The following procedures were undertaken for developing an assessment scale of medical professionalism. First, the concepts of medical professionalism is extracted. Second, an item pool will be created based on the concepts extracted as a source for the scale items. Third, a pre-test will be conducted to develop the Level 1 scale for assessment readiness in pre-clinical students. Fourth, the main survey for developing the Level 1 scale for assessment of readiness in pre-clinical students will be conducted. Fifth, the Level 2 scale adapted for assessing the readiness of students at the time of graduation will be developed.
Step 1: Extracting the concepts of medical professionalism
A close investigation was performed on various documents (Table 1) describing medical professionalism of physicians, nurses and physiotherapists as presented or published by associations of each profession in the four countries of Japan, the United States, United Kingdom and Canada. Content corresponding to medical professionalism were coded and abstraction and specification of concepts were repeated until 90 codes in 21 categories, 7 areas and 3 fields on the concept of medical professionalism were extracted (Table 2).
Table 1. Referrences for constructing of the concept of medical professionalism
No.
|
Profession
|
Name
|
Person or Group, Nation
|
Year of publication
|
1
|
Doctor
|
Medical professionalism in the new millennium: a physician charter
|
ABIM: American Board of Internal Medicine, .ACP-ASIM: American College of Physiciasn-American Society of Internal Medicine, EFIM: European Federation of Internal Medicine
|
2002
|
2
|
Doctor
|
Good medical practice
|
General Medical Council, U. K.
|
2013
|
3
|
Doctor
|
CanMEDS 2015 physician competency framework
|
The Royal College of Physicians and Surgeons of Canada, Canada
|
2015
|
4
|
Doctor
|
Professional ethics guidelines of the doctor
|
Japan Medical Association (Japan)
|
2008
|
5
|
Doctor
|
A draft proposal of goals for professionalism
|
Japan Society for Medical Education, Japan
|
2015
|
6
|
Doctor
|
International code of medical ethics
|
World Medical Association
|
2006
|
7
|
Doctor
|
Measuring Medical Professionalism
|
Stern, D. T. Arnold, L.
|
2005
|
8
|
Nurse
|
The ICN code of ethics for nurses
|
ICN: International Council of Nurses
|
2012
|
9
|
Nurse
|
The ANA nursing code of ethics
|
ANA: American Nurses Association, U. S.
|
2015
|
10
|
Nurse
|
The code of ethics for nurses
|
Japan Nursing Association, Japan
|
2003
|
11
|
Nurse
|
A model for professionalism
|
Miller, B. K
|
1988
|
12
|
Physical
therapist
|
Professionalism: Physical therapy core values
|
APTA: American Physical Therapy Association, U. S.
|
2012
|
13 |
Occupational therapist |
Code of professional values and behaviour |
CSP: Chartered Society of Physiotherapy, U. K. |
2011 |
Table 2. Medical professionalism concepts extracted from various products
Area
|
Field
|
Cateogory
|
Personality development, knowledge and skills as the basis for medical professionalism(1)
|
Personality development and social skills(11)
|
Character, integrity, empathy(11a)
|
Self-management (11b)
|
Communication skills (11c)
|
Continued education and career development (11d)
|
Reflective practice (11e)
|
Practice based on high skill levels and knowledge (12)
|
Practice based on high skills and knowledge (12a)
|
Establishing autonomy (13a)
|
Interactions between the patient, the medical profession and other health professionals(2)
|
Patient-centred care (21)
|
Patient-centred approach (21a)
|
Supporting patient autonomy (21b)
|
Understanding and interacting with the patient as a whole person (21c)
|
Collaborative practice (22)
|
Collaboration with professionals in other fields (22a)
|
Collaboration within the medical/healthcare profession (22b)
|
Building an organizational environment for care(23)
|
Preparing the organizational environment for care (23a)
|
Providing and promoting safe medical care (23b)
|
Fulfil social responsibilities (3)
|
Contributing to the community, professional associations and society (31)
|
Affiliation and contributions to professional medical/healthcare associations (31a)
|
Understanding of and contribution to public health activities in the community (31b)
|
Contributing to health policies (31c)
|
Use of mass media and information provision (31d)
|
Understand the general legal and ethical principles to fulfil social responsibilities(32)
|
Respect legal and ethical principles (32a)
|
Appropriate handling and protection of personal information (32b)
|
Fulfilling social responsibilities (32c)
|
Concept identification numbers in parentheses.
Ninety "code" subordinated to the "category" are omitted due to the lack of space.
|
Step 2: Investigating the concepts of medical professionalism and creating an item pool
Based on the concepts of medical professionalism, a working group of seven individuals, including the author made a close investigation of the draft items and created an item pool composed of 259 items.
Step 3: Developing the Level 1 Scale: Pre-test
Study design: A cross-sectional study with a collective survey using anonymous, self-administered questionnaires were conducted in April – June 2016.
Subjects: Subjects were first-year students of two universities located in Hokkaido, the northernmost part of Japan. The survey was conducted on 714 first-year students in eight departments (pharmacy, dentistry, nursing, clinical social welfare, clinical psychology, physical therapy, occupational therapy, speech-language-hearing therapy and dental hygiene) of University A, and 110 first-year students of the department of medicine of University B.
Survey items: As demographic characteristics, students’ academic faculty and department, year, and gender were surveyed. Thirty-five items were selected from the item pool as items to assess medical professionalism. The response options were as follows: Agree’ (5 points), ‘Agree to a certain extent’ (4 points), ‘Neither’ (3 points), ‘Disagree to a certain extent’ (2 points), and ‘Disagree’ (1 point).
Analysis: Exploratory factor analysis was performed to confirm the factor structure of the concepts of medical professionalism. The method for factor extraction consisted of the principal factor method using the promax rotation. The Kaiser-Meyer-Olkin (KMO) test and the Bartlett's test of sphericity were used to examine the appropriateness of factor analysis. A result of the former of ≥0.8 and the latter of p<0.05 was considered to define approapriateness.
Step 4: Developing the Level 1 Scale: Main Survey
Study design: A cross-sectional study by collective survey using an anonymous, self-administered questionnaire was conducted in September 2016.
Subjects: 131 fourth-year students in the medical department and 40 students in the department of pharmacy of University C located near Tokyo.
Survey items: As demographic characteristics, students’ academic faculty and department, year, and gender were surveyed. Twelve items were excluded from 35 items used in pre-test, and 12 items were newly added from the item pool, so that 35 items were used in the main survey.
The KiSS-18 is an 18-item scale for measuring social skills in young adults developed in Japan with confirmed reliability and validity (Kikuchi, 2004; Niitsuma et al., 2012), The KiSS-18 evaluates skills in communication and developing personal relationships, and is used to assess criterion-related validity of the present medical professionalism scale. Each question on the KiSS-18 can be answered according to a following five-point Likert scale.
Analysis: Exploratory factor analysis was performed basically the same as that of pre-test. The Pearson correlation coefficient between the KiSS-18 and total score for items that compose the factors were calculated to assess criterion-related validity of the scale. As the KiSS-18 scale assess and measures social skills, the correlations with the medical professionalism scale were as follows: Moderate correlation (0.5) or above was expected with subscale items related to communication skills and interpersonal skills, whereas a mild positive correlation (0.3 or greater but less than 0.5) was expected with other subscale items.
The Cronbach’s coefficient alpha for each subscale item and all items were calculated to assess reliability of the scale.
Step 5: Developing the Level 2 scale
Study design: A cross-sectional study of a collective survey using anonymous, self-administered questionnaires was conducted in March – September 2016.
Subjects: Subjects were 352 junior residents immediately before starting their residencies in 35 postgraduate education hospitals affiliated with University B (i.e., immediately after graduation), and 83 fourth-year students in the nursing department of University C. Questionnaires were either collected and mailed back by the person in charge, or were mailed by individual residents.
Survey items: Gender was surveyed as a demographic characteristic. Level 2 items of the medical professionalism assessment scale were selected among the item pool. Fifty items were selected. Twenty-two of the 50 items were re-selected among items used in the Level 1 scale.
The Japanese version of the P-MEX (Professionalism Mini-Evaluation Exercise) (Tsugawa et al., 2011; Tsugawa et al., 2009), often used as a scale to assess professionalism in residents, were used to test criterion-related validity with the Level 2 scale. The P-MEX is composed of 4 factors and 24 items, among which the second factor, “Reflective skills” (5 items) was used as skills assumed to be largely acquired at the time of graduation. The P-MEX is used to assess others, not for self-assessment, the options for answers were revised to five-point Likert scale.
Analysis: The same methods as those used to for the main survey for the development for the Level 1 scale were used.
SPSS Statistics 22.0 (IBM) was used for the analysis of both surveys, and p<0.05 was set statistically significant.
Ethical considerations
Anonymous, self-administered questionnaires were used for the survey. Subjects were explained orally and in writing of the purpose, methods, ethical considerations and publication of the study results, and the survey was conducted on those who gave consent. Subjects were clearly explained the ethical considerations, including the following: (1)Data that allow identification of individuals would be deleted before use in analysis; (2)Subjects would not be subjected to losses or disadvantages regardless of their decision to cooperate or not cooperate in the study.
This study was approved by the Ethical Board of the Sapporo Medical University (27-2-58).