Clinical Medical Students ’ Experiences of Unprofessional Behaviour and How These Should Inform Approaches to Teaching of Professionalism

Objectives: This mixed method research explores unprofessional behaviour experienced by clinical Medical students, during clinical training in Ireland; with a view to obtaining learning points that inform future design of modules on Professionalism. It also looks at the impact of these on students and the relationship between gender/ethnicity and students’ experiences of these behaviours. Methods: A survey using the QUBPI (Queens University Belfast Professionalism Index) questionnaire was disseminated among a random sample of 139 (100% response rate) fourth year medical students in College from February to May 2014 to identify the frequency and nature of unprofessional behaviours experienced. Subsequently, 10 semi structured interviews were conducted with two students from each of the five blocks of students completing their Psychiatry Clinical placement during the year. This was to obtain in-depth insights into students’ experiences, the impact of these and to establish learning points from these. These different types of data were then analysed iteratively using SPSS and NVIVO software respectively, to allow for triangulation, member checking and reflexivity. Results: There was no significant difference in students’ experiences of unprofessional behaviour based on Gender, entry level (graduate or under-graduate entry) or Ethnicity. There was however a moderate/small effect size in terms of male vs. female gender and ethnicity (Caucasian vs. non-Caucasian) (Males=Cohen’s d of 0.38, females=Cohen’s D Abu O, Flaherty G MedEdPublish https://doi.org/10.15694/mep.2016.000040 Page | 2 of 0.2) which could be explained by the fact that in group and out group dynamics rise such that as students move away from the dominant mentor/teacher characteristic, they may start to experience or perceive the occurrence of higher levels of unprofessional behaviour. The Qualitative arm of the study confirm that some students even experience marked levels of discrimination; with students’ often been shouted out/criticised publicly during clinical training. Conclusions: More practical vignettes/role playing of common ethical dilemmas should be introduced into Professionalism training and these should not target only students, but also mentors to reduce students’ experiences of unprofessional behaviours. Feedback training and awareness of contextual issues in Medical clinical training must be provided to clinical trainers.


Background to Study
Definition of Professionalism Freidson (1988) contends that a profession is often identified by the possession of a body of knowledge or competence that allows for practice under an ethical framework to fulfil the broad needs of society, in return for which society pays good remuneration and rewards, and gives the freedom to regulate the education and performance of its members (Calman, 1994).Cruess et al (2002) expresses the same sentiment by asserting that society and Medicine share a social contract founded on the fact that doctors are allowed autonomy, self regulation and financial privileges by society in return for the provision of a competent, equitable, ethical, respectful, evidence based, morally upright and altruistic service.
Professionalism is therefore a term used to define the acceptable attributes of professions.Definitions of professionalism include those given by Swick (2000) whose normative definition is based on nine core principles and Sullivan's concept of "Civic Professionalism" (Sullivan, 2000).According to Pellegrino (2002) professionalism can be understood by considering that the possession of certain virtues are a prerequisite for professional medical practice, although virtue theory has been criticised for lacking a defined content; he asserts that a doctor who is yet to swear to some version of the Hippocratic Oath is but a skilled technician (not a professional) competent to work on the human machine.Beauchamp and Childress (1994) on the other hand, consider that there is a very close relationship between virtue ethics and principle-based ethics, even though this has been criticised as being too abstract.
The professional and personal development curriculum has been introduced as part of undergraduate medical training in most medical schools.This includes modules on medico-legal ethics, communication skills and humanistic attributes (Cruess & Cruess, 1997).However, some values are under-represented in the medical curricula.Altruism, morality, satisfaction based on serving others, personal and professional accountability, integrity, collegiality but not to the extent of colluding with incompetent or unethical colleagues and adaptability to the ever changing economic, clinical and social environments in which clinicians work; are some of these (Cruess et al, 2002).Medical students do not automatically accept these tenets, just because a traditional or predominantly didactic curriculum on professionalism exists (Hafferty, 2002).
Professionalism is important because, when the focus of medical practice shifts from the quality of social benefits and necessity of services produced, to business profitability and success; then the nature of Medicine changes (Relman, 2007).When Supplier induced demand takes over, altruism decreases and this is detrimental to society.Thus health care providers may pursue their economic self-interests in ways that may be unethical.Hospital abandonment of the uninsured; premature discharge of patients when their insurance cover run out; reduced quality of care, pushing un-needed high-profit services on patients and refusal to provide necessary services that are a financial loss become the norm (Persaud, 1991).It may become very difficult for a student training in this kind of hospital to do what is preached (taught professionalism curriculum) rather than what they observe being done (hidden professionalism curriculum).
It is up to medical tutors to teach undergraduates by example, how to deal with professional dilemmas such as; acceptance of gifts, honesty in difficult situations, confidentiality, issues of Physician impairment (whether personal or in a colleague), sexual harassment, bullying by senior colleagues, difficult patient/colleague interactions and conflict of interest between patients driven services and service provider demands.Effective teaching of this type is invaluable because although most doctors face these kinds of difficulties, many students and Physicians are often unable to provide the right answer on how to deal with these scenarios.Physicians were found to do better than senior house officers (SHOs) and medical students were found to do less well than SHOs in a recent study.Trainees and doctors also felt that the amount of training they received in professionalism in Medical School was inadequate or insufficient (Barry et al, 2000).

Frequency of negative experiences amongst medical students and how it affects them
Historically, the occurrence of abuse in medical training is well documented (Silver, 1982;Rosenberg & Silver, 1984;Sheehan et al, 1990;Kassebaum & Cutler, 1998;Elnicki et al, 2002).Wilkinson et al (2006) found that humiliation had the worst impact on learning and on students, who mostly avoided the perpetrators who were often senior doctors and nurses.According to Sheehan et al (1990) a lot of students report having experienced one or more incidents of abuse and that most occur during clinical training, with 63 percent reporting being worse off than other professionals and a quarter saying they would have chosen another profession if they knew the extent of the abuse.One-third considered leaving medical school and nearly 76 percent became cynical about the medical academia profession.In another study the incidence of abuse was greater than 68 percent (Nagata-Kobayashi et al, 2006).Decline in professional development with advancing clinical training, Racism and discrimination were also problems confronting students based on findings of a recent research (Johnston et al, 2011).Although negative feedback has sometimes wrongly been interpreted as abuse by students, the evidence that this is a problem in medical training is substantial.Other impacts of abuse during medical training include poor mental health and low career satisfaction (Frank et al, 2006).
This difficulty with dealing with future challenges that students face when they become doctors and the lack of satisfaction with the formal undergraduate medical professionalism curriculum may stem from the negative experiences that students sometimes face during their clinical placements.Kenny et al (2003) found that professionalism in medical students can be adversely affected by poor role models and postulate that the use of positive role modelling and mentorship will hopefully give trainees enough training in professionalism through a process of moral enculturation.
In terms of curriculum development and teaching of professionalism, adding more instructional content and communicating the abstractions and ideals of medical ethics is not enough, rather it is necessary to spend time designing it, consider why we are modifying it and perhaps ask the help of the medical students we teach (Wear & Kuczewski, 2004).Grounding in student experiences while keeping an eye on overarching values could help narrow the gap between theory and practice (Ginsburg & Stern, 2004).Medical educators run the risk of concentrating so much on teaching the abstract precepts of medical ethics that they fail to address the subtle nuances being transmitted within the hidden curriculum or informal learning environment which may be unprofessional in nature.Thus, rather than mistakenly focusing exclusively on universal human virtues, virtue theory or ethical principles paradigm, the undergraduate medical professionalism curriculum should concentrate on those attributes that are essential for medical practice such as fiduciary responsibility, trustworthiness, medical knowledge and competence, confidentiality, caring nature, non-judgemental/non-sexual regard and respect for patients' preferences and beliefs (Rhodes et al, 2004).
Continued development in professionalism is more effective when it is understated, emphasises the hidden curriculum and relies mainly on role modelling, apprenticeship and mentorship.If change in clinical practice, behaviour and patient outcomes are desired, then work-based multifaceted methods that include predisposing, facilitating and reinforcing content are most effective for teaching professionalism in the professional development context (Mazmanian & Davies, 2002;Baernstein et al, 2009).Didactic approaches are less effective.
The Irish literature on clinical medical students' experiences of unprofessional behaviour during clinical training will be improved by this study and will further inform the design and teaching of medical professionalism during clinical training.A better understanding of the hidden curriculum that students are exposed to will help Colleges and Faculty in designing and disseminating practical and evidence based training in professionalism.Perhaps professionalism training cannot be separated from the quality of the learning environment.According to Rhodes et al (2004), costsaving agendas such as those of the Health Service Executive and institutional reward mechanisms such as the recent scandal of salary top-ups from tax payers' money in Ireland might not be aligned with espoused standards of professionalism.Students learn considerably from the physical environment of medical institutions that fail to promote trust, wards that are understaffed, poorly maintained, under-resourced and populated by professionals in tainted white coats with low morale/integrity.Therefore, despite our best efforts to instruct for professionalism, there is reason to worry about what our students actually learn.

Methodology Rationale for choice of topic
This topic is of interest because there is a strong body of evidence that professionalism wanes as students advance in their medical training with males more negatively affected (Johnston et al, 2011).This could be due to the fact that the behaviour of mentors or senior role models (mostly male), during clinical training may be different from what they were taught to expect during pre-clinical professionalism training.The nature, impact and differences in these experiences based on gender, maturity and ethnicity is yet to be fully understood.This research could throw more light on certain attributes of professionalism that require further development in their measurement such as reflectiveness, advocacy and dealing with uncertainty (Wilkinson et al, 2009); and inform future professionalism modules.

Research question
The research questions are, "What is the nature of unprofessional behaviours that students experience during clinical placement, how do these negative experiences affect them and how should these experiences inform future design of professionalism modules."

Research design
A mixed method research paradigm was adopted in this study.A pragmatic research philosophy was employed because this epistemological standpoint is well aligned with the mixed method research paradigm (Onwuegbuzie & Leech, 2005).

Rationale for research choices
The aim of the semi structured interviews was to gather in-depth detail on unprofessional behaviours as experienced by students during clinical placement, as opposed to the espoused or preached standards that medical students are taught in Medical school, while the survey was necessary to gather extensive information on the frequency of same, from many respondents at the same time.

Sampling, recruitment and access to participants
Ethical approval was obtained from the relevant College's research ethics committee before commencing the Study.Difficult disclosures that endangered students compromised clinicians or amounted to patient safety breaches were dealt with through established College policy.Counselling was also made available to students who required it through the College's Student's support office (See participant information leaflet in annex twelve and other access documents).

Quantitative part of study
The quantitative study was done first, using a modified version of the Queen's University Professionalism Index questionnaire (QUBPI).The only modification was that half of the questionnaire was used (Section 2) with the addition of one new question (question 20).The QUBPI is an already validated questionnaire in its unabridged format and was previously used amongst pre-clinical and clinical medical students in Belfast to study Professionalism (Johnston et al 2011).This version has good internal consistency figures (Cronbach alpha 0.8), indicating the questionnaire's ability to measure unprofessional behaviours is acceptable.Permission was obtained before using it in this study and piloting was done among 10 students (who were not participants).This is because my study population of clinical students in Ireland might be a slightly different population and to ensure that the questionnaire was acceptable, easy to understand and complete in its shortened version.Quantitative Results were analysed using the statistical package of social sciences (SPSS) as described by Foster (1998).
The survey was carried out amongst a sample of medical students at one of the Colleges of Medicine in Dublin.The students had the opportunity of completing the questionnaires before or after a lecture in their clinical placement sites during several face to face sessions at Beaumont and Connolly Hospitals.The primary researcher distributed the questionnaires, the information leaflets and consent checklist to participants and asked those who consented; to complete the questionnaire and leave it in a labelled box for collection by the researcher.The researcher was not present while they completed it and the students were made aware that the class lecturers were unconnected with the study and that study participation or otherwise would not adversely affect their scores.No inducements were given to encourage participation.Students were asked to comment based on their experiences during all their clinical placements including; Paediatrics, Medicine, Surgery, Obstetrics and Gynaecology, General Practice and Psychiatry.

Qualitative study
Thereafter, students were invited to volunteer for semi-structured interviews via the questionnaire either by contacting the researcher via College email or writing their email on the completed questionnaire.Of the fifteen students who volunteered, 10 were chosen via a blind ballot by the investigator.The interview theme sheet was designed and piloted among the five students who were excluded from the interviews by the investigator.
Although there are few clear guidelines for pre-determining sample sizes for non probabilistic qualitative sampling, Guest et al (2006) found that saturation is usually reached after 12 interviews, with the skeletons of meta-themes already in place after six.Ten interviews were done because saturation was reached at that point.Interviews were conducted in the department of Psychiatry, by the principal investigator.
Interviews were recorded, transcribed and coded iteratively as they occurred, allowing the investigator to develop emergent themes from previous interviews/initial survey as the research progressed.The original data was distilled into a Start List (see annex four) comprising 37 descriptive codes, these were then drilled down to five theoretical codes during Data Display (see annex five).During the final stage of analysis which was Data Reduction, three concepts were derived in an inductive and stepwise way (Boyatzis, 1998;Miles & Huberman, 1994).Thematic analysis of data was done using computer aided NVIVO software (Bazeley, 2007), according to the analytical framework described by Miles and Huberman (1994).

Theoretical underpinning
Although there are a number of controversies and reservations about combining two different research methods or even paradigms, many researchers provide sound arguments and tools for combining them in a way that provides a new and better research paradigm (Tashakkori & Teddlie, 2003;Savin-Baden & Major, 2013;Creswell, 1998).Suri (2013) contests the seeming supremacy of the hegomy of positivism and argues that combining several diverse epistemological approaches can improve the research process when these paradigms complement each other.

Rigour
Rigour was demonstrated by processes that increase validity and reliability.Validity refers to the integrity of conclusions that are drawn from a research study (Bryman 2008).Guba and Lincoln (1994) define it as credibility and transferability.This refers to whether the findings are believable and applicable to other contexts respectively.Legitimisation, deviant case analysis, demonstration of reflexivity helped improve validity (Onwuegbuzie et al, 2011;Silverman, 2006).Triangulation was done by combining both qualitative and quantitative data and respondent validation ensured that interviewees had a chance to review the initial transcripts (Silverman, 2003).
Reliability refers to the link between a measure and the concept being researched (Bryman 2008).Sarantakos (1994) defines reliability as dependability and objectivity as confirmability.Dependability and confirmability were improved by keeping audit trails.Memos were used to systematically build up the findings from the coded content and annotations were used to give contextual detail.Peer debriefing of the first two transcripts ensured that similar descriptive codes were drawn from the data by both researchers and not from the researcher's preconceptions or already established theories (Silverman, 2003).Effort was made to be self-aware; to prevent researcher bias due to my Medical background, erstwhile positivist inclination and insider status (clinical tutor).

PARTICIPANTS Descriptive Statistics
Dependent Variable: Total number 20.

GENDER DIFFERENCES
The Figure below shows that there is a difference in experiences of unprofessional behaviours between Caucasian and non-Caucasian students and the difference between Caucasian males and females are greater than that between non-Caucasian males and females.See Figure One below.

Figure 1
Results of Two way ANOVA However, a two way analysis of variance (ANOVA) with the independent variables as gender (male versus female), ethnicity (Caucasian versus not Caucasian) and the dependent variable the score on the Queen's university questionnaire; did not show a significant difference.).There were no main effects of gender or ethnicity neither was there a significant interaction between these two variables.See Table 2.The lack of significance can be explained by the sample size being relatively small.However, the effect size of the differences between the males on the basis of just ethnicity shows a Cohen's d of 0.38 (medium effect size) and for the females Cohen's d is 0.2 (small effect size).The graph also shows a difference in exposure to unprofessional behaviours between Caucasian males/females compared to non-Caucasian males/females.However, given the lack of significant findings similar research with a larger sample size will be needed to prove this difference definitively.Nonetheless, it is interesting to note that most of the non-Caucasian participants in the qualitative interviews state that being treated differently is a common occurrence during clinical Medical training.
There is no significant difference between graduate and undergraduate entry students, (t (130) =0.20, p<.05) in terms of exposure scores, which shows that the negative influence of the hidden curriculum affect students in the same manner regardless of maturity in terms of age, life experience or prior learning.This lack of difference is expected because of the mean scores.See Table 3 below.

Results of the Qualitative part of Study
Three major themes emerged from the qualitative interviews which buttress and enhance the findings of the quantitative survey.

Potentiation of the Hidden Curriculum
Majority of students expressed the feeling that they were taught to practice certain laudable values during didactic lectures in College, but found out that majority of doctors and other mentors did not practice these in clinical settings.The main subthemes were discrimination, disrespect and negative emotional impacts on students.Students felt they learnt negative values and unprofessional behaviours because this was what they witnessed in real world settings and because their mentors sometimes treated both them and their patients unprofessionally.This was echoed by comments included in Table 4.

Instructionism versus deep learning in professionalism training
This research also showed that a lot of training in professionalism still targets the lower levels of the Kilpatrick's triangle, such that didactic lectures are still used to teach students a list of expected behaviours to memorise and adopt in the future, without the opportunity to engage in experiential learning through role play or use of vignettes to demonstrate possible real life ethical dilemmas that are common in clinical practice settings.This only leads to surface learning, rather than targeting the higher levels such as "shows how" and "does" which medical students should aspire to at the end of their Medical training.

Group Think
Another key issue was that of in-group and out-group dynamics such that if you were a Caucasian student you were less likely to experience discrimination or racism, whereas, if you were from an ethnic minority or non-Caucasian background you were treated differently, not accepted as part of the group and not given the support or tutelage that is expected to be provided to all Medical students irrespective of race, gender or level of entry (Janis, 1972;Janis, 1982).This can be explained by the phenomenon of Group Think as described by Janis, 1972.The high level of amiability between the Caucasian or Irish students and the Irish Mentors (doctors or nurses), may result in suppression of dissenting views/critical appraisal of discriminatory behaviour displayed towards fellow non-Irish Students in the interest of conformity, in often hierarchical clinical settings.This often leads to demoralising consequences for the out-groups (Non -Caucasian students) as found by Janis's research.
It is therefore not surprising that the qualitative study revealed themes bordering on differential treatments, discrimination, negative in-group-out-group dynamics, humiliation and a sense of frustration and disappointment, for students from minority ethnic groups, more so than other students.This echoes the findings of previous researchers (Wilkinson et al, 2006 andJohnston et al, 2011).
Other important themes such as the need to use positive role models in teaching professionalism, rather than just delivering didactic lectures was made by students.This is important because while the latter only yield surface learning opportunities (Mazmanian and Davies, 2002), the former results in deeper and more experiential learning which allows students to achieve the important lifelong competency of professionalism in Clinical Practice.Otherwise as shown in previous research, exposure to negative role models made students feel lied to, question the nobility of medicine and other negative impacts (Frank et al, 2006;Kenny et al, 2003).
Students also indicated that feedback was often given negatively by mentors in clinical settings.They were either told they should know it already or where shouted at and humiliated publicly for either real or perceived wrongs.This is an area that requires urgent focus in Medical training, because despite years of research and improvements in medical school classrooms, students report it is still not handled in a constructive or productive manner in clinical settings.This concurs with the findings of previous research (Nagata-Kobayashi et al, 2006).Clinical Feedback in particular and Medical professionalism in general should focus on caring, less judgemental and respectful treatment of both students and patients (Rhodes et al, 2004).
Another key finding was that students felt that professionalism training should not be focused on Medical Students alone, but rather on senior Colleagues as well.One student expresses this aptly by saying," if you want to treat the stem, you must first start at the head in order to succeed".This is important because many students said they are unable to challenge bullying because of the hierarchy in Medicine and this causes more emotional distress (Lomis et al, 2009), which they may try to manage by accepting, justifying and/or perpetuating the bad behaviour (Festinger, 1962).
It is thus imperative to have an in-depth understanding of students' experiences of unprofessional behaviour as they sojourn through the potential minefields of our clinical learning environments in Ireland and how these experiences affect them.Professionalism training can then be formatted to address real professional dilemmas that students face in training and after graduation.This will foster the development of budding professionals, justify the resources spent in medical training and ensure that society is offered doctors that are fit for purpose.A system designed by medical leaders and establishments set up by doctors and informed by students themselves (Wear and Kuczewski, 2004), will be best suited to preserving the teaching of medical ethics in both undergraduate and postgraduate training and will by extension uphold public interest better (Reed & Evans, 1987).

Limitations/strengths of study
This study was limited by the fact that only 10 interviews were done.Time and financial constraints are other limitations.The fact that the researcher is a novice at using NVIVO was an exciting learning process, but also a limitation.This research only explores students' experiences and further research exploring the views of consultants, senior registrars and registrars using a larger sample size will be a valuable endeavour in the future.It may have been better if interviews were conducted by fellow students who were trained beforehand, to make for a better balance of power and remove the power differential created by the researcher's insider status.The author also regrets not interviewing more Caucasian students because this would have allowed for more in-depth comparism of their experiences to those of their non-Caucasian counterparts.It would also have been beneficial if open ended questions were included in the questionnaire study, as this would have helped to obtain more insight into the students' experiences, in addition to the qualitative interviews conducted.

Conclusion
This

Take Home Messages
Students still experience negative behaviours during clinical rotation and the impact of these on them is profund.Some factors such as gender and ethnicity may have a bearing on differential experiences for students (moderate effect size shown in this research), but this needs a better powered study to show a significant association between gender/ethnicity and certain experiences of negative behaviours.Trainers need to be educated on the need to be better role models for trainees, in order to avoid potentiating the hidden curriculum and other un-intended consequences, during the clinical education of medical undergraduates.

Notes On Contributors
Dr Abu is a consultant Psychiatrist with an interest in medical education.She worked as a clinical tutor for the Royal College of Surgeons Ireland during this research that was completed in part fulfilment of her MSc in Medical Education.
Abu Sanni is a an allied health care practitioner who was instrumental in completing this research and was attending the Institute of Technology Carlow during this study.
Dr Gerard Flaherty is a senior lecturer in the national University of Ireland and also a consultant Physician in University Hospital Galway.He supervised the principal author during this work.
1. Never 2. Rarely 3. Sometimes 4. Frequently 5. very frequently 20.A doctor /student allowing their culture or their ethnic beliefs to interfere with the standard guidelines for obtaining informed consent from patients for medical interventions In Group-Out Group Dynamics "Okay, so in my first placement there was a situation I just felt that I wasn't being treated like other people" "I believe I was referred to that nurse by one of the other medical students and he did mention to me that she was very helpful and she would help me out and I could ask her whatever I needed to be done and she would help me as he had had an encounter with her and she was very nice.When I went she basically didn't pay me any attention so I felt that I was treated differently to my other colleague".
Her body language also was very 'closed' towards us and we could see that she only wanted to talk our Irish colleague.She also never really acknowledged us in the team, only concentrating on our Irish colleague all along our attachment.Every time I talked to her enquiring about educational stuffs, she would answer but only making eye contact to my Irish colleague, which I found very unusual.

Figure 2 :
Figure 2: Conceptual Overview of Qualitative Findings study reveals that Clinical Medical Students experience different types of behaviours from their senior colleagues in clinical settings.The experiences of students are often different from what lectures in professionalism prepared them for.Students experience different kinds of unprofessional behaviours including disrespect, poor feedback and in-group and out-group issues; which often leave them sad, disappointed and demoralised.This research indicates that the further a student's characteristics are from those of their supervisors in terms of gender and ethnicity, the more likely they are to report experiences of unprofessional behaviour from supervisors during clinical Medical placements.This research re-emphasises the need for problem-based experiential Professionalism modules during clinical Medical training, as well as ongoing training for mentors in both professionalism and how to deliver productive and unharmful feedback to their students.

Table 4 :
Free text comments from Qualitative study A doctor/ student writing something in the notes which is not true (.e.g. an examination which has not been performed).The course makes me believe that everyone acts in professional/ethical manners all the time.In the real world things aren't as black and white"."It is different in reality"."I didn't like seeing it, I think it diminishes trust" "sometimes it makes me to think negatively and push me to be unprofessional" "I actually feel disappointed because they have taught you one thing in class, the perfect world; but then in real life they have actually done the opposite, so you feel that they have failed in a way or they have really disappointed you".Surface learning "It is just a lecture from people telling you that you should wear professional dress and talk to people like this but it is just informative and just some instructions.I don't think we're going to do it if we just hear it.I think we need to practice it more" 1. What kind of situation have you been involved in? 2. How did being involved make you feel?3.Did you receive any formal instruction in medical professionalism during undergraduate training?