Abstract
BACKGROUND:
Observing professional behavior in clinical settings encounters many obstacles. In this research, the effect of defects of the educational system in observing professional behavior in clinical settings of Tehran University of Medical Sciences (TUMS) has been investigated.
MATERIALS AND METHODS:
This qualitative content analysis study was conducted using focused group discussions in TUMS. Twenty-two focused group discussions with 182 faculty members, medical students, and clinical staff were conducted. Conventional content analysis was used to analyze the data.
RESULTS:
One hundred and sixty codes (90 codes from the viewpoint of clinical staff and 70 codes from the viewpoint of faculty members and medical students) were extracted. The codes are categorized into 4 categories and 17 subcategories. The categories include “educators’ imperfections,” “inadequate initial training,” “lack of attention to continuous professional education,” and “lack of passion for professionalism education.”
CONCLUSION:
Greater efforts to empower educators, planning for the effectiveness of initial education, and motivating employees might play a role in promoting the observance of professional behavior in clinical settings. Professional behavior training should be considered at the entrance into the system. This education should be strengthened by continuing theoretical and practical training and addressed by proper supervision. It is also important to focus on attracting the attention of teachers to their own model role in observing professional behavior by others.
Keywords: Barriers, education, professional behavior, Tehran University of Medical Sciences, training
Introduction
Professionalism is a set of attitudes, values, behaviors, and relationships that are the basis of the contract of health workers with the community.[1] Professional behavior is the basis for interactions between physicians and other health-care team members with themselves and patients in health system. Observance of professional behavior is influenced by many factors.[2] One of the issues that have complicated the observance of professional behavior in Iran is the lack of attention to its challenges.[3]
Some researchers have identified administrative, individual, and environmental factors as influential in observing professional behavior.[4,5] Others have focused on the role of learning and have cited the ineffectiveness of teaching professionalism during medical education.[3] Training helps people translate value chants into ethical codes in daily behavior.[6] Medical education system should teach professional behavior as a personal characteristic that requires multifaceted ability, critical thinking skill, and judgment. Educational programs should work to train adaptive capacity doctors and educate them on how to identify and manage professional problems.[2]
Although the teaching of concepts related to professional commitment in different educational levels has been considered as a necessary component of the curriculum of medical programs and many related studies have been done,[7,8] the factors and obstacles related to professional commitment training have not been seriously taken into consideration in researches. Given the barriers to professional conduct, people who do not have the necessary knowledge and skills are more likely to deviate from the professional pathway,[8] so more attention to education and the removal of barriers seems to be necessary. Of course, the training of professional responsibilities in full is not a simple task and is associated with many challenges.[9,10]
Professionalism is a culture-dependent ability[11] and it is rational to carry out qualitative research to clarify the reasons for not complying with it. The purpose of this qualitative study is to identify educational system defects as barriers that make it difficult to adhere to clinical behaviors in clinical settings associated with Tehran University of Medical Sciences (TUMS). These obstacles are explained from the perspective of staff, learners, and faculty members in the context of Iran. The purpose of this research was to identify barriers to observing professional conduct in clinical settings affiliated to TUMS.
Materials and Methods
This qualitative content analysis study was conducted using focused group discussions in TUMS. This article addresses educational barriers. The approval for this research was obtained from the Ethics Committee of TUMS (94-02-74-29163).
The data were collected using 22 focused group discussions with faculty members, 6- and 7-year medical students, and specialty residents from clinical specialties and staff. In 14 group discussions with the staff, 82 nursing and midwifery staff provided valuable insights into the barriers to observance of professional conduct. There were also 3 group discussion sessions with the participation of 35 faculty members and 3 sessions with 40 assistants and 2 sessions with 25 interns participating.
The inclusion criteria were studying medicine or being an employee in one of the hospitals affiliated to TUMS. Faculty members and specialty residents were selected from all clinical specialties. Medical students were selected from the 6- and 7-year lists. Nurses were selected from different clinical settings including wards, clinics, and operating rooms. Acceptance of the invitation and participation of participants in the group discussion session were considered as a willingness to participate in the study. The method of selecting participants was a purposeful sampling strategy. To ensure identification of all themes, the strategy of maximum diversity, considering age, gender, background, and workplace for the staff, and age, gender, expertise, background, and workplace for faculty members were used in sampling. In the case of learners, gender and the year of university entrance diversity were taken into consideration. Meetings were conducted by two authors. The duration of the meeting varied from 90 to 120 min. The researchers played a coordinating and facilitating role in these groups and prevented the participants from leaving the topic of the discussion. All participants agreed to allow recording. The data collection began in November 2015 and ended in April 2016.
The topic was discussed at the beginning of the meeting and participants were assured that the discussions would remain confidential and only the overall results would be reported. A list derived from “the code of conduct,” approved and announced by TUMS in 2013,[12] was provided to participants. Participants were requested to first review the list and then comment on the barriers to observingany item that was less stringent at their place of work or the general barriers to observing professional code of conduct. The discussions were open and the participants were able to express every obstacle they had in mind. After each group discussion, the audio file was prepared in handwritten form. By carefully studying the manuscripts, the researchers reached a general sense of the sessions, and then, the texts were coded. Finally, managing and analyzing data using the MAXQDA software version 10 were performed based on conventional content analysis. Content analysis is a subjective content clarification of textual data using a process of systematic classification.[13] By inductive reasoning, through careful inspection and continuous data comparison, categories were emerged.[14]
To ensure the scientific accuracy of the study, the Guba and Lincoln criteria (1994) which included acceptance, reliability, portability, and acceptability were met.[15] For this reason, the researchers have tried not to exclude any relevant data during the analysis process and not enter any unrelated data. In addition, the validity of the data has increased in the research process with long-term involvement and full immersion in the data. The texts were reviewed along with the codes in the team meetings of the research team. The research team again analyzed the texts together, reviewed, and corrected their misunderstandings.
Results
Educational barriers include obstacles caused by the weakness of knowledge, attitude, and ability of individuals. Concerning training barriers, 160 codes including 90 codes from the viewpoint of clinical staff and 70 codes from the viewpoint of faculty members and medical students were extracted. The codes are categorized into 4 categories and 17 subcategories. The categories include “educators’ imperfections,” “inadequate initial education,” “lack of attention to continuous professionalism education,” and “lack of passion for professionalism education,” the last category being extracted only from nurses’ statements [Table 1].
Table 1.
Educational system defects in observing professional behavior
| Educational system defects in observing professional behavior |
|---|
| Educators’ imperfections |
| Lack of knowledge |
| lack of mastery |
| lack of attention |
| Inadequate initial training |
| Lack of transparency and structuring of the content |
| Lack of an effective assessment method |
| Lack of a suitable platform for admission and observance |
| Inadequate training at the time of recruitment |
| Not training the administrative staff |
| Lack of attention to continuous professionalism education |
| Shortcomings in proper education of trainers |
| Behavior according to personality traits |
| Reducing the moral sensitivity |
| Forgetfulness over time |
| Intentional negligence |
| Normalization |
| Lack of passion for professionalism education |
| Not feeling the need to learn |
| The ineffectiveness of learned professional behaviors |
| Not giving credit to people |
Educators’ imperfections
Participants expressed that the role of educators is one of the most important factors in the proper training of professional behaviors. The codes of “lack of knowledge of instructors in the field of professional behavior,” “the lack of mastery of instructors for management of clinical settings and issues in the field of professionalism,” and “the lack of attention of instructors to their role in the hidden curriculum” were extracted from their speeches and were classified in the category “educators’ imperfections.”
From the physicians’ point of view, the teachers in the field of ethics are unfamiliar with the clinical environment and the actual working environment, sometimes they are not a medical doctor, and in some cases, they are physicians but somehow disconnected from clinical setting and/or lack enough clinical encounters.
In addition, clinical educators do not have enough knowledge over the issues of professionalism and medical ethics and are ignorant of their role as a negative and/or positive behavioral role model and in the formation of hidden curriculum. Some doctors say that the mentors through their acts teach that professional behavior is a matter of indifference and sometimes ignorable in some situations.
Some of the items that were extracted from these codes are listed below. One of the assistants referred to the lack of knowledge of the professors in the field of professional behavior and their lack of attention to their role as model and said: “The ethical attribute is a theory-based discipline, for this part of the educational course, we had a series of training classes and a communication skills workshop, but in practice many things were not followed at the bedside. The class was not taken seriously, neither on the part of the students nor on the part of the mentors.” This statement may also refer to “not believing in the professionalism” or the “gap between knowledge and practice.” One of the faculty members said “And when a new faculty member enters the system, at least this code of conduct booklet should be provided. Especially the younger faculty who are supposed to be models and more involved with students.”
Another assistant said: “Part of the problem is related to background training and another part is related to the mistaken education of the individual. It is important for the general medicine student to know what (s) he is supposed to see and learn. I sometimes see a faculty member stand in front of a student when he enters his room; I am embarrassed not to do the same with my own lower level students. Respect is formed from the higher levels down. A student who is not respected by his master, does not respect anyone else, neither a patient nor a colleague.” Although the role model function is dominant here, other factors may play a role too.
Inadequate initial training
Participants referred to the inadequacy of the professional commitment training system. From the doctors and nurses’ talk of “the lack of transparency and structuring of the content of professional behavior training,” “the lack of an effective assessment method for examining the impact of professional behavior training,” “the lack of a suitable platform for admission and observance of trained content,” “inadequate training at the time of recruitment about rules and regulations,” and “not training the administrative staff for professional conduct” are classified in the category “inadequate initial training.”
One of the assistants in his talk spoke about the “ineffectiveness of education” and “lack of readiness to accept the trained content:” What has changed in our behavior after passing the course of medical ethics? I came up the same way as I entered. I answered in response to my professors in the professionalism exam: I introduce myself to the patient and I introduce myself to the patient grinning. That course did not affect my true behavior and attitude. I cannot handle it at all. That is, our mind is not yet ready to show a professional attitude.”
Another assistant referred to the code of “lack of an effective assessment method for assessing the impact of education,” in the following way: “Like other training courses, professional ethics should be taught with earnestness, if this is a way to measure it at Assistant or Student Levels, and then you can claim why people do not observe. When I have not been properly trained in this issue and no one is serious about its training, it is meaningless to interrogate.”
Lack of attention to continuous professionalism education
In the present study, the participants noted the lack of attention to continuing education of professional conduct as a barrier to observing professional behavior in the clinical setting.
Codes for “shortcomings in proper education of trainers,” “behavior according to personality traits,” “reducing the moral sensitivity of individuals over time,” “forgetfulness over time due to lack of proper reminder,” “intentional negligence of learned professional codes”, and “normalization due to repeatedly encountering the unethical conditions” were extracted from the participants’ comments and categorized in the category “lack of attention to continuous professional education.”
One of the faculty members referred to the codes of “learning shortcomings for teachers” and “behavior according to personality traits” and said: “I feel that we-as doctors-do not know much about these principles. Ethics courses are needed for us too, not just the students. First, we should focus on learning professionalism. I myself, for the first time, see this guideline for professional behavior in this session. All that I know is the contents of the medical ethics sessions that were told to us many years ago. Of course, someone who has been away from the general course for a few years does not care about professional behavior training courses, but does what he has in his nature and essence. If he is a kind person, he will pay attention to the patient and feel compassion.”
Another faculty member referred to the codes “reduce people's moral sensitivity over time” and “forgetfulness over time,” as follows: “We also have to take some courses regardless, over time, forgetting things is usual. We are stuck in a daily routine, and if the mental and physical conditions are not appropriate (stressful situations), we forget to pay attention to our professional behavior and monitor it.” or another faculty member in this context pointed out the code “forgetting over time”: “If the learning of learners does not last, the knowledge will diminish over time.” Moreover, one of the assistants said: “I think this sort of issue should be recapped frequently. Classes need to be repeated. Continuing education solves many problems.”
One medical student pointed to “normalization due to repeatedly encountering the unethical conditions,” in this way: “The stitching skill of us from the beginning of the internship to the end of the period improves significantly, but the observance of professional behavior worsens over time, that is, our moral teachings-contrary to our clinical skills-will be weakened instead of strengthened during the clinical course.”
Lack of passion for professionalism education
Nurses referred to the reasons for not welcoming professional behavior education by clinical staff such as “not feeling the need to learn professional behavior,” “the ineffectiveness of learned professional behaviors in a crowded hospital,” and “not giving credit to nurses who are committed to professional behavior.” Another case that was extracted from participants’ talk was that people considered professional behavior as a subordinate task, which led to a lack of people's acceptance of professional behavior training.
One of the head nurses described this issue: “We hold educational classes for the staff, no one willingly attends. You have to keep track of people a hundred times. Everyone says that these classes do not apply to our hospital and we barely have enough time to do our core tasks.” Moreover, one of the nurses spoke of the lack of appreciation from the managers and patients’ side of the nurses’ professional behavior: “I have never seen a nurse who is honored for his/her professional behavior, nor do patients even appreciate it. It is important for everyone to get the patients’ medications in a timely manner and accurately….”
Discussion
In the present study, the problems of teaching professional behavior in a clinical setting from the perspective of clinical staff of TUMS in four categories include “educators’ imperfections,” “inadequate initial education,” “lack of attention to continuous education,” and “lack of passion for professionalism education.”
Educators’ imperfections
In the present study, the weakness of educators in teaching professional behaviors was considered as a major barrier to observance of professional behavior, which was emphasized by medical practitioners working in hospitals. Since professional behavior is intertwined and is not isolated from the whole clinical practice, all professors and senior members of the system are – intentionally or unintentionally – considered to be role models and their professional or nonprofessional behavior is very influential in shaping the professional characteristics of the students or lower level employees.
Medical trainers are subject to this rule at any level. Obviously, the expectations of professionalism and ethics instructors are much higher. For learners, observation and informal learning in the curriculum is the most important determinant of professional conduct in the future,[16] and the organization's atmosphere is formed by this hidden training.
In their research, Karimi et al. referred to the coach as a unique learning element in the hidden curriculum. The role of medical teachers in teaching professional behavior is one of the issues that have been emphasized in another study.[17]
The present study referred to the codes: “lack of knowledge of instructors in the field of professional behavior,” “the lack of mastery of instructors for management of clinical settings and issues in the field of professionalism,” and “the lack of attention of instructors to their role in the hidden curriculum.” The first three codes correspond to the results of Dehghani's research[4] which points to “inadequate training of educators” as the main obstacle for observing professional behavior, but “the lack of attention of instructors to their role in the hidden curriculum” was not mentioned in their research. Although professors are a major source of unofficial learning[16,17] and practical adherence to professional behavior is a primary step in promoting the status of professionalism,[3] the results of this study showed that professors sometimes ignored this role.
Students talked about professors who ignore professionalism principles in clinical setting and unofficially behave as negative role models. In a qualitative study in Iran, faculty members emphasized that structured training at the faculty and learning from the role models are considered as the main factors affecting professional commitment learning.
In this regard, the students mentioned the behavior of the professors and received feedback from them as the most influential factor in their learning. In addition, in this research, “ignorance of this role from the trainers’ point of view” was one of the challenges mentioned as a barrier to professional commitment training.[3] It seems that this study also implies the implicit role of professors in the hidden curriculum.
Based on the views of the professors participating in this research, it seems that one of the reasons for ignoring the importance of being observed, as a role model, is the lack of or inadequacy of proper knowledge of the issues of professionalism and medical ethics. Problems in the system, such as the high load of work and the multiplicity of tasks intended for clinical professors, are also influential.
Since the modeling of faculty members in the clinical settings has a great role in learning professional behavior in medical students, the use of appropriate people in terms of professional behavior as a faculty member is a necessity in medical education.[3,18] In the research of Dehghani et al., “the inadequate experience of educators in ethical and legal issues in the nursing course” is mentioned as a barrier to observing professional ethics standards in clinical care from nurses’ point of view.[4] Participants in our research focused on professional behavior as a criterion for the job allocation and the initial training of instructors at the start of the recruitment.
Inadequate initial training
”Inadequate initial education” was one of the problems mentioned in this study. The lack of a specific framework and process for training and evaluation of professional commitment, namely the lack of transparency and structuring of the content of professional behavior training, has also been considered in previous researches.[3] The faculty members’ awareness of the professionalism culture[7] and its theoretical foundations[3] is a basic step in promoting the status of professionalism.
The results of this study showed that the evaluation of educational program in practice is a topic that ensures the effectiveness of this training. In addition, the evaluation of professors in terms of adherence to professional commitment could be a guarantor of student adherence to professional behavior.[3]
According to the participants of the present study, in addition to the basic training of teachers and senior members of the system, basic training in the principles of professional behavior and observance techniques is necessary for all members of the health system and staff in hospitals – even the administrative staff – before entering the health system. The ethical codes for administrative staff may be different from professional codes of health-care staff, but they are in line.
Although it is necessary to focus on theoretical approaches at the preparatory level,[3] many faculty members and students have stated that they have not passed coherent education in this field which has a disruptive effect both in their function as a team member of health management and as a role model. This finding is in line with the study of Saberi, in which the residents acknowledged that what they learned from professional commitment was hidden in the curriculum and that more attention should be paid to theoretical and practical teaching of professional commitment.[19]
In the research of Dehghani et al., the “lack of necessary education in the field of ethical issues during nursing education” was mentioned from the viewpoint of nurses regarding barriers to observance of professional ethics standards in clinical care. They also mentioned “the lack of attention to personnel training and necessary planning to meet these needs.”[4] This finding also emphasizes the need for a curriculum in the field of professionalism.[20] In the Allamy study, the participants mentioned a lack of curriculum for professional commitment education and acknowledged that this has caused an aberration in students’ thorough understanding of professional commitment.[3]
Lack of attention to continuous professional education
The participants in the present study, regardless of occupation and education, have acknowledged that continuing professional ethics training is a must-have for practitioners in clinical settings. In another study, the emphasis was on the need to provide continuous and applied training combined with medical education during the period[3] and after graduation.[19] Nurses also emphasized the lack of continuing education courses.[4] A study in Turkey also reported that the lack of attention to continuing education has reduced nurses’ moral sensitivity.[7]
Of course, frequent emphasis on the role of behavioral models is a kind of continuing education that needs to be given more attention. Similarly, it is necessary to teach the use of feedback and reflection techniques in the clinical setting to teachers and models, and the need for continuous use of them is emphasized by the senior management of the system.
Lack of passion for professionalism education
Nurses and clinical staff believed that they did not welcome professional behavior training in clinical settings. “Not feeling the need to learn professional behavior,” “the ineffectiveness of learned professional behaviors in a crowded hospital,” “professional behavior as a subordinate task,” and “lack of appreciation from professional nurses” were the reasons mentioned in this research. In other researches, “lack of motivation and lack of interest in the profession” were barriers to observing the standards of professional ethics in nursing staff.[4] The lack of satisfaction of basic needs such as the adequacy of income or adequate rest in nursing staff is also mentioned as a reason for nurses’ lack of motivation.[4,21] Since the reasons mentioned in this study may also lead to people's lack of motivation in the profession, creating motivators and incentives for staff is essential. On the other hand, sending the message that employees’ professional attitude and behavior is important for the management system can enhance the motivation of individuals to learn.
Limitations of the study
Although researchers have chosen to select participants from all clinical settings affiliated with TUMS and use the maximum diversity strategy, researchers acknowledge that this study is a qualitative research and its results may not be generalizable. In addition, this study is part of a major study on barriers to observing professional conduct in clinical settings, in which participants also discussed educational barriers to professional conduct. Therefore, the educational barriers mentioned may not be comprehensive enough.
Conclusion
Systems should pay special attention to professional behavior training at the time of hiring clinical staff, and this should be reinforced with continuing education. In the event of inadequate initial and continuous education and inadequate supervision of people's professional behavior, the sensitivity of individuals toward professional behavior in stressful situations decreases. It seems that efforts to empower educators, planning for the effectiveness of initial education, and motivating employees will play an important role in promoting the observance of professional behavior in clinical settings. Professional behavior training should be considered at the entrance to the system and should be strengthened by continuing theoretical and practical training. Additionally, obstacles that weaken the theoretical knowledge or the importance of considering the principles of professional behavior in clinical practice should be addressed by proper supervision. It is also a matter to attract the attention of teachers to the key role of their own model in observing professional behavior.
Financial support and sponsorship
The protocol of the study was supported by Tehran University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The authors thank all participants for making this research possible. Moreover, we wish to express our gratitude to our colleagues in the nursing office of TUMS.
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