Students' perceptions of whistle blowing: implications for self-regulation. A questionnaire and focus group survey

Don't be a rat: An investigation of the taboo against reporting other students for cheating

This research examines barriers to reporting academic dishonesty in early adulthood (Study 1; N = 92) and adolescence (Study 2; N = 137). Participants were asked to describe a recent time they observed a peer cheating and to reflect on their decision about whether to report the cheating. They also responded to hypothetical scenarios about observing typical cheating actions, and the presence of social motives (e.g., whether people who report tend to gain reputations for being snitches) was manipulated in each scenario. Even though participants judged reporting to be the morally right thing to do, doing so was rare and approval for it was low, especially in adolescence. Participants also tended to say they would rather be friends with people who do not report cheaters than with those who do. Participants reasoned about a variety of social concerns to support their judgments about reporting (e.g., concern about their relationship with the cheater, concerns for others' welfare), and the manipulated social motives in the hypothetical scenarios significantly influenced judgments about reporting. These findings inform our understanding of the social dynamics that contribute to decisions about policing academic honesty.

Raising professionalism concerns as a medical student: damned if they do, damned if they don't?

BACKGROUND

Understanding professionalism is an essential component of becoming a doctor in order to ensure the trust of patients and wider society. Integrally linked to the concept of professionalism is the importance of identifying and raising concerns to ensure high quality, safe patient care. It is recognised that medical students are uniquely placed to identify and report concerns given their frequent rotations through multiple clinical placements and their peer relationships and, in so doing, develop and enact their own medical professionalism. Although there is existing literature exploring medical students' willingness to raise concerns about observed professionalism lapses, this has largely been in the context of clinical interactions. Medical students will however undoubtedly encounter concerning behaviours or attitudes in their fellow students, an area that has not specifically been reported upon. This study therefore set out to explore medical students' willingness to report professionalism concerns they encounter both within and away from the clinical setting, particularly focusing on peer-related concerns.

METHODS

10 medical students, in later clinical years of a large UK medical school, volunteered to take part in in-depth semi-structured interviews. Interviews were recorded, transcribed and then analysed thematically to generate themes and subthemes to represent central organising concepts.

RESULTS

Three broad themes were generated from the data. Hidden curricular effects including role models, hierarchical structures and the operational systems in place to raise concerns subconsciously influenced students' decisions to raise concerns. Secondly, students offered a range of justifications to defend not taking action, including considering their own vulnerabilities and values alongside demonstrating empathy for perceived mitigating circumstances. The third theme highlighted the complex interplay of influencing factors that students considered when encountering professionalism issues in their peers including wider peer cohort effects and a desire to maintain individual peer-relationships.

CONCLUSIONS

Medical students will inevitably encounter situations where the professionalism of others is brought into question. However, despite clear curricular expectations to report such concerns, these findings demonstrate that students undergo a complex decision-making process in determining the threshold for reporting a concern through navigating a range of identified influencing factors. This study highlights the important role medical schools play in helping reduce the inner conflict experienced by medical students when raising concerns and in ensuring they provide supportive processes to empower their students to raise concerns as part their own developing professionalism.

Twelve tips to foster healthcare student recognition and reporting of unprofessional behaviour or concerns

Medical trainees and students are required to report concerns where they identify concerning practice or behaviours. While leadership attributes and skills are increasingly expected curricular outcomes, students still struggle to report concerns due to a variety of factors. Changing societal awareness and expectations continue to shine light on poor professionalism and unethical behaviours whose reach extends to medical training and education and that need to be systematically reported and addressed. To prepare graduates for these challenges in professional practice and for exercising skills of reporting concerns, education and training environments must ensure that speaking up is ingrained in the organisational ethos. Supported by evidence from the literature and our experience of revising and enhancing approaches, this paper outlines tips for developing and embedding an infrastructure that facilitates robust concerns reporting and management. Further, we consider mechanisms that support students to develop tendencies and skills for reporting concerns.

Exploring predoctoral dental student use of YouTube as a learning tool for clinical endodontic procedures

PURPOSE/OBJECTIVES

The goal of the present study was to examine perceived barriers to achieving clinical competence in endodontics and explain how YouTube is used to supplement formal education in this discipline.

METHODS

Postgraduate endodontic students conducted focus groups with fourth-year dental students at NYU College of Dentistry. The discussion was facilitated by a semistructured interview guide. Open-ended questions about participants' perceived barriers to clinical competency in endodontics, experiences using YouTube to learn about clinical endodontics, and preferences for video format learning were asked. Demographic information was gathered. Thematic analysis of data was conducted and data collection was terminated once saturation was achieved.

RESULTS

Thirty fourth-year dental students were enrolled in the study. The majority, 96.7%, reported using YouTube as a learning tool for dental procedures and 83.3% to learn about endodontics, specifically. The following domains were explored during data analysis: barriers to clinical competency, YouTube uses/experiences, and content preferences. The following themes within barriers to clinical competency were identified: psychological, educational, and clinical. Within the YouTube domain, the following themes were examined: goals of use, timing and frequency of use, search strategies, benefit/ shortcomings of YouTube, and validity of content. Students primarily used YouTube to enhance confidence and understand procedural flow.

CONCLUSION

YouTube videos were primarily used to help students overcome perceived educational and psychological barriers that resulted in gaps in confidence and knowledge of performing endodontic procedures. Dental students placed high value on easily accessible video content of limited duration, where clinical procedures were performed on live patients.

Snitches Get Stitches and End Up in Ditches: A Systematic Review of the Factors Associated With Whistleblowing Intentions

Blowing the whistle on corruption or wrongdoing can facilitate the detection, investigation, and then prosecution of a violation that may have otherwise gone undetected. The purpose of this systematic review was to identify the factors that are associated with intentions to blow the whistle on wrongdoing. We searched Academic Search Premier, CINAHL Complete, Education Research Complete, ERIC, Medline, PsycARTICLES, PsycINFO, Regional Business News, and SPORTDiscus in January 2020. The quality of evidence was assessed using the Cochrane risk of bias tool. Of the 9,136 records identified, 217 studies were included in this systematic review. We identified 8 dimensions, 26 higher-order themes, and 119 lower-order themes. The whistleblowing dimensions were personal factors, organizational factors, cost and benefits, outcome expectancies, the offense, reporting, the wrongdoer, and social factors. Based on the findings, it is apparent that organizations should empower, educate, protect, support, and reward those who blow the whistle, in order to increase the likelihood on individuals blowing the whistle on corruption and wrongdoing. A combined approach may increase whistleblowing intentions, although research is required to test this assertion. From a policy perspective, more consistent protection is required across different countries.

Students’ Reasoning About Whether to Report When Others Cheat: Conflict, Confusion, and Consequences

Nearly all students believe academic cheating is wrong, yet few students say they would report witnessed acts of cheating. To explain this apparent tension, the present research examined college students’ reasoning about whether to report plagiarism or other forms of cheating. Study 1 examined students’ conflicts when deciding whether to report cheating. Most students gave reasons against reporting a peer (e.g., social and physical consequences, a lack of responsibility to report) as well as reasons in favor of reporting (e.g., concerns about welfare, justice, and fairness). Study 2 provided experimental confirmation that the contextual factors referenced by Study 1 participants in fact influenced decisions about whether to report cheating. Overall, the findings indicate that students often decide against reporting peers’ acts of cheating, though not due to a lack of concern about integrity. Rather, students may refrain from reporting because of conflicting concerns, lack of information about school policy, and perceived better alternatives to reporting.

Why do few medical students report their experiences of mistreatment to administration?

INTRODUCTION

Over 50% of medical students worldwide report experiencing mistreatment and abuse during their clinical education, yet only a small proportion of students report these concerns to administration. It is unknown how medical students make sense of their experiences of mistreatment and come to decide whether to formally report these experiences. Improved understanding of this phenomenon will facilitate changes at the administrative and institutional levels to better support students.

METHODS

Using Constructivist Grounded Theory, we interviewed 19 current and former medical students from one institution about their experiences with mistreatment and reporting. Data were analysed in an iterative fashion, using focused and theoretical forms of coding.

RESULTS

The decision of whether to report mistreatment is only one phase in the process that students report experiencing when encountering mistreatment. This process can be understood as a journey consisting of five phases: Situating, Experiencing and Appraising, Reacting, Deciding and Moving Forward. Students move through these phases as they come to understand their position as medical learners and their ability to trust and be safe within this institution. Each experience of mistreatment causes students to react to what has happened to them, decide if they will share their experiences and reach out for support. They choose if they are going to report the mistreatment, at what cost and for what outcomes. Students continue through their training while incorporating their experiences into their understanding of the culture in which they are learning and continually resituating themselves within the institution.

DISCUSSION

Student perceptions of trust or mistrust in their educational institution are highly influential when it comes to reporting mistreatment. Interventions designed to support students and decrease exposure to mistreatment may be best focused on increasing organisational trust between students and the medical school.

Good friend or good student? An interview study of perceived conflicts between personal and academic integrity among students in three European countries

Students are often reluctant to report the academic dishonesty of their peers. Loyalty to friends and classmates has previously been identified as an important reason for this. This paper explores loyalty conflicts among students from upper secondary school, through bachelor's, to Ph.D. level. Drawing on semi-structured qualitative interviews (N = 72) conducted in Denmark, Ireland and Hungary, we show that loyalty considerations among students can be complex and draw on a range of norms including responsibility. The study demonstrates how students are often willing to assume substantial personal responsibility for dealing with the academic dishonesty of a peer, often preferring this to reporting. However, when deciding on the right course of action, they also perceive tensions between the norms of the good researcher and student and their own norms of being a good friend and person. The loyalty considerations and tension were identified in all three countries and across the educational levels, which suggests that this is a cross-cultural challenge. We argue that institutions should formally decide whether they want students to take some degree of responsibility themselves for addressing less serious cases of academic dishonesty and communicate their decision to their students.

Impact of Collaborative Leadership in Dental School Team Clinics

Dental students' ability to critique team performance in dental school team clinics is a key component of dental education. The aim of this study was to determine if students' perceptions of their team leaders' openness of communication, cooperative decision making, and well-defined goals were positively related to the students' improvement-oriented voice behavior and willingness to raise concerns in the clinical environment. This study used a voluntary 12-question survey, distributed via email to all 311 students at the University of Nevada, Las Vegas School of Dental Medicine after completion of the spring 2017 semester. Eighty-seven students responded, for a response rate of 28%. Responses were stratified by team, class year, and gender, and the quantitative distribution of answers to each question was correlated with each other. Team leader collaborative qualities, which included openness for communication, cooperative decision making, and well-defined goals, were found to have a significant positive relationship with students' willingness to both raise concerns and make suggestions. Additionally, when measured by class year and gender, team differences in voice behavior assessment by students across the teams were found to be independent of class year, and no significant differences were found by gender. These results suggested that, to maintain high levels of communication, proper reporting of concerns, and a high standard of care, dental schools should encourage team leaders to enhance their capacity to present active collaborative behaviors in the school's clinic. The study also highlighted potential opportunities for further study of faculty traits and development in the dental school team model.

The social psychology of whistleblowing: An integrated model

Whistleblowing is the disclosure of ingroup wrongdoing to an external agency and can have important functions for the regulation of moral and legal conduct. Organizational research has focused largely on the impact of individual and organizational factors, while overlooking the role of group memberships and associated social identities. Further, social psychologists have so far paid little attention to this phenomenon, or else have tended to subsume it within analysis of dissent. To address these lacunae, we present a psychological model of whistleblowing that draws on social identity theorizing (after Tajfel & Turner, 1979). This model describes when and how social identities and different forms of power motivate group members to respond to ingroup wrongdoing by engaging in whistleblowing. Our review of the literature points to the model’s ability to integrate existing evidence while providing direction for future research. We also discuss the model’s capacity to inform whistleblowing policy and procedures.

Investigating US medical students' motivation to respond to lapses in professionalism

CONTEXT

As unprofessional behaviour in physicians can compromise patient safety, all physicians should be willing and able to respond to lapses in professionalism. Although students endorse an obligation to respond to lapses, they experience difficulties in doing so. If medical educators knew how students respond and why they choose certain responses, they could support students in responding appropriately.

OBJECTIVES

The aim of this study was to describe medical students' responses to professionalism lapses in peers and faculty staff, and to understand students' motivation for responding or not responding.

METHODS

We conducted an explorative, qualitative study using template analysis, in which three researchers independently coded transcripts of semi-structured, face-to-face interviews. We purposefully sampled 18 student representatives convening at a medical education conference. Preliminary open coding of a data subset yielded an initial template, which was applied to further data and modified as necessary. All transcripts were coded using the final template. Finally, three sensitising concepts from the Expectancy-Value-Cost model were used to map participants' responses.

RESULTS

Students mentioned having observed lapses in professionalism in both faculty staff and peers. Students' responses to these lapses were avoiding, addressing, reporting or initiating policy change. Generally, students were not motivated to respond if they did not know how to respond, if they believed responding was futile and if they feared retaliation. Students were motivated to respond if they were personally affected, if they perceived the individual as approachable and if they thought that the whole group of students could benefit from their actions. Expectancy of success, value and costs each appeared to be influenced by (inter)personal and system factors.

CONCLUSIONS

The Expectancy-Value-Cost model effectively explains students' motivation for responding to lapses. The (inter)personal and system factors influencing students' motivation to respond are modifiable and can be used by medical educators to enhance students' motivation to respond to lapses in professionalism observed in medical school.

Student-derived solutions to address barriers hindering reports of unprofessional behaviour

BACKGROUND

Barriers hinder medical students from reporting breaches in professional behaviour, which can adversely impact institutional culture. No studies have reported student perspectives on how to address these barriers successfully. Our study (i) evaluated the likelihood of reporting based on violation severity, (ii) assessed barriers to reporting and (iii) elicited students' proposed solutions.

METHODS

Four medical students designed a cross-sectional study in 2015. In response to seven scenarios, students rated the likelihood of reporting the violation, indicated perceived barriers and identified solutions. Additional questions investigated the perceived importance of professionalism, confidence in understanding professionalism and trust in administrative protection from negative consequences.

RESULTS

Two hundred and seventy-two students in their clinical years (MS2-4) responded to the survey (RR = 50%). Students were 70-90% likely to report major violations, but < 30% likely to report minor or moderate violations. Barriers included concerns about an uncomfortable relationship (41%), potential negative repercussions on grades or opportunities (23%), and addressing by direct discussion rather than reporting (23%). Solutions included simplified reporting, control over report release date, improved feedback to reporters, training for real-time resolution of concerns and a neutral resource to help students triage concerns. No differences existed between classes regarding the importance or understanding of professionalism. In linear regression, only importance of professionalism predicted likelihood of reporting and this did not change with training.

CONCLUSIONS

Hindered by common barriers, students are unlikely to report a violation unless it is a serious breach of professionalism. Student-derived solutions should be explored by medical school administrators to encourage reporting of violation of professionalism.

Improving health care quality: the implementation of whistleblowing

Purpose

In line with the current literature, the purpose of this paper is to contribute to a better understanding of whistleblowing procedures and their influence on overall organisational quality. To this end, institutional, organisational, and cultural barriers to whistleblowing implementation have been investigated.

Design/methodology/approach

A qualitative analysis based on three explorative case studies investigates and compares different whistleblowing practices implemented in health care organisations, operating within the Italian National Health Service (INHS).

Findings

INHS organisations have implemented whistleblowing procedures in different ways, despite the fact that the procedures are laid down by law. These differences are mainly due to cultural, administrative, organisational, and process barriers, which have a deep impact on whistleblowing integration in managerial practices and their influence on the overall quality of health processes and services.

Research limitations/implications

This research paper was limited by the analysis of three Italian public health care organisations, which did not allow the generalisability of findings. Therefore, the study offers interesting insights on the way effective whistleblowing systems should be implemented in order to support managers to improve organisation’s management and service quality.

Originality/value

The paper represents one of the first attempts to structurally analyse the practice of whistleblowing in an Italian healthcare system. Therefore the study has mainly focussed not only on the analysis of whistleblowing practices, but also on their impacts on the improvement of organisational processes’ quality and, subsequently, on social well-being.

Whistle-blowing in Medical School: A National Survey on Peer Accountability and Professional Misconduct in Medical Students

OBJECTIVE

This study examines medical students' attitudes towards peer accountability.

METHODS

A nationally representative sample of 564 third year medical students was surveyed. Students reported their agreement or disagreement with two statements: "I feel professionally obligated to report peers whose personal behaviors compromise their professional responsibilities" and "I feel professionally obligated to report peers who I believe are seriously unfit to practice medicine."

RESULTS

The majority of students (81.6 %) either agreed strongly or agreed somewhat that they feel obligated to report peers whose personal behaviors compromise their professional responsibilities. The majority (84.1 %) also agreed that they feel professionally obligated to report peers who they believe are seriously unfit to practice medicine.

CONCLUSION

In contrast with previous studies, this national study found that a significant majority of students reported that they feel obligated to report unfit peers.

Harnessing the hidden curriculum: a four-step approach to developing and reinforcing reflective competencies in medical clinical clerkship

Changing the culture of medicine through the education of medical students has been proposed as a solution to the intractable problems of our profession. Yet few have explored the issues associated with making students partners in this change. There is a powerful hidden curriculum that perpetuates not only desired attitudes and behaviors but also those that are less than desirable. So, how do we educate medical students to resist adopting unprofessional practices they see modeled by supervisors and mentors in the clinical environment? This paper explores these issues and, informed by the literature, we propose a specific set of reflective competencies for medical students as they transition from classroom curricula to clinical practice in a four-step approach: (1) Priming-students about hidden curriculum in their clinical environment and their motivations to conform or comply with external pressures; (2) Noticing-educating students to be aware of their motivations and actions in situations where they experience pressures to conform to practices that they may view as unprofessional; (3) Processing-guiding students to analyze their experiences in collaborative reflective exercises and finally; (4) Choosing-supporting students in selecting behaviors that validate and reinforce their aspirations to develop their best professional identity.

Perspectives on whistleblowing: faculty member viewpoints and suggestions for organizational change

Given the prevalence of unethical behavior in research, whistleblowing may serve an important policing function. Despite this potential value of whistleblowing to organizations, engaging in this type of activity often has negative ramifications for those who choose to blow the whistle. Organizations may fail to provide adequate support for these individuals. In order to help inform best practices for organizations in terms of whistleblowing support infrastructure, the present effort content analyzed interviews with university faculty members regarding ethical decision making in which whistleblowing was a topic. Relevant themes in these interviews are discussed.

Using focus groups in medical education research: AMEE Guide No. 91

Qualitative research methodology has become an established part of the medical education research field. A very popular data-collection technique used in qualitative research is the "focus group". Focus groups in this Guide are defined as "… group discussions organized to explore a specific set of issues … The group is focused in the sense that it involves some kind of collective activity … crucially, focus groups are distinguished from the broader category of group interview by the explicit use of the group interaction as research data" (Kitzinger 1994, p. 103). This Guide has been designed to provide people who are interested in using focus groups with the information and tools to organize, conduct, analyze and publish sound focus group research within a broader understanding of the background and theoretical grounding of the focus group method. The Guide is organized as follows: Firstly, to describe the evolution of the focus group in the social sciences research domain. Secondly, to describe the paradigmatic fit of focus groups within qualitative research approaches in the field of medical education. After defining, the nature of focus groups and when, and when not, to use them, the Guide takes on a more practical approach, taking the reader through the various steps that need to be taken in conducting effective focus group research. Finally, the Guide finishes with practical hints towards writing up a focus group study for publication.

Self-reported attitudes and behaviours of medical students in Pakistan regarding academic misconduct: a cross-sectional study

Background

Honesty and integrity are key attributes of an ethically competent physician. However, academic misconduct, which includes but is not limited to plagiarism, cheating, and falsifying documentation, is common in medical colleges across the world. The purpose of this study is to describe differences in the self-reported attitudes and behaviours of medical students regarding academic misconduct depending on gender, year of study and type of medical institution in Pakistan.

Methods

A cross sectional study was conducted with medical students from one private and one public sector medical college. A pre-coded questionnaire about attitudes and behaviours regarding plagiarism, lying, cheating and falsifying documentation was completed anonymously by the students.

Results

A total of 465 medical students filled the questionnaire. 53% of private medical college students reported that they recognize copying an assignment verbatim and listing sources as references as wrong compared to 35% of public medical college students. 26% of private medical college students self-report this behaviour as compared to 42% of public medical college students. 22% of private versus 15% of public medical college students and 21% of students in clinical years compared to 17% in basic science years admit to submitting a fake medical certificate to justify an absence. 87% of students at a private medical college believe that cheating in an examination is wrong as compared to 66% of public medical college students and 24% self-report this behaviour in the former group as compared to 41% in the latter. 63% of clinical year students identify cheating as wrong compared to 89% of their junior colleagues. 71% of male versus 84% of female respondents believe that cheating is wrong and 42% of males compared to 23% of females admit to cheating.

Conclusions

There are significant differences in medical students’ attitudes and behaviours towards plagiarism, lying, cheating and stealing by gender, seniority status and type of institution. The ability to identify acts of academic misconduct does not deter students from engaging in the behaviour themselves, as evidenced by self-reporting.

Peer assessment among first year medical students in anatomy

Peer assessment has been shown to be an effective tool to promote professionalism in medical students. Peer assessment may be particularly useful in anatomy dissection laboratory as the required close collaboration and long hours of anatomy laboratory provide students insights into their peers' work habits and interpersonal skills. The objective of this study was to quantitatively and qualitatively analyze the use of a validated peer assessment tool in Gross Anatomy. Students in a first year medical school class evaluated three members of their dissection group using an online survey tool. The mid-course and end-of-course evaluation included open-ended comments, as well as a five-point scale that measured three work habits, two interpersonal attributes and one overall score. All 267 students completed the assignment. The overall score and four of the five other assessed categories showed significant improvement from the mid- to end-of-course evaluations. Quantitative and qualitative data also revealed significant improvement among the students who received the lowest mid-course assessments. Seventy-six percent of the class agreed with the statement: "Based on the feedback I received, I made a change in how I worked with or taught my peers." The use of this peer assessment tool used by students in anatomy was associated with improvements in work habits and interpersonal attributes, particularly by the cohort of students who received the lowest mid-course feedback. Peer assessment offers students an opportunity to improve their interpersonal skills and work habits.

What if continuing education became mandatory? Opinions of Belgian community pharmacists

Objective In July 2003, a survey (n = 1032) was conducted on issues related to continuing education for community pharmacists. This study aims to explore specific results of this survey in-depth. The objectives were to examine how current continuing education courses can be optimised, how much interest pharmacists have in distance learning, and how pharmacists think about mandatory continuing education.

Setting Community pharmacy in the Dutch-speaking part of Belgium.

Method Six focus group discussions were held: two with attenders (n = 14), two with non-attenders (n = 13), and two with the management of the Institute for Permanent Study for Pharmacists (n = 12). A theme plan was used to moderate discussions. Framework analysis was applied to analyse data.

Key findings To optimise live courses, continuing education providers should select good speakers, provide extensive course notes, and focus on issues that are relevant to day-to-day pharmacy practice. The interest in distance learning as a continuing education format was limited. Non-attenders are likely to need a formal obligation to engage in continuing education, with the preferred format being live courses. By increasing patients' awareness and appreciation of pharmacists' capabilities, pharmacists could be more motivated to counsel patients, to engage in continuing education, and to accept a system of mandatory continuing education.

Conclusion Implementation of mandatory continuing education in Belgium might encourage more pharmacists to take part in live continuing education courses than in distance learning. The arguments for and against mandatory continuing education as well as the suggestions for improvement of live continuing education courses should be taken into account when implementing a system of mandatory continuing education.

Peer assessment of professionalism: a five-year experience in medical clerkship

INTRODUCTION

Faculty assessment of students' professionalism is often based upon sporadic exposure to students. Peers are in a unique position to provide valid judgments of these behaviors.

AIMS

(1) To learn if peer assessments of professional conduct correlate with traditional performance measures; (2) to determine if peer assessments of professionalism influence the designation of honors, and (3) to explore student and faculty opinions regarding peer assessment.

SETTING

Internal Medicine Clerkship at Southern Illinois University.

PROGRAM DESCRIPTION

Since 2001 anonymous student peer assessments of professionalism have been used in assigning clerkship grades.

PROGRAM EVALUATION

Peer assessments of professionalism had weak, though significant, correlations with faculty ratings (r = 0.29), performance on the NBME subject test (r = 0.28), and performance on a cumulative performance assessment (r = 0.30), and did not change the total number of honors awarded. A majority of students (71%) felt comfortable evaluating their peers, and 77% would keep the peer evaluation procedure in place. A majority of faculty (83%) indicated that peer assessments added valuable information.

DISCUSSION

Peer assessments of professional conduct have little correlation with other performance measures, are more likely to have a positive influence on final clerkship grades, and have little impact on awarding honors.

Can there be a single system for peer assessment of professionalism among medical students? A multi-institutional study

PURPOSE

Peer assessment is a valuable source of information about medical students' professionalism. How best to facilitate peer assessment of students' professional behavior remains to be answered, however. This report extends previous research through a multi-institutional study of students' perspectives about system characteristics for peer assessment of professionalism. It examines whether students from different schools and year levels prefer different characteristics of peer assessment to assess each other candidly, or whether a single system can be designed. It then identifies the characteristics of the resulting preferred system(s).

METHOD

At the beginning of academic year 2004-2005, students (1,661 of 2,115; 78%) in years one through four at four schools replied to a survey about which peer assessment characteristics - related to, for example, who receives the assessment, its anonymity, and timing - would prevent or encourage their participation. Multivariate analysis of variance was used to detect differences among institutions and students from each year level.

RESULTS

Students across year levels and schools generally agreed about the characteristics of peer assessment. They prefer a system that is 100% anonymous, provides immediate feedback, focuses on both unprofessional and professional behaviors, and uses peer assessment formatively while rewarding exemplary behavior and addressing serious repetitive professional lapses. The system, they emphasize, must be embedded in a supportive environment.

CONCLUSIONS

Students' agreement about peer-assessment characteristics suggests that one system can be created to meet the majority of students' preferences. Once implemented, the system should be monitored for student acceptability to maximize participation and to determine the formative and summative value of the process.

Responding to the professionalism of learners and faculty in orthopaedic surgery

Recent developments in assessing professionalism and remediating unprofessional behavior can curtail the inaction that often follows observations of negative as well as positive professionalism of learners and faculty. Developments include: longitudinal assessment models promoting professional behavior, not just penalizing lapses; clarity about the assessment's purpose; methods separating formative from summative assessment; conceptual and behavioral definitions of professionalism; techniques increasing the reliability and validity of quantitative and qualitative approaches to assessment such as 360-degree assessments, performance-based assessments, portfolios, and humanism connoisseurs; and systems-design providing infrastructure support for assessment. Models for remediation have been crafted, including: due process, a warning period and, if necessary, confrontation to initiate remediation of the physician who has acted unprofessionally. Principles for appropriate remediation stress matching the intervention to the cause of the professional lapse. Cognitive behavioral therapy, motivational interviewing, and continuous monitoring linked to behavioral contracts are effective remediation techniques. Mounting and maintaining robust systems for professionalism and remediating professional lapses are not easy tasks. They require a sea change in the fundamental goal of academic health care institutions: medical education must not only be a technical undertaking but also a moral process designed to build and sustain character in all its professional citizens.

New technology to enable personal monitoring and incident reporting can transform professional culture: the potential to favourably impact the future of health care

There have been recent exposures of poor health care performance in many countries with western health care systems. The poor performance has either related to poor or criminal practices routinely going undetected or to organizational indifference or hostility to staff raising concerns about perceived poor standards of care. The demonstration that routine performance data monitoring would have detected and prevented many of the deaths attributed to poor surgical standards in the Bristol Royal Infirmary paediatric cardiac surgery scandal and criminal behaviour in the Harold Shipman scandal has highlighted the need for routine data collection to demonstrate to both health care administrators and patients that minimum standards of clinical practice are being achieved. The recent proposal that surgical report cards represent an important minimum ethical standard for health care consent will force the medical profession to engage in the debate surrounding routine data collection for performance monitoring and other purposes. This article considers the cultural background to data collection in the medical profession and the cost implications of failing to improve data collection in the areas of performance monitoring and incident reporting. A potential solution developed by the Geelong hospital group and in use in Australia is proposed as a novel, technologically appropriate and working example of practical data collection. This model is endorsed by the professional specialties and supported by modern regulatory theory. The individual, local and system wide benefits of such personal professional data collection are outlined and the necessary prerequisites are detailed.

Maximizing participation in peer assessment of professionalism: the students speak

BACKGROUND

Medical students have unique information about peers' professionalism but are reluctant to share it through peer assessment.

METHOD

Students (231 of 375; 62%) in one school replied to a survey about whether various characteristics of peer assessment (e.g., who receives the assessment, its anonymity, implications for the classmate) would prevent or encourage their participation.

RESULTS

Sixty-six percent of the students agreed that there should be peer assessment of professionalism as long as the assessment reflected their preferences for how the assessment should take place. Some of their preferences included reporting unprofessional behavior to an impartial counselor, a 100% anonymous process, and having the classmate receive corrective instruction. Students across year levels generally agreed about the characteristics of peer assessment. Men and women disagreed about some characteristics.

CONCLUSION

Most students are willing to participate in peer assessment as long as their preferences are taken into consideration.

Medical students' views on peer assessment of professionalism

BACKGROUND

Although peer assessment holds promise for assessing professionalism, reluctance and refusal to participate have been noted among learners and practicing physicians. Understanding the perspectives of potential participants may therefore be important in designing and implementing effective peer assessment.

OBJECTIVE

To identify factors that, according to students themselves, will encourage or discourage participation in peer assessment.

DESIGN

A qualitative study using grounded theory to interpret views shared during 16 focus groups that were conducted by leaders using a semi-structured guide.

PARTICIPANTS

Sixty-one students in Years 1, 3, and 4 in 2 mid-western public medical schools.

RESULTS

Three themes students say would promote or discourage peer assessment emerged: personal struggles with peer assessment, characteristics of the assessment system itself, and the environment in which the system operates. Students struggle with reporting an unprofessional peer lest they bring harm to the peer, themselves, or their clinic team or work group. Who receives the assessment and gives the peer feedback and whether it is formative or summative and anonymous, signed, or confidential are important system characteristics. Students' views of characteristics promoting peer assessment were not unanimous. Receptivity to peer reports and close positive relationships among students and between students and faculty mark an environment conducive to peer assessment, students say.

CONCLUSIONS

The study lays a foundation for creating acceptable peer assessment systems among students by soliciting their views. Merely introducing an assessment tool will not result in students' willingness to assess each other.

Making sense of focus groups

CONTEXT

This paper provides an overview of the contribution of medical education research which has employed focus group methodology to evaluate both undergraduate education and continuing professional development.

PRACTICALITIES AND PROBLEMS

It also examines current debates about the ethics and practicalities involved in conducting focus group research. It gives guidance as to how to go about designing and planning focus group studies, highlighting common misconceptions and pitfalls, emphasising that most problems stem from researchers ignoring the central assumptions which underpin the qualitative research endeavour.

PRESENTING AND DEVELOPING FOCUS GROUP RESEARCH

Particular attention is paid to analysis and presentation of focus group work and the uses to which such information is put. Finally, it speculates about the future of focus group research in general and research in medical education in particular.

Interaction in cyberspace: an online focus group

AIM

This paper reports a study that explored whether active engagement and group interaction could be captured in an online environment.

BACKGROUND

Focus groups have become a common means of capitalizing on group interaction to collect rich responses to questions posed. Whilst their use is well established in the repertoire of qualitative researchers, with changing technology there is the opportunity to use a computer program that facilitates online engagement and interaction to bring together a group of people to explore issues, attitudes and perceptions.

METHOD

Using a qualitative descriptive method and purposive sampling, 38 Australian Enrolled Nurses participated in an online focus group. WebCT, a program that facilitates online engagement and interaction, was used to enable participants to interact from any computer, from any location, at any time.

FINDINGS

The experience of conducting an online focus group was a positive one. Advantages such as cost savings and convenience for both researcher and participants were identified. This study demonstrated that participants could be actively engaged over a 2-month period and that group interaction could be achieved to collect richly detailed research data.

CONCLUSION

Whilst online focus groups may not be suitable in every situation, the potential exists to capitalize on technology to bring together a group of people separated by distance in an online environment that encourages interactive discussion.

Before the white coat: perceptions of professional lapses in the pre-clerkship

BACKGROUND

It has been shown that the professional development of clinical clerks is influenced by their experiences of unprofessional behaviour, but the perceptions of pre-clerkship students have received relatively little attention. Our purpose was to develop a greater contextual understanding of the situations in which pre-clerkship students encounter professional challenges, and to investigate what pre-clerkship students consider to be professional lapses in these situations.

METHODS

We conducted 4 focus groups (n = 22 students); transcripts were analysed by 3 researchers using grounded theory.

RESULTS

Pre-clerkship students reported lapses in the areas of communicative violation, role resistance, objectification, accountability and harm, validating our previous clerkship-based framework. However, they also reported numerous lapses committed by fellow students and many instances of lack of accountability to students, which were not reported by clerks. Many of their reports involved non-health care professionals.

CONCLUSIONS

The willingness of pre-clerkship students to report on fellow students was associated with a tendency to blame their colleagues, at the expense of a more reflective analysis, and their views on professionalism appeared to be generic rather than medicine-specific. We should reinforce students' appreciation of these generic values and add on medicine-specific values as the students progress, in order to better cultivate professionalism without entitlement.

Academic misconduct among medical students in a post-communist country

AIM

To assess the prevalence of, attitudes towards and willingness to report different forms of academic dishonesty among medical students in a post-communist transitional country.

METHODS

An anonymous, self-administered questionnaire was distributed to medical students in Years 2-6 at the Zagreb University School of Medicine; 827 (70%) valid questionnaires were returned and analysed.

RESULTS

Most of the students (94%) admitted cheating at least once during their studies. The most frequent type of misconduct was 'signing in an absent student on a class attendance list' (89.1%), and the least frequent 'paying for passing an examination' (0.7%). The number of committed types of misconduct out of 11 listed types increased from Year 2 (median 2) to Year 6 (median 4). Cheating behaviours could be clustered into 4 groups based on self-reported cheating, perceived prevalence of cheating, attitude towards cheating, and willingness to report cheating. The clustered behaviours that most students admitted to were perceived as the most frequent, more approved of and less likely to be reported. The strongest predictors of dishonest behaviour were attitude, perception of peer group behaviour and study year. Almost half (44%) the students said they would never report any form of cheating.

CONCLUSION

Academic misconduct is widespread among medical students at the largest medical school in Croatia and its prevalence is greater than that reported for developed countries. This may be related to social and cultural factors specific to a country in the midst of a post-communist transition to a market economy, and calls for measures to be instigated at an institutional level to educate against and prevent such behaviour.

Exploring perceptions and attitudes of senior medical students and interns to academic integrity

CONTEXT

Academic integrity is fundamental to the role of aspiring doctors. However, little is known about Middle Eastern students' perceptions and experiences of educational dishonesty.

PURPOSE

To describe the self-reported attitudes and behaviours of senior medical students and interns regarding educational integrity and to determine whether there are any differences according to gender and year of study.

DESIGN

Cross-sectional study using a self-administered questionnaire to 88 participants.

SETTING

Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, UAE.

RESULTS

A total of 82 (93.2%) respondents considered educational misconduct to be wrong. A total of 78 (88.6%) participants would not engage in such activities. Unethical educational practices such as plagiarism were viewed less seriously than other aspects of educational misconduct such as misuse of power. Female students were significantly less likely than males to report that they would engage in dishonest educational practices (P = 0.04). Interns were more stringent than medical students regarding penalties appropriate for academic misconduct (P = 0.002). Only 13 (15%) subjects stated that they would inform faculty of dishonest behaviour on the part of their peers.

CONCLUSION

Most participants, particularly females and interns, consider educational misconduct to be wrong and would not engage in such activities.

Students' attitudes and potential behaviour with regard to whistle blowing as they pass through a modern medical curriculum

OBJECTIVE

To examine students' attitudes and potential behaviour with regard to whistle blowing as they progress through a modern undergraduate medical curriculum.

DESIGN

Cohort design.

SETTING

University of Glasgow Medical School.

SUBJECTS

A cohort of students entering Glasgow University's new learner-centred, integrated medical curriculum in October 1996.

METHODS

Students' pre- and post-Year 1, post-Year 3 and post-Year 5 responses to the whistle blowing vignette of the Ethics in Health Care Instrument (EHCI) were examined quantitatively and qualitatively. Analysis of students' multichoice answers enabled measurement of movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes in students' reasoning behind their decisions of whether or not to whistle blow were also identified.

RESULTS

There was little improvement in students' performance as they progressed through the curriculum in terms of their proposed behaviour on meeting the whistle blowing scenario. There was also no improvement in the quality of justifications provided. Students' reasoning on whether or not to whistle blow was found to change as the curriculum progressed.

CONCLUSIONS

The EHCI has the potential to elicit students' attitudes towards ethical issues at entry to medical school and to measure change as they progress through the curriculum. Students should be encouraged to contemplate dilemmas from all ethical standpoints and consider relevant legal implications. Whistle blowing should be addressed as part of the wider domain of professionalism.