities, interventions that address determinants of health, improving others practice, and advocacy for changes to practices and systems that manifest inequities exist within standard statements [10]. The other benefit of the framework is its acknowledgement of the affective domain of system‐based practice. Values, ethics, and emotional competencies have been described as critical for health professional readiness for practice [21, 22]. Other models such as Reilly et. al. (2024) measurement scale for measurement of systems thinking articulates the role of individuals practising within systems that affect health outcomes and how they intersect with microsystems (people working together), mesosystem (aggregates of microsystems), macrosystems (aggregates of meso‐ and microsystems) and environment (society), may also be useful to ensure the breadth and depth of systems‐based practice is evidenced in competency standards [14].
Our findings may prompt advancement of educational approaches to improving systems‐based practice capability in our pre‐registration health professions. There have been calls for new teaching methodologies together with an expansion of the scope of systems‐based practice content which emphasise systems‐based practice as interprofessional and interconnected across the health system [1]. Work‐integrated learning and education approaches that build professional identity as systems citizens have been shown to develop health professionals systems‐based practice capability [19]. Experiential learning can support the development of skills to address the determinants of health yet is often confined to single professions with few studies of students working in interprofessional teams [2, 23]. Interprofessional learning activities in these partnerships could include completing quality improvement projects, completing quality audits to improve performance and system performance with reports providing evidence of learning [23]. There is a need to test these approaches further across professions.
Ensuring graduates recognise their role as systems citizens as well as providers of care to patients may be the first step in advancing this systems‐based practice competency [19]. Existing approaches to assessing systems‐based practice are difficult because systems‐based practice does not easily translate into observable actions or behaviours [15]. Health professions engagement with systems‐based thinking could be measured using the Systems Thinking Scale [3]. Reports from quality improvement projects or quality audits to improve performance may providing evidence of learning or a proxy for systems‐based practice observable actions or behaviours [15, 23, 24]. Assessment needs to focus on graduates' ability to have a systems thinking mindset [1, 14]. Competency standards provide one mechanism to emphasise the importance of systems‐based practice. Accreditation standards for health care professions and professional development policy may need to call for explicit evidence of outcomes of systems‐based practice of learners to drive change [25].
Our study is not without limitations. Competency standards themselves are minimum requirements for health professionals, so our analysis is a generalisation of minimum expectation rather than an actual analysis of systems‐based practice curriculum and assessment across professions. Analysis of documents limits a more detailed understanding of how well graduates are prepared in systems‐based practice and what helps or hinders practice in this way in the workplace. These warrant further investigation. Using keyword searches to identify systems‐based practice concepts may have missed statements that imply systems thinking. Our sample, while diverse across health professions, did not include some health professions (e.g., exercise physiologists, dental practitioners, optometrists, chiropractors and osteopaths), and was limited to only three western countries with similar education and health systems. The focus on systems‐based practice in competency standards in non‐western contexts and in other professions may have provided different results.
5. Conclusion
Systems‐based practice focus within health professions competency standards is on the knowledge and skills to recognise and navigate the systems in which health professions work and to improve patient care, with limited focus on competencies that challenges systems or broader determinants of health. Developing the ingredients for systems‐based practice competency standards that can be shared across professions while ensuring quality learning and assessment of this key capability, may advance the practice of future health professionals.
Author Contributions
C.P. designed the research with input from V.M. and S.M. D.V. analysed the data with validation undertaken by C.P., V.M., and S.M. All authors interpreted the data. C.P. drafted the manuscript. All authors critically revised the manuscript and read and approved the final manuscript.
Funding
The authors have nothing to report.
Ethics Statement
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgements
The authors have nothing to report. Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australasian University Librarians.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.