Descriptors for unprofessional behaviours of medical students: a systematic review and categorisation

Unprofessionalism in anesthesiology: A qualitative study on classifying unprofessional behavior in anesthesiology residency education

STUDY OBJECTIVE

This study aims to identify the domains that constitute behaviors perceived to be unprofessional in anesthesiology residency training programs.

DESIGN

Qualitative study.

SETTING

Anesthesiology residency training programs.

PATIENTS

Not applicable. The participants involved residents, fellows, and faculty members purposefully sampled in four US-based anesthesiology residency programs.

INTERVENTIONS

Participants were asked to submit examples of unprofessional behavior they witnessed in anesthesiology residents, fellows, or faculty members via a Qualtrics link.

MEASUREMENTS

Not applicable. The behavior examples were independently reviewed and categorized into themes using content analysis.

MAIN RESULTS

A total of 116 vignettes were collected, resulting in a final list of 111 vignettes after excluding those that did not describe behavior exhibited by anesthesiology faculty or trainees. Fifty-eight vignettes pertained to unprofessional behaviors observed in faculty members and 53 were observed in trainees (residents and fellows). Nine unprofessionalism themes emerged in the analysis. The most common themes were VERBAL, SUPERVISION, QUALITY, ENGAGEMENT, and TIME. As to the distribution of role group (faculty versus trainee) by theme, unprofessional behaviors falling into the categories of BIAS, GOSSIP, LEWD, and VERBAL were observed more in faculty; whereas themes with unprofessional behavior primarily attributed to trainees included ENGAGEMENT, QUALITY, TIME, and SUPERVISION.

CONCLUSION

By reviewing reported professionalism-related vignettes within residency training programs, we identified classification descriptors for defining unprofessional behavior specific to anesthesiology residency education. Findings from this study enrich the definition of professionalism as a multi-dimensional competency pertaining to anesthesiology graduate medical education. This framework may facilitate preventative intervention and timely remediation plans for unprofessional behavior in residents and faculty.

Impact of group work on the hidden curriculum that induces students' unprofessional behavior toward faculty

BACKGROUND

Hidden curriculum (HC) can limit the effects of professionalism education. However, the research on how HC triggers unprofessional behavior among medical students is scant. Furthermore, there is no established approach for how faculty members may create a context, such as an educational environment and education system, that prevents students' unprofessional behavior. This study aimed to develop an educational approach to prevent unprofessional behavior and clarify how faculty members consider HC that triggers students' unprofessional behavior.

METHODS

The study sample comprised 44 faculty members and eight medical students from the Chiba University School of Medicine. The participants were divided into groups and asked the following question: "What attitudes, statements, and behaviors of senior students, physicians, and faculty members trigger medical students' unprofessional behavior?" The responses were collected using the affinity diagram method. The group members discussed the causes and countermeasures for the selected attitudes, statements, and behaviors of senior students, physicians, and faculty members based on the affinity diagram. The impact of the group work on the faculty members was surveyed using questionnaires immediately after its completion and six months later. Furthermore, the cards in the group work were analyzed using content analysis.

RESULTS

The responses to the questionnaire on group work indicated that some faculty members (43.8%) improved HC, while others suggested conducting group work with more participants. The content analysis revealed six categories - inappropriate attitude/behavior, behavior encouraging unprofessional behavior, lack of compliance with regulations, harassment of other medical staff, inappropriate educational environment/supervisor, and inappropriate self-control - and 46 subcategories.

CONCLUSIONS

The HC that triggers students' unprofessional behavior includes the words and actions of the educator, organizational culture, and educational environment. Group work makes faculty members aware of the HC that triggers unprofessional behavior, and induces behavioral change for HC improvement in the educational activities. Educators should refrain from using words and actions that encourage unprofessional behavior, such as personal anecdotes, as they reduce students' learning motivation.

Incorporating a situational judgement test in residency selections: clinical, educational and organizational outcomes

BACKGROUND

Computer-based assessment for sampling personal characteristics (Casper), an online situational judgement test, is a broad measure of personal and professional qualities. We examined the impact of Casper in the residency selection process on professionalism concerns, learning interventions and resource utilization at an institution.

METHODS

In 2022, admissions data and information in the files of residents in difficulty (over three years pre- and post- Casper implementation) was used to determine the number of residents in difficulty, CanMEDS roles requiring a learning intervention, types of learning interventions (informal learning plans vs. formal remediation or probation), and impact on the utilization of institutional resource (costs and time). Professionalism concerns were mapped to the 4I domains of a professionalism framework, and their severity was considered in mild, moderate, and major categories. Descriptive statistics and between group comparisons were used for quantitative data.

RESULTS

In the pre- and post- Casper cohorts the number of residents in difficulty (16 vs. 15) and the number of learning interventions (18 vs. 16) were similar. Professionalism concerns as an outcome measure decreased by 35% from 12/16 to 6/15 (p < 0.05), were reduced in all 4I domains (involvement, integrity, interaction, introspection) and in their severity. Formal learning interventions (15 vs. 5) and informal learning plans (3 vs. 11) were significantly different in the pre- and post-Casper cohorts respectively (p < 0.05). This reduction in formal learning interventions was associated with a 96% reduction in costs f(rom hundreds to tens of thousands of dollars and a reduction in time for learning interventions (from years to months).

CONCLUSIONS

Justifiable from multiple stakeholder perspectives, use of an SJT (Casper) improves a clinical performance measure (professionalism concerns) and permits the institution to redirect its limited resources (cost savings and time) to enhance institutional endeavors and improve learner well-being and quality of programs.

Is insufficient introspection a reason to terminate residency training? - Scrutinising introspection among residents who disputed dismissal

INTRODUCTION

Insufficient introspection as part of the 4I's model of medical professionalism (introspection, integrity, interaction, and involvement) is considered an important impediment in trainees. How insufficient introspection relates to decisions to terminate residency training remains unclear. Insights into this subject provide opportunities to improve the training of medical professionals.

METHODS

We analysed the Dutch Conciliation Board decisions regarding residents dismissed from training between 2011 and 2020. We selected the decisions on residents deemed 'insufficient' regarding introspection as part of the CanMEDS professional domain and compared their characteristics with the decisions about residents without reported insufficiencies on introspection.

RESULTS

Of the 120 decisions, 86 dismissed residents were unable to fulfil the requirements of the CanMEDS professional domain. Insufficient introspection was the most prominent insufficiency (73/86). These 73 decisions described more residents' insufficiencies in CanMEDS competency domains compared to the rest of the decisions (3.8 vs. 2.7 p < 0.001), without significant differences regarding gender or years of training.

CONCLUSIONS

Insufficient introspection in residents correlates with competency shortcomings programme directors reported in dismissal disputes. The 4I's model facilitates recognition and description of unprofessional behaviours, opening avenues for assessing and developing residents' introspection, but further research is needed for effective implementation in medical education.

Unprofessional behaviour of GP residents leading to a dismissal dispute: characteristics and outcomes of those who appeal

BACKGROUND

Recognition of poor performance in General Practice trainees is important because underperformance compromises patients' health and safety. However, in General Practice, research on persistent underperformance while in training and its ultimate consequences is almost completely lacking. We aim to explore the unprofessional behaviours of residents in General Practice who were dismissed from training and who litigated against dismissal.

METHODS

We performed a structured analysis using open-source data from all General Practice cases before the Conciliation Board of the Royal Dutch Medical Association between 2011 and 2020. Anonymised law cases about residents from all Dutch GP training programmes were analysed in terms of the quantitative and qualitative aspects related to performance.

RESULTS

Between 2011 and 2020, 24 residents who were dismissed from training challenged their programme director's decision. Dismissed residents performed poorly in several competencies, including communication, medical expertise and most prominently, professionalism. Over 90% of dismissed residents failed on professionalism. Most lacked self-awareness and/or failed to profit from feedback. Approximately 80% failed on communication, and about 60% on medical expertise as well. A large majority (more than 80%) of dismissed residents had previously participated in some form of remediation.

CONCLUSIONS

Deficiencies in both professionalism and communication were the most prevalent findings among the dismissed General Practice residents. These two deficiencies overlapped considerably. Dismissed residents who challenged their programme director's decision were considered to lack self-awareness, which requires introspection and the appreciation of feedback from others.

Dutch dismissal practices: characteristics, consequences, and contrasts in residents' case law in community-based practice versus hospital-based specialties

BACKGROUND

In the Netherlands, 2 to 10% of the residents terminate training prematurely. Infrequently, termination of training is by dismissal. Incidentally, residents may disagree, dispute and challenge these decisions from the programme directors. Resident dismissal is always a difficult decision, most commonly made after, repeated assessments, and triangulation of the resulting assessment data and one or more remediation attempts. Nevertheless, the underlying reasons for dismissal and the policies for remediation and dismissal may differ between training programmes. Such differences may however impact the chance of remediation success, the chance of dismissal and subsequent residents' appeals.

METHOD

We included a total of 70 residents from two groups (community-based and hospital-based specialties) during 10 years of appeals. Subsequently, we compared these groups on factors potentially associated with the outcome of the conciliation board decision regarding the residents' dismissal. We focused herein on remediation strategies applied, and reasons reported to dismiss residents.

RESULTS

In both groups, the most alleged reason to dismiss residents was lack of trainability, > 97%. This was related to deficiencies in professionalism in community-based practice and medical expertise in hospital-based specialties respectively. A reason less frequently mentioned was endangerment of patient care, < 26%. However, none of these residents accused of endangerment, actually jeopardized the patients' health, probably due to the vigilance of their supervisors. Remediation strategies varied between the two groups, whereas hospital-based specialties preferred formal remediation plans in contrast to community-based practice. A multitude of remediation strategies per competency (medical expertise, professionalism, communication, management) were applied and described in these law cases.

DISCUSSION

Residents' appeals in community-based practice were significantly less likely to succeed compared to hospital-based specialties. Hypothesised explanatory factors underlying these differences include community-based practices' more prominent attention to the longitudinal assessment of professionalism, the presence of regular quarterly progress meetings, precise documentation of deficiencies, and discretion over the timing of dismissal in contrast to dismissal in the hospital-based specialties which is only formally possible during scheduled formal summative assessment meetings.

Faculty and Student Perceptions of Unauthorized Collaborations in the Preclinical Curriculum: Student or System Failure?

PURPOSE

Unauthorized collaboration among medical students, including the unauthorized provision of assistance and sharing of curricular and assessment materials, is a reported problem. While many faculty view such sharing as academic dishonesty, students do not always perceive these behaviors as problematic. With the trend toward more small-group and team-based learning and the proliferation of resource-sharing and online study aids, collaboration and sharing may have become a student norm. This multi-institutional, qualitative study examined faculty and student perceptions of and student motivations for unauthorized collaboration.

METHOD

Using a constructivist approach, the authors conducted scenario-prompted semistructured interviews with faculty and students in the preclinical curriculum. Participants were asked to reflect on scenarios of unauthorized collaboration and discuss their perceptions of student motivation and the influence of personal or environmental factors. The authors performed inductive thematic analysis of the interview transcripts using open and axial coding followed by abstraction and synthesis of themes.

RESULTS

Twenty-one faculty and 16 students across 3 institutions were interviewed in 2021. There was variation in perceptions among faculty and among students, but little variation between faculty and students. Both participant groups identified the same 3 areas of tension/themes: faculty/curriculum goals vs student goals, inherent character traits vs modifiable behavioral states, and student relationships with their peer group vs their relationships with the medical education system. Student behaviors were perceived to be influenced by their environment and motivated by the desire to help peers. Participants suggested cultivating trust between students and the education system, environmental interventions, and educating students about acceptable and unacceptable behaviors to prevent unauthorized collaboration.

CONCLUSIONS

Given the various tensions and positive motivations behind unauthorized collaborations, institutions should consider explicitly preparing students to make thoughtful decisions when faced with competing priorities in addition to developing mitigation strategies that address the environment and its interactions with students.

Perception and engagement in unprofessional behaviors of medical students and residents: a mixed-method study

BACKGROUND

The present study aimed to investigate perception and engagement in unprofessional behavior of residents and medical interns and explore the factors affecting their engagement in unprofessional behavior.

METHOD

This study has an explanatory (quantitative-qualitative) mixed-method design. This study was conducted at Shahid Sadoughi University of Medical Sciences in 2022-2023. Participants, including residents and medical interns (n = 169), were entered by stratified random sampling. A survey was conducted in the quantitative step. A by an unprofessional behavior in clinical practice questionnaire (29 items) was used. For each behavior, the participants were asked to report whether they (a) participated in the behavior and (b) stated that the behavior Is unprofessional. In the qualitative step, 17 participants contributed. The qualitative data were collected by semi-structured interviews and analyzed according to the conventional content analysis approach Graneheim and Lundman introduced.

RESULTS

The highest ratio of participants' engagement in unprofessional behavior was reported in 'failure to introduce yourself and nurses and physician assistants to the patient and his family' (n = 145 (85.8%)). The results showed the proportion of participants who engaged in unprofessional behavior more than those who did not participate. There were associations between participants' engagement in each behavior and their perception of that particular behavior as unprofessional. (p = 0.0001). In the following behaviors, although the participants acknowledged that these behaviors were unprofessional, those who participated in the unprofessional behaviors were significantly more than those who did not participate: failure to comply with clinic regulations and policy (p = 0.01), eating or drinking in the hallway of the clinic (p = 0.01), medical negligence in duties in the clinic setting (p = 0.04) and failure to perform duties in teamwork (p = 0.04). The qualitative results were explored in a theme entitled "internalized unprofessional culture," including three categories "encouraging contextual risk factors towards unprofessionalism," "suppressing of unprofessionalism reporting," and "disbelieving professionalism as a key responsibility."

CONCLUSION

The results indicated that most participants engaged in unprofessional behaviors. The findings resulted from the internalized unprofessional culture in the workplace. The findings showed that engagement in unprofessional behaviors resulted from personal and systemic factors. The weakness of responsibility recognition and identity formation as a professional facilitated the engagement in unprofessional behaviors at the personal level. Furthermore, systemic factors including the contextual risk factors (such as deficiency of explicit and hidden curriculum), and the suppression of unprofessionalism reporting mechanism as a hidden factor played an important role in normalizing unprofessional behavior and promoting engagement in unprofessional behaviors among the participants. Recognition of the nature and extent of students' unprofessional behaviors facilitates educational discussion among teachers and students in this field. The results might assist to establish an assessment system and feedback mechanism to solve the problem of the "failure to fail" problem. In addition, these results provide medical educators insights into the development of professional courses that equip learners with adherence to professionalism and coping skills to deal with unprofessionalism in the healthcare system.

An exploratory university-based cross-sectional study of the prevalence and reporting of mistreatment and student-related factors among Thai medical students

BACKGROUND

Mistreatment is a behavior that reflects disrespect for the dignity of others. Mistreatment can be intentional or unintentional, and can interfere with the process of learning and perceived well-being. This study explored the prevalence and characteristics of mistreatment, mistreatment reporting, student-related factors, and consequences among medical students in Thai context.

METHODS

We first developed a Thai version of the Clinical Workplace Learning Negative Acts Questionnaire-Revised (NAQ-R) using a forward-back translation process with quality analysis. The design was a cross-sectional survey study, using the Thai Clinical Workplace Learning NAQ-R, Thai Maslach Burnout Inventory-Student Survey, Thai Patient Health Questionnaire (to assess depression risk), demographic information, mistreatment characteristics, mistreatment reports, related factors, and consequences. Descriptive and correlational analyses using multivariate analysis of variance were conducted.

RESULTS

In total, 681 medical students (52.4% female, 54.6% in the clinical years) completed the surveys (79.1% response rate). The reliability of the Thai Clinical Workplace Learning NAQ-R was high (Cronbach's alpha 0.922), with a high degree of agreement (83.9%). Most participants (n = 510, 74.5%) reported that they had experienced mistreatment. The most common type of mistreatment was workplace learning-related bullying (67.7%), and the most common source was attending staff or teachers (31.6%). People who mistreated preclinical medical students were most often senior students or peers (25.9%). People who mistreated clinical students were most commonly attending staff (57.5%). Only 56 students (8.2%) reported these instances of mistreatment to others. Students' academic year was significantly related to workplace learning-related bullying (r = 0.261, p < 0.001). Depression and burnout risk were significantly associated with person-related bullying (depression: r = 0.20, p < 0.001, burnout: r = 0.20, p = 0.012). Students who experienced person-related bullying were more often the subject of filed unprofessional behavior reports, concerning conflict or arguments with colleagues, being absent from class or work without reasonable cause, and mistreatment of others.

CONCLUSIONS

Mistreatment of medical students was evident in medical school and was related to the risk for depression and burnout, as well as the risk of unprofessional behavior.

TRIAL REGISTRATION

TCTR20230107006(07/01/2023).

A Qualitative Study of How On-Campus Faculty and Off-Campus Preceptors Evaluate Veterinary Students' Professionalism

Professionalism is defined and described in a variety of ways that differ considerably in details and quantity. While professionalism has become increasingly important, educators' opinions regarding the types of professionalism vary. The objective of this qualitative study was to evaluate faculty and preceptors' perspectives regarding veterinary medical students' professionalism during their clinical rotations. A thematic content analysis was performed to classify 2,014 comments. Five main themes emerged: (a) work ethic and attitude; (b) effective interactions with clients and delivering patient care; (c) effective interactions with health care professionals; (d) punctuality, task completion, and organization; and (e) commitment to improving competency in self and others. The importance of professionalism was stressed by both groups of faculty and preceptors through written comments; however, the magnitude of each theme differed. The results indicate that without understanding professionalism elements, the lack of conceptual clarity and consensus related to expected behaviors and attitudes would make it challenging to assess professionalism appropriately. The themes identified can be used to begin a discussion about expected behavior among faculty, preceptors, and students, therefore prompting a reasonable assessment of professionalism, as well as avoiding unprofessional behavior.

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace

BACKGROUND

Unprofessional behaviour undermines organizational trust and negatively affects patient safety, the clinical learning environment, and clinician well-being. Improving professionalism in healthcare organizations requires insight into the frequency, types, sources, and targets of unprofessional behaviour in order to refine organizational programs and strategies to prevent and address unprofessional behaviours.

OBJECTIVE

To investigate the types and frequency of perceived unprofessional behaviours among health care professionals and to identify the sources and targets of these behaviours.

METHODS

Data was collected from 2017-2019 based on a convenience sample survey administered to all participants at the start of a mandatory professionalism course for health care professionals including attending physicians, residents and advanced practice providers (APPs) working at one academic hospital in the United States.

RESULTS

Out of the 388 participants in this study, 63% experienced unprofessional behaviour at least once a month, including failing to respond to calls/pages/requests (44.3%), exclusion from decision-making (43.0%) and blaming behaviour (39.9%). Other monthly experienced subtypes ranged from 31.7% for dismissive behaviour to 4.6% for sexual harassment. Residents were more than twice as likely (OR 2.25, p<0.001)) the targets of unprofessional behaviour compared to attending physicians. Female respondents experienced more discriminating behaviours (OR 2.52, p<0.01). Nurses were identified as the most common source of unprofessional behaviours (28.1%), followed by residents from other departments (21%).

CONCLUSIONS

Unprofessional behaviour was experienced frequently by all groups, mostly inflicted on these groups by those outside of the own discipline or department. Residents were most frequently identified to be the target and nurses the source of the behaviours. This study highlights that unprofessional behaviour is varied, both regarding types of behaviours as well as targets and sources of such behaviours. This data is instrumental in developing training and remediation initiatives attuned to specific professional roles and specific types of professionalism lapses.

What we think about professional and unprofessional behaviors: differences between the perception of clinical faculty members and medical students

INTRODUCTION

Differences in the viewpoints of clinical faculty members and medical students about prioritizing professional norms accepted by the professional community and lack of alignment of these views can lead to distortion of understanding, problems in learning and assessment of professionalism, and failure in students' professional identity formation. This study aimed to identify the differences in viewpoints of clinical faculty members and medical students about prioritizing the importance and prevalence of professional and unprofessional behaviors among undergraduate medical students.

METHODS

A multi-stage qualitative study was conducted at Tehran University of Medical Sciences during 2020-2021. At first, a systematic search was conducted to identify professional and unprofessional behaviors using the directional content analysis method. A panel of experts was formed to check the codes obtained from reviewing the literature and to evaluate its compliance with the context. Then, the modified nominal group technique sessions were held with clinical faculty members and medical students to strengthen the codes extracted from the studies and systematically integrate their views to achieve a comprehensive list of professional and unprofessional behaviors in accordance with the context. Finally, a consensus was made among them about prioritizing the importance and prevalence of these behaviors in undergraduate medical students.

RESULTS

A total of 490 codes of professional behaviors and 595 unprofessional behavior codes were identified in the literature review. In the following sessions of the modified nominal group, 13 clinical faculty members listed 105 codes of professional and unprofessional behaviors, and 51 medical students also listed 313 codes. The results of the modified nominal group technique showed that the faculty members reported the importance of unprofessional behaviors higher than professional ones. At the same time, students rated the importance of professional behaviors higher than unprofessional ones. Both faculty members and students rate the prevalence of professional behaviors as high and the prevalence of unprofessional behaviors as low.

CONCLUSION

The results showed a difference of views between clinical faculty members and medical students about prioritizing professional and unprofessional behaviors. It is essential to align their viewpoints to understand, learn and value professionalism to develop a professional identity.

Are Iranian graduating dental students prepared to act as future role models of good oral health behaviour? A 10-year study

INTRODUCTION

Dentists by their professional knowledge of prevention have a key role in providing a positive role model for oral health-promoting behaviours. We aimed to investigate the health behaviour of Iranian senior dental students in terms of oral self-care and tobacco use during a 10-year period to assess their preparedness to act as role models for health-promoting behaviours.

MATERIALS AND METHODS

The study was performed in six dental schools selected through stratified cluster random sampling to have a representative sample of all dental schools in Iran. Data were collected in four occasions in 2005, 2008, 2011 and 2015. Senior dental students (N = 1188) were invited to voluntarily complete a self-administered anonymous questionnaire about their oral self-care and tobacco use. Recommended tooth-brushing habit (RTH) was defined as at least twice a day brushing with fluoridated toothpaste. Three separate questions about cigarette, pipe and waterpipe use were applied to assess the students' reported use of tobacco.

RESULTS

The response rate was 81%. Female students reported more frequently RTH than males (p < .001). The reported RTH was more prevalent among nonsmokers. In 2005, 2008, 2011 and 2015, 22.5%, 26%, 28.5% and 24.6% of the students reported smoking, respectively. The trend of reported smoking had the least variation among female students. This was true also for male students regarding RTH.

CONCLUSION

The status and trend of oral self-care and tobacco use among Iranian dental students call for more emphasis on adopting health-promoting behaviours during dental education.

Changing Professional Behaviors in the Digital World Using the Medical Education e-Professionalism (MEeP) Framework-A Mixed Methods Multicentre Study

Background:

There is increasing evidence on the exponential use of technology-based social media in medical field that has led to a proliferation of unprofessional behaviors in digital realm. Educating, training, and changing the behaviors of healthcare professionals are essential elements to restrain the rising unprofessional incidents. Therefore, this research was designed to determine the impact of an interventional workshop on the medical and dental students in improving their professional behaviors in the digital world using the newly developed medical Education e-Professionalism (MEeP) framework.

Methods

We adopted the Theory of Planned Behavior (TPB) as a benchmark reference which explores constructs intertwined with the mission-based MEeP framework; values (whistleblowing-raising concerns), behaviors (being responsible in the digital world) and identity (reflective practice in the digital world). A multicentre 3-phased mixed-method study was conducted using a pre-workshop survey, an online interventional workshop, and a post-workshop survey. SPSS and NVivo were the tools used for the data analysis.

Results

A total of 130 students registered for workshop out of which 120 completed the pre-workshop survey, 62 joined the workshop and 59 completed the workshop and post-workshop survey. From the whistleblowing – raising concern perspective, we found that attitudes and perceived behavioral control had a significant relationship. While for responsible in digital world category, attitude and perceived behavioral control had a significant bearing on the intentions. Third, for reflective practice, attitude and subjective norms significantly enhanced the intention of participants. A multi layered thematic analysis yielded four overarching themes of attitudes, subjective norms, perceived behavioral control and intentions. Most students showed positive attitudes of being reflective, self-directed, and humane. Students realized the subjective norms had made them conscientious, self-aware and conformative. While perceived behavioural control manifested as identity and Intentions were heavily reliant on self-actualization.

Conclusion

Our mixed method study found that the interventional workshop using MEeP framework significantly improved attitudes, subjective norms, perceived behavioral control, and intentions. This study provides valuable evidence of MEeP framework evaluation using the theoretical underpinning of TPB by reporting positive changes in professional values, behaviors, and identities of undergraduate medical and dental students.

Unprofessional behaviours experienced by hospital staff: qualitative analysis of narrative comments in a longitudinal survey across seven hospitals in Australia

BACKGROUND

Unprofessional behaviours of healthcare staff have negative impacts on organisational outcomes, patient safety and staff well-being. The objective of this study was to undertake a qualitative analysis of narrative responses from the Longitudinal Investigation of Negative Behaviours survey (LION), to develop a comprehensive understanding of hospital staff experiences of unprofessional behaviours and their impact on staff and patients. The LION survey identified staff experiences and perceptions related to unprofessional behaviours within hospitals.

METHODS

Two open-ended questions within the LION survey invited descriptions of unprofessional staff behaviours across seven hospitals in three Australian states between December 2017 and November 2018. Respondents were from medical, nursing, allied health, management, and support services roles in the hospitals. Data were qualitatively analysed using Directed Content Analysis (DCA).

RESULTS

From 5178 LION survey responses, 32% (n = 1636) of participants responded to the two open-ended questions exploring staff experiences of unprofessional behaviours across the hospital sites surveyed. Three primary themes and 11 secondary themes were identified spanning, i) individual unprofessional behaviours, ii) negative impacts of unprofessional behaviours on staff well-being, psychological safety, and employee experience, as well as on patient care, well-being, and safety, and iii) organisational factors associated with staff unprofessional behaviours.

CONCLUSION

Unprofessional behaviours are experienced by hospital staff across all professional groups and functions. Staff conceptualise, perceive and experience unprofessional behaviours in diverse ways. These behaviours can be understood as enactments that either negatively impact other staff, patients or the organisational outcomes of team cohesion, work efficiency and efficacy. A perceived lack of organisational action based on existing reporting and employee feedback appears to erode employee confidence in hospital leaders and their ability to effectively address and mitigate unprofessional behaviours.

Unprofessional behaviour of GP residents and its remediation: a qualitative study among supervisors and faculty

BACKGROUND

Lapses in professionalism have profound negative effects on patients, health professionals, and society. The connection between unprofessional behaviour during training and later practice requires timely identification and remediation. However, appropriate language to describe unprofessional behaviour and its remediation during residency is lacking. Therefore, this exploratory study aims to investigate which behaviours of GP residents are considered unprofessional according to supervisors and faculty, and how remediation is applied.

METHODS

We conducted eight semi-structured focus group interviews with 55 broadly selected supervisors from four Dutch GP training institutes. In addition, we conducted individual semi-structured interviews with eight designated professionalism faculty members. Interview recordings were transcribed verbatim. Data were coded in two consecutive steps: preliminary inductive coding was followed by secondary deductive coding using the descriptors from the recently developed 'Four I's' model for describing unprofessional behaviours as sensitising concepts.

RESULTS

Despite the differences in participants' professional positions, we identified a shared conceptualisation in pinpointing and assessing unprofessional behaviour. Both groups described multiple unprofessional behaviours, which could be successfully mapped to the descriptors and categories of the Four I's model. Behaviours in the categories 'Involvement' and 'Interaction' were assessed as mild and received informal, pedagogical feedback. Behaviours in the categories 'Introspection' and 'Integrity', were seen as very alarming and received strict remediation. We identified two new groups of behaviours; 'Nervous exhaustion complaints' and 'Nine-to-five mentality', needing to be added to the Four I's model. The diagnostic phase of unprofessional behaviour usually started with the supervisor getting a 'sense of alarm', which was described as either a 'gut feeling', 'a loss of enthusiasm for teaching' or 'fuss surrounding the resident'. This sense of alarm triggered the remediation phase. However, the diagnostic and remediation phases did not appear consecutive or distinct, but rather intertwined.

CONCLUSIONS

The processes of identification and remediation of unprofessional behaviour in residents appeared to be intertwined. Identification of behaviours related to lack of introspection or integrity were perceived as the most important to remediate. The results of this research provide supervisors and faculty with an appropriate language to describe unprofessional behaviours among residents, which can facilitate timely identification and remediation.

Tutor Uncertainty in Dealing with Unprofessional Behaviours of Medical Students and Residents: a Mixed Methods Study

BACKGROUND

Despite acknowledgement of medical students' expected professional behaviours and attitudes, there remains widespread reluctance to report students that behave inappropriately. Existing literature focuses on why faculty fail to fail, overlooking the tutors who deal with students day to day. We investigated how tutors address inappropriate behaviours and attitudes in students and residents.

METHODS

A mixed methods study was carried out consisting of a survey and two focus groups with tutors. Seventeen tutors from the University of Limerick School of Medicine, Ireland, took part in the survey (n = 22%) and eight tutors participated in two focus groups during the 2018-2019 academic year.

RESULTS

Findings suggested that 59% of tutors would take a different approach to addressing unprofessional behaviours witnessed in medical students and residents. A total of 88% of tutors said they intervened on a professionalism issue with 52% saying 'once in a while'. In contrast to the survey, tutors in the focus groups expressed a lack of confidence in addressing some behaviours due to a lack of time, not seeing the outcome of process/remediation etc. Tutors indicated a strong preference for case-based training on assessing professional identity formation (PIF).

CONCLUSIONS

We found tutors typically work closely with students on a day-to-day basis managing unprofessionalism issues. Tutors valued regular communication about policies and procedures about appropriate conduct as well as support, advice, and/or oversight from independent members of university staff. This research highlights the need for training designed for busy tutors as a distinct type of medical teacher.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01429-1.

A Preliminary Study on Uncovering Medical Students' Unprofessional Behaviors from YouTube Videos

Creation of guidelines and education on digital professionalism have been sluggish despite the ever-increasing use of social media by digitally native medical students, who are at risk of blurring the line between their professional and personal lives online. A qualitative thematic analysis was applied on 79 videos extracted from 70,154 YouTube videos uploaded by Korean medical students between March and April 2020. We found 20% contained at least one concerning behavior themed under 'failure to engage,' 'disrespectful behaviors,' or 'poor self-awareness.' Professional lapses identified were classified into seriousness levels. Mostly were "controversial' or 'concerning' but some 'highly concerning' contents were also found. This is the first study on digital professionalism behavior on medical students' YouTube videos. The potential negative impact on the medical profession of the easily accessible public online videos cannot be ignored and thus we suggest the need for them to be taken more seriously.

'Doctors can't be doctors all of the time': a qualitative study of how general practitioners and medical students negotiate public-professional and private-personal realms using social media

OBJECTIVE

The objective of this study is to explore the experiences and perspectives of general practitioners' and medical students' use of, and behaviour on, social media and to understand how they negotiate threats to professional and personal life on social media.

DESIGN

A two-phase qualitative design was used, consisting of semistructured interviews and follow-up vignettes, where participants were asked to respond to vignettes that involved varying degrees of unprofessional behaviour. Data were analysed using template analysis.

SETTING AND PARTICIPANTS

Participants were general practitioner tutors and third year medical students who had just completed placement on the University of Limerick longitudinal integrated clerkship. Five students and three general practitioners affiliated with the medical school were invited to participate in one-to-one interviews.

RESULTS

Three overarching themes, each containing subthemes were reported. 'Staying in contact and up to date' outlines how social media platforms provide useful resources and illustrates the potential risks of social media. 'Online persona' considers how social media has contributed to changing the nature of interpersonal relationships. 'Towards standards and safety' raises the matter of how to protect patients, doctors and the medical profession.

CONCLUSION

Guidance is required for students and medical practitioners on how to establish reasonable boundaries between their personal and professional presence on social media and in their private life so that poorly judged use of social media does not negatively affect career prospects and professional efficacy.

Development of a taxonomy of unprofessional behavior in clinical learning environments using learner-generated critical incidents

PURPOSE

Few studies have examined medical residents' and fellows' (trainees) direct experience of unprofessional behavior in clinical learning environments (CLE). The purpose of this study was to create a taxonomy of unprofessional behavior in CLEs using critical incidents gathered from trainees.

METHOD

In step 1 (data collection), the authors collected 382 critical incidents from trainees at more than a dozen CLEs over a six-year period (2013-2019). In step 2 (model generation), nine subject matter experts (SMEs) sorted the incidents into homogenous clusters and this structure was tested with principal components analysis (PCA). In step 3 (model evaluation), two new groups of SMEs each re-sorted half of the incidents into the PCA-derived categories.

RESULTS

A 13-component solution accounted for 62.46% of the variance in the critical incidents collected. The SMEs who re-sorted the critical incidents demonstrated good agreement with each other and with the 13-component PCA solution. The resulting taxonomy included 13 dimensions, with 48.7% of behaviors focused on displays of aggression or discriminatory conduct.

CONCLUSIONS

Critical incident methodology can provide unique insights into the dimensionality of unprofessional behavior in the CLE. Future research should leverage the taxonomy created to inform professionalism assessment development in the CLE.

Self-Reported Academic Misconduct among Medical Students: Perception and Prevalence

Academic integrity is the basis of an education system and must be taught as an ethical behavior during academic training. Students who reflect honesty and truthfulness during the academic years are more likely to follow this path, develop professional integrity, and thus become responsible and dependable professionals. Here, we determine the prevalence of academic lapses among medical students by a cross-sectional descriptive survey based on a self-assessment questionnaire. Students' perception of 37 behaviors comprising five domains, plagiarism, indolence, cheating, disruptive behavior, and falsifying data, were explored. A high percentage of students (83%) indicated that all 37 behaviors constitute misconduct. Approximately 65% of students thought that their fellow students were involved in dishonest behaviors, and 34% answered that they were indulged in some form of misconduct. Content analysis identified some prevalent behaviors such as doing work for another student (82.5%), getting information from the students who already took the exam (82.5%), copying the answer from neighbors (79%), and marking attendance for absent friends (74.5%). Multiple regression analysis points out that future indulgence in a behavior is significantly (p ≤ 0.5) correlated with understanding a behavior as wrong, perceiving that others do it and whether one has already indulged in it. This study can serve as a diagnostic tool to analyze the prevalence of misconduct and a foothold to develop the medical school system's ethical guidelines.

Unprofessional practice and student professionalism dilemmas: What can radiography learn from the other health professions?

OBJECTIVE

Professionalism in radiography is a complex, multidimensional concept seldom investigated. During clinical placements, students may observe or be involved in unprofessional practice/professionalism lapses which result in professionalism dilemmas. Establishing what constitutes a professionalism dilemma and what action to take may be challenging for students and also practitioners. This is due to unclear reporting pathways and fear of retribution, both deterrents to raising concerns. The aim of this integrative literature review was to investigate how and why professionalism dilemmas occur. In addition, to explore the types of dilemma students experience during clinical placement and to contextualise and reflect on these findings within radiography. Ovid MEDLINE, PubMed, Google Scholar and the grey literature were reviewed, analysed and themed.

KEY FINDINGS

Twenty-eight papers (published between 2004 and 2020) were analysed and summarised. Four themes emerged, and were discussed within the radiography context; the nature of professionalism lapses (mistreatment, verbal abuse, exclusion and intimidation), reasons for professionalism lapses (burnout and poor role modelling), student response at the time of the professionalism dilemma (accept, resist or report) and long-term impacts on students (moral/emotional distress, professional development and choice of career).

CONCLUSION

Professionalism dilemmas are not reported in the radiography literature but are cited in radiology and other health professions studies. Student experiences of such dilemmas can be profound and long lasting. Thus, research is required to investigate specifically the professional dilemmas experienced by radiography students in the unique environment in which they develop their clinical skills.

IMPLICATIONS FOR PRACTICE

The literature review findings can be used to support the development of strategies to enhance future teaching and modelling of professionalism and develop related research in radiography.

Redefining scholarship for health professions education: AMEE Guide No. 142

Scholarship is an integral aspect of academia. It shapes the practice of individuals and the field and is often used to inform career progression decisions and policies. This makes it high stakes. Yet it is complex, and ambiguous. Definitions vary and the term does not necessarily translate well across contexts. In this AMEE guide, our aim is to establish a contemporary definition of scholarship which is appropriate to health professions education (HPE). Our specific objectives are to provide guidance to support colleagues in their career development as professional educators and to challenge biases and assumptions about scholarship which may still exist in educational systems and structures. Ultimately, we hope that this work will advance the stature/standing of scholarship in the field. We provide a general definition of scholarship and how this relates to the scholarship of teaching (and learning) (SoT[L]) and scholarly teaching. Drawing on Boyer's seminal work, we describe different types of scholarship and reflect on how these apply to HPE, before moving on to describe different types of engagement with scholarship in HPE, including scope of contribution and influence. Using cases and examples, we illustrate differences in scholarly engagement across stages of a career, contexts, and ways of engaging. We provide guidance on how to assess 'quality' of scholarship. We offer practical advice for health professions' educators seeking academic advancement. We advocate that institutional leaders consider their systems and structures, so that these align with faculty work patterns, and judge teaching and professional practice appropriately. We conclude by offering a new definition of scholarship in HPE.

Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study

BACKGROUND

Professionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited.

AIM

To characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist.

DESIGN & SETTING

A retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009-2019).

METHOD

Complaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding.

RESULTS

Out of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints.

CONCLUSION

Most unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category.

Adverse Childhood Experiences in Trainees and Physicians With Professionalism Lapses: Implications for Medical Education and Remediation

PURPOSE

Unprofessional behavior, which can include failure to engage, dishonest and/or disrespectful behavior, and poor self-awareness, can be demonstrated by medical trainees and practicing physicians. In the authors' experience, these types of behaviors are associated with exposure to adverse childhood experiences (ACEs). Given this overlap, the authors studied the percentage of ACEs among trainees and physicians referred for fitness-for-duty evaluations and patterns between the types of ACEs experienced and the reason for referral.

METHOD

A final sample of 123 cases of U.S. trainees and physicians who had been referred to a Midwestern center for assessment and/or remediation of professionalism issues from 2013 to 2018 was created. Included professionalism lapses fell within 3 categories: boundary violation, disruptive behavior, or potential substance use disorder concerns. All participants completed a psychosocial developmental interview, which includes questions about ACE exposure. Overall rate of reported ACEs and types of ACEs reported were explored.

RESULTS

Eighty-six (70%) participants reported at least 1 ACE, while 27 (22%) reported 4 or more. Compared with national data, these results show significantly higher occurrence rates of 1 or more ACEs and a lower occurrence rate of 0 ACEs. ACEs that predicted reasons for referral were physical or sexual abuse, feeling unwanted or unloved, witnessing abuse of their mother or stepmother, or caretaker substance use.

CONCLUSIONS

In this sample, ACE exposure was associated with professionalism issues. Remediating individuals with professionalism issues and exposure to ACEs can be complicated by heightened responses to stressful stimuli, difficulties with collaboration and trust, and decreased self-efficacy. Adoption of a trauma-informed medical education approach may help those that have been impacted by trauma rebuild a sense of control and empowerment. The findings of this study may be useful predictors in identifying those at risk of problematic behavior and recidivism before a sentinel event.

Professional responsibility-acquiring process among bachelor degree nursing students: A grounded theory study

INTRODUCTION

Professional responsibility-acquiring process among bachelor degree nursing students is important for their current and future performance and educational and health-care system, but this process has not been explored in the literature. The aim of the current study is to explore the process of acquiring professional responsibility among bachelor degree nursing students.

METHODOLOGY

The study design was based on grounded theory (Corbin and Strauss 2015). Purposive and theoretical sampling led to the inclusion of 18 individual interviews and a focus group interview with bachelor degree nursing students, their instructors, and key informants in a nursing school and university, an educational hospital, and a health comprehensive service center in Tehran in 2019-2020.

RESULTS

After data analysis, 6 categories, 17 primary categories, 64 subcategories, and 1747 initial codes were extracted. Trying to optimal use of the educational period was the main category of this study and its primary categories were responsible learning and performance management strategies, there were facilitators and inhibitors categories for applying these strategies. Personal, educational, and professional context factors were primary categories that may lead to the main concern (uncertain productivity of the educational period) with regard to acquiring professional responsibility. Protection of the students and others versus irresponsibility was consequence category of this process.

CONCLUSION

Knowing the process of acquiring professional responsibility among bachelor degree nursing students can be used to facilitate the formation, promotion, and evaluation of professional responsible behaviors. Further researches in these areas are recommended.

Seeing but not believing: Insights into the intractability of failure to fail

CONTEXT

Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure to fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualise incompetence. Because frameworks tend to itemise competence as well as being vague about incompetence, assessment design may be improved by better understanding and describing of how supervisors experience being confronted with a potentially incompetent trainee.

METHODS

Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term 'incompetence,' so we began to use 'underperformance' in its place.

RESULTS

Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualised underperformance as: an inability to engage with learning due to illness, a life event or learning disorders, so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight or humility.

CONCLUSION

Physicians conceptualise underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure to fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.

Development of a framework to describe patient and family harm from disrespect and promote improvements in quality and safety: a scoping review

PURPOSE

Patients and families may experience 'non-physical' harm from interactions with the healthcare system, including emotional, psychological, socio-behavioral or financial harm, some of which may be related to experiences of disrespect. We sought to use the current literature to develop a practical, improvement-oriented framework to recognize, describe and help prevent such events.

DATA SOURCES

Searches were performed in PubMed, Embase, PsychINFO, CINAHL, Health Business Elite and ProQuest Dissertations & Theses: Global: Health & Medicine, from their inception through July 2017.

STUDY SELECTION

Two authors reviewed titles, abstracts, full texts, references and cited-by lists to identify articles describing approaches to understanding patient/family experiences of disrespect.

DATA EXTRACTION

Findings were evaluated using integrative review methodology.

RESULTS OF DATA SYNTHESIS

Three-thousand eight hundred and eighty two abstracts were reviewed. Twenty three articles were identified. Components of experiences of disrespect included: (1) numerous care processes; (2) a wide range of healthcare professional and organizational behaviors; (3) contributing factors, including patient- and professional-related factors, the environment of work and care, leadership, policies, processes and culture; (4) important consequences of disrespect, including behavioral changes and health impacts on patients and families, negative effects on professionals' subsequent interactions, and patient attrition from organizations and (5) factors both intrinsic and extrinsic to patients that can modify the consequences of disrespect.

CONCLUSION

A generalizable framework for understanding disrespect experienced by patients/families in healthcare may help organizations better prevent non-physical harms. Future work should prospectively test and refine the framework we described so as to facilitate its integration into organizations' existing operational systems.

Conflict between clinician teachers and their students: the clinician perspective

The relationship between clinician teachers and their students is of major importance in medical education. However, there is little known about the effects on clinicians when conflict occurs with their students. What do clinicians perceive to be major causes of these conflicts? How do they react when and after conflict occurs? A phenomenological inquiry exploring the lived experience of 12 clinician teachers in medical schools was performed. The clinicians were selected using purposeful sampling and snowballing techniques. The interviews revolved around discussions based on episodes of conflict with medical students that the clinicians considered significant. The analysis and emergent themes were partially constructed around and informed by theories of conflict, and conflict management. A number of themes emerged from this study. Clinicians experienced that significant psychological and behavioural problems of students had a dominant impact on the likelihood and severity of conflict; these conflicts had a significant emotional impact on clinicians; though the responses to conflict varied, "avoidance" was a mechanism commonly used by clinicians and thus the assessment of attitudinal and behavioural professional issues in the workplace was problematic. This study shows how the clinician perspective to challenging student/clinician encounters impacts on the quality of education they are able to provide. We recommend medical schools consider these issues when designing their programs in order to develop and maintain clinician-teacher engagement and participation.

A professionalism program in medical education and training - From broad values to specific applications: YLL School of Medicine, Singapore

The process for introducing and developing a program for teaching medical professionalism at the National University of Singapore, School of Medicine is outlined. Professionalism was recognised as embracing 'honesty and integrity,' 'responsibility and participation,' 'respect and sensitivity,' and 'compassion and empathy.' Those broad values are expressed as specific attitudes and behaviours that are taught and assessed throughout the course. Honesty and integrity, for example, are demonstrated by 'presenting original, authentic assignments' (in medical education); and 'accepting personal mistakes and honestly acknowledging them' (in clinical training and practice). Values and items of behaviour were drawn from the literature, and reviewed and refined to address needs identified within the Medical School. A broad spectrum of pre-clinical and clinical teachers contributed to this development. The program was reassessed to determine the extent to which it has been implemented and has evolved following its adoption. The results are confirming in that: the majority of recommendations have been implemented; the program has developed further; and is supported by ancillary student enrichment activities. Medical professionalism has been given prominence through all phases of the course. Nevertheless, challenges remain and particularly in the extent to which medical professionalism is taught and assessed in various clinical postings.

How to identify, address and report students' unprofessional behaviour in medical school

This AMEE guide provides a research overview of the identification of, and responding to unprofessional behaviour in medical students. It is directed towards medical educators in preclinical and clinical undergraduate medical education. It aims to describe, clarify and categorize different types of unprofessional behaviours, highlighting students' unprofessional behaviour profiles and what they mean for further guidance. This facilitates identification, addressing, reporting and remediation of different types of unprofessional behaviour in different types of students in undergraduate medical education. Professionalism, professional behaviour and professional identity formation are three different viewpoints in medical education and research. Teaching and assessing professionalism, promoting professional identity formation, is the positive approach. An inevitable consequence is that teachers sometimes are confronted with unprofessional behaviour. When this happens, a complementary approach is needed. How to effectively respond to unprofessional behaviour deserves our attention, owing to the amount of time, effort and resources spent by teachers in managing unprofessional behaviour of medical students. Clinical and medical educators find it hard to address unprofessional behaviour and turn toward refraining from handling it, thus leading to the 'failure to fail' phenomenon. Finding the ways to describe and categorize observed unprofessional behaviour of students encourages teachers to take the appropriate actions.

Towards a Definition of Distinction in Professionalism

Phenomenon: Professionalism can be characterized by a particular set of attributes that clinicians demonstrate in practice. Although much has been described on those attributes that define acceptable professionalism, the characteristics that define distinction in professionalism have not yet been well defined. Approach: In this exploratory project, qualitative methods were used to triangulate three sources of data collected from three campuses of one medical school: student assessment summaries, teacher interviews, and an institutional policy. Findings: One hundred-thirty student assessment summaries, eight teacher interviews, and one institutional policy were analyzed. Three characteristics emerged that define distinction in professionalism: improvement of oneself, helping others learn, and teamwork. These characteristics are in addition to students demonstrating a clear minimum standard in all other aspects of professionalism. Insights: Findings from this project offer a first step toward a definition of distinction in professionalism for assessing student performance. The characteristics can be demonstrated by students to varying degrees of proficiency and are potentially achievable by all students. Finally, the characteristics would be required in addition to demonstrating a clear minimum standard of performance in all other aspects of professionalism and cannot be inferred by the absence of negative or unprofessional behaviors. Recognizing that conceptions of professionalism have contextual and cultural influences, the characteristics of distinction identified by this project expand the language available for teachers and learners to discuss professionalism. Teachers may use these characteristics to help inform their teaching, learning, and feedback practices. Students will gain clarity about the expectations regarding their professional behavior.

Professional practice behaviour: Identification and validation of key indicators

Introduction

Professional behaviour is regarded as an important competency for occupational therapy practice, yet little guidance exists for indicators underpinning development or remediation in the educational or practice settings. This study sought to confirm the content validity of observable professional behaviour indicators from an existing evaluation framework for representativeness and relevance for occupational therapy practice.

Methods

A modified Delphi approach was conducted with expert panellists ( n = 30) consisting of regulators, administrators, faculty members, practitioners, and students for professional behaviour indicator consensus, together with a cross-sectional survey of practitioners ( n = 119). Fleiss’ κ and χ2 contingency tables were completed for agreement across panellists, and between panellist and survey groups. Cross-case qualitative analyses identified facilitators and barriers for professional behaviour practice.

Results

Content validity of 17 professional behaviour indicators was achieved, with >85% agreement from the expert panellists and the cross-sectional survey group. Main professional behaviour reporting issues in practice included fear of reprisal, lack of formal policies, and an unsupportive culture. Support from others, documented workplace policies, and self-regulation/duty to monitor were the critical facilitators for supporting professional behaviour in practice.

Conclusion

The professional behaviour indicators in this study offer observable behaviours from which assessment rubrics or tools may be developed. Further study is warranted.

Investigating Patient Preferences in Medical Student Attire in the Outpatient Otolaryngology Setting

BACKGROUND

The authors sought to investigate patient preferences on physician and medical student attire in the outpatient otolaryngology setting.

METHODS

A prospective sample of 50 (23 males, 27 females) patients presenting to an otolaryngology clinic in a North American teaching hospital, Boston, MA, were included. Patients were seen by a researcher wearing a white coat and either (1) a shirt and tie or (2) surgical scrubs, then completed a Likert-style survey evaluating feelings of trust, comfort, and professionalism. Statistical significance was set at α = 0.05.

RESULTS

Most patients (82%, 41/50) believed that attire was important. Men and older patients were significantly more likely to believe attire was important (P = .01 and .005, respectively). Patients were significantly more comfortable when seen by a provider wearing a shirt and tie compared to scrubs (U = 109.5, P = .021); however, there was no difference in feelings of trust or professionalism (P = .5* and .6*, respectively).

CONCLUSIONS

Physician attire is important for patients presenting to otolaryngology clinic. Patients favored a white coat with a shirt and tie. Level of Evidence: NA.

Developing a two-dimensional model of unprofessional behaviour profiles in medical students

Standardized narratives or profiles can facilitate identification of poor professional behaviour of medical students. If unprofessional behaviour is identified, educators can help the student to improve their professional performance. In an earlier study, based on opinions of frontline teachers from one institution, the authors identified three profiles of medical students' unprofessional behaviour: (1) Poor reliability, (2) Poor reliability and poor insight, and (3) Poor reliability, poor insight and poor adaptability. The distinguishing variable was Capacity for self-reflection and adaptability. The current study used Nominal Group Technique and thematic analysis to refine these findings by synthesizing experts' opinions from different medical schools, aiming to develop a model of unprofessional behaviour profiles in medical students. Thirty-one experienced faculty, purposively sampled for knowledge and experience in teaching and evaluation of professionalism, participated in five meetings at five medical schools in the Netherlands. In each group, participants generated ideas, discussed them, and independently ranked these ideas by allocating points to them. Experts suggested ten different ideas, from which the top 3 received 60% of all ranking points: (1) Reflectiveness and adaptability are two distinct distinguishing variables (25%), (2) The term reliability is too narrow to describe unprofessional behaviour (22%), and (3) Profiles are dynamic over time (12%). Incorporating these ideas yielded a model consisting of four profiles of medical students' unprofessional behaviour (accidental behaviour, struggling behaviour, gaming-the-system behaviour and disavowing behaviour) and two distinguishing variables (reflectiveness and adaptability). The findings could advance educators' insight into students' unprofessional behaviour, and provide information for future research on professionalism remediation.

A Road Map for Attending to Medical Students' Professionalism Lapses

PURPOSE

To develop a road map for educators attending to medical students' professionalism lapses, aiming to offer an empirical base for approaching students who display such lapses.

METHOD

Between October 2016 and January 2018, 23 in-depth interviews with 19 expert faculty responsible for remediation from 13 U.S. medical schools were conducted about the way they handle students' professionalism lapses. Three researchers independently completed three rounds of coding. Data collection, coding, and analysis were performed in a constant comparative process. A constructivist grounded theory approach was used to develop an explanatory model for attending to students' professionalism lapses.

RESULTS

Based on participants' descriptions, the authors developed a three-phase approach for attending to professionalism lapses. In phase 1, experts enacted the role of concerned teacher, exploring the lapse from the student's perspective. In phase 2, they functioned as supportive coach, providing feedback on professionalism values, improving skills, creating reflectiveness, and offering support. In phase 3, if the student did not demonstrate reflectiveness and improvement, and especially if (future) patient care was potentially compromised, participants assumed an opposite role: gatekeeper of the profession.

CONCLUSIONS

An explanatory model for attending to professionalism lapses that fits in the overarching "communities of practice" framework was created. Whereas phase 1 and 2 aim at keeping students in the medical community, phase 3 aims at guiding students out. These findings provide empirical support to earlier descriptive, opinion-based models and may offer medical educators an empirical base for attending to students who display professionalism lapses.

A Practical Approach to Clinical Ethics Education for Undergraduate Medical Students: A Case Study From Guatemala

OBJECTIVE

This case study describes a faculty initiative to create a curriculum in applied medical ethics for undergraduate medical students at the Universidad Francisco Marroquin (UFM) in Guatemala City, Guatemala.

METHODS

The new ethics curriculum (PRACTICE) incorporates ethics short-courses into the university's system of nontraditional, credit-bearing electives offered to students as part of their 6-year undergraduate medical education and complements existing didactic courses in normative ethics. Structured case-based activities allow for flexibility in design and scheduling, do not compete with core requirements of the existing curriculum, and enable students to develop critical reasoning approaches to ethical situations they will encounter in medical practice. Two preliminary workshops provided teaching opportunities for the faculty, stimulated student interest in future ethics courses, and provided an evidence base to guide the development of a formal curriculum.

RESULTS

The elective currently includes six 2-hour modules, each of which is a stand-alone unit with learning goals and objectives, brief didactic lecture, assigned readings, discussion case, and assessment. To date, more than 110 students have participated in the workshops and courses. Student feedback and evaluations are being used to refine pedagogical approaches and drive future course content.

CONCLUSIONS

The PRACTICE course format offers a transformative model for ethics education in Guatemala that can be used in medical education throughout the country and region.

Student response to reports of unprofessional behavior: assessing risk of subsequent professional problems in medical school

BACKGROUND

An early concern note (ECN) program is used by some medical schools to identify, counsel, and intervene when students exhibit unprofessional behavior. Student maturity, insight, propensity for reflection, and receptiveness to feedback have been suggested as predictors of future behavior.

OBJECTIVE

We hypothesized that (a) classifying students with a first ECN based on their response to the report would identify students at risk of repeat ECNs better than the action that prompted it and (b) receipt of multiple ECNs would identify students at risk of adverse academic events.

DESIGN

For this study, 459 ECNs were classified based on students' (1) recognition that their behavior was inappropriate and (2) acceptance of responsibility for the behavior. Student academic progress and receipt of subsequent ECNs were tracked.

RESULTS

Students who recognized their behavior was inappropriate and accepted responsibility after an initial ECN received subsequent ECNs at lower rates (14-19%) than students who disagreed with the significance of their behavior or were resistant to accepting responsibility (36-59%). Students with limited insight and adaptability appeared to be at highest risk. Seventy-one percent of students with three or more ECNs encountered adverse academic events during enrollment.

CONCLUSION

Student reactions to reports of unprofessional behavior may be useful as a tool to help assess risk of recurrent lapses. Students with diminished capacity to recognize behaviors as unprofessional or accept responsibility for them appear to be at highest risk for additional adverse academic and professionalism events while in medical school.

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.