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

Figures & data

Figure 1. Four categories including 30 descriptors for unprofessional behaviours in medical students (Mak-van der Vossen et al. 2017).

Table 1. Examples of factors involved in the occurrence of unprofessional behaviour.

Personal factors

Competency deficits (Levinson et al. 2014) Learning disabilities (Hays et al. 2011, Guerrasio et al. 2014) Mental health issues (e.g. depression, autism spectrum type symptoms, personality disorders (Bennett et al. 2005; Hickson et al. 2007; Hays et al. 2011; Levinson et al. 2014) Physical health issues (Parker et al. 2008; Levinson et al. 2014) Substance abuse (Bennett et al. 2005; Hickson et al. 2007; Guerrasio et al. 2014; Levinson et al. 2014) Lack of motivation for medical school (Teherani et al. 2009) Unmet needs (fatigue, hunger) (Levinson et al. 2014)

Interpersonal factors

Different cultural expectations (Parker et al. 2008; Hays et al. 2011; Barnhoorn et al. 2017) Hierarchy (Levinson et al. 2014) Poor understanding of roles and responsibilities (Parker et al. 2008; Hays et al. 2011; Levinson et al. 2014) Poor communication (Guerrasio et al. 2014; Levinson et al. 2014) Language difficulties (Levinson et al. 2014; Barnhoorn et al. 2017) Poor organizational skills (Hays et al. 2011; Guerrasio et al. 2014)

External factors

Psychosocial stressors (Hickson et al. 2007; Parker et al. 2008; Hays et al. 2011; Guerrasio et al. 2014) Family problems (Hickson et al. 2007; Hays et al. 2011; Levinson et al. 2014) Financial challenges (Parker et al. 2008; Hays et al. 2011; Levinson et al. 2014)

Contextual factors

Unclear standards (Hickson et al. 2007) Bureaucratic organization (Hickson et al. 2007; Levinson et al. 2014) High expectations, high workload in medical school (Hickson et al. 2007; Levinson et al. 2014) Learning environment does not encourage professionalism (Hickson et al. 2007) Inadequate supervision (Levinson et al. 2014) Poor role modeling (Hickson et al. 2007) Culture that rewards bad behaviour (Hickson et al. 2007; Levinson et al. 2014)

Figure 2. Profiles of unprofessional behaviour (Mak-van der Vossen et al. 2019).

Table 2. Facilitators for educators to respond to unprofessional behaviour of students.

	Improving expectancy of success of responding (Can I respond?)	Improving value of responding (Do I want to respond?)	Diminishing cost of responding (Are there barriers to respond?)
Faculty development	Teach practical skills how to address unprofessional behaviour (Howe et al. 2010; Ziring et al. 2015; Yepes-Rios et al. 2016) Provide individual guidance by staff (Howe et al. 2010)	Stress the effect of students’ unprofessional behaviour on future patient-safety (Howe et al. 2010; Yepes-Rios et al. 2016; Wong et al. 2017) Emphasize role modeling of responding to unprofessionalism to educators (Rougas et al. 2015) Inform teachers about policies (Rougas et al. 2015)	Offer the possibility to educators to discuss their experiences with colleagues and get mutual support (e.g. in teacher communities). (Mak-van der Vossen et al. 2014; Ziring et al 2015; Yepes-Rios et al. 2016; Rougas 2015)
Institutional strategies	Make ‘triage’ of observed unprofessional behaviour possible (Mak-van der Vossen et al. 2014; Rougas et al. 2015) Create a strong (longitudinal) assessment system (Parker et al. 2008; Yepes-Rios et al. 2016) Give institutional support, e.g. through faculty development (Ziring et al. 2015; Yepes-Rios et al. 2016) Create an online repository of examples of remediation policies and procedures (Ziring et al. 2015)	Organize forward feeding of professionalism concerns (Mak-van der Vossen et al. 2014; Parker et al. 2008) Create effective opportunities for students after failing (Ziring et al. 2015; Yepes-Rios et al. 2016) Provide feedback about the results of remediation, give evidence of student support (Howe et al. 2010; Mak-van der Vossen et al. 2014; Rougas et al. 2015) Formulate clear expectations and policies (Ziring et al. 2015) Focus on help, not on punishment (Ziring et al. 2015)	Give teachers adequate time to observe and evaluate behaviours (Daelmans et al. 2016) Provide short assessment and report forms that are easy to use (Howe et al. 2010) Make assessment of professionalism part of normal assessment procedures (Howe et al. 2010) Separate teaching and assessing of professionalism (Howe et al. 2010)

Figure 3.  A roadmap for responding to professionalism lapses (Mak-van der Vossen et al. 2019).

Table 3. Ten questions to explore a student’s unprofessional behaviour.

To be explored	Question
1. Student’s perspective about the facts	What happened?
2. Alignment with assessment outcome	Do you agree with the unprofessional behaviour judgment?
3. Intentions	What did you intend to do?
4. Beliefs	What did you expect to happen?
5. Context	What circumstances influenced your behaviour?
6. Power	Were you able to influence the circumstances?
7. Effect on others	What do you think your behaviour did to others?
8. Emotions	How do you feel about it now?
9. Causes	Are there any circumstances that make it more difficult for you than for other students to comply with the professionalism expectations?
10. Plans	How would you act in a similar situation next time?

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