Faculty development for learning and teaching of medical professionalism

Abstract

Introduction: Professionalism must be explicitly taught, but teaching professionalism is challenging, because medical teachers are not prepared to teach this content area.

Aim: This study aims at designing and evaluating a faculty development programme on learning and teaching professionalism in the Arabian context.

Programme development: The study used a participatory design, where four authors and 28 teachers shared the responsibility in programme design in three steps: orientation workshop for teachers, vignette development, and teaching professionalism to students. The workshop provided the cognitive base on the salient attributes of professionalism in the Arabian context. After the workshop, authors helped teachers to develop a total of 32 vignettes in various clinical aspects, portraying a blend of professionalism dilemmas. A battery of seven questions/triggers was suggested to guide students’ reflection.

Programme evaluation: The programme was evaluated with regard to its “construct” and its “outcomes”. The programme has fulfilled the guiding principles for its design and it has emerged from a genuine professionalism framework from local scholarly studies in the Arabian context. Programme outcomes were evaluated at the four levels of Kirkpatrick’s model; reaction, learning, behaviour, and results.

Discussion: The study communicates a number of context-specific issues that should be considered when teaching professionalism in Arabian culture with respect to teachers and students. Three lessons were learned from developing vignettes, as reported by the authors. This study advocates the significance of transforming faculty development from the training discourse of stand-alone interventions to mentorship paradigm of the communities of learning.

Conclusion: A three-step approach (orientation workshop, vignettes development, and teaching professionalism) proved effective for faculty development for learning and teaching of professionalism. Professionalism can be taught using vignettes that demonstrate professionalism dilemmas in a particular context.

Introduction

Professionalism exemplifies the desired behaviours and attributes towards which physicians – and other health professionals – aspire while serving their patients and society (Wearn et al. 2010). Medical professionalism received a global interest in recent years, mainly because of the high profile failures in the practice of medicine, which are often related to unprofessional behaviour (Talbott 2006). Traditionally, professional values and behaviours have been caught from role models (Kenny et al. 2003; Cruess & Cruess 2010). The presence of role models is essential in promoting professionalism, but this informal process is no longer considered sufficient with the current heterogeneity of medical students, who were admitted to medical schools with different social, cultural, and socioeconomic backgrounds (Swick et al. 1999). Such diversity nourishes a full spectrum of views among learners about what is professional and what is not professional in different contexts. Professionalism, therefore, must be explicitly taught in the formal curriculum (Cruess & Cruess 1997), and it has already been incorporated into many medical education systems for both undergraduates (Hesketh et al. 2001) and postgraduates (Batalden et al. 2002).

Table

Practice points

Teaching professionalism should be based on a genuine framework that reflects the societal norms, culture, values, traditions, and expectations. The attributes of professionalism cannot be taught as abstract concepts, but they have to be embedded in situations or vignettes. Teachers should plan a battery of questions to trigger reflection on professionalism vignettes. Teachers and learners have to acknowledge the complexity of medical practice, as there is more than one correct behaviours to be considered for each professionalism dilemma. Professionalism can drive a more student-centered approach to learning.

Teaching professionalism is challenging for faculty members (Bryden et al. 2010), because of two main concerns. The first concern is related to the context-specific nature of professionalism, because it is a privilege granted by the society in return of specific expectations from medical professionals (Cruess 2006). That’s why professionalism is sensitive to culture and there is no one-size-fits-all curriculum on professionalism (Ho et al. 2011). An institutional cognitive base should be developed to encompass the core professional values, attributes and behaviours that should be addressed in teaching and learning professionalism.

The second concern is about how professionalism can be taught and learned. The domains of professionalism cannot be taught as abstract concepts (Steinert et al. 2007). Lectures on preaching what doctors “should do” and “should not do” proved to have least educational impact on students and may “…force all students into the straight jacket of political correctness” (Gordon, 2003, p. 342). A more promising approach is described in “situated learning theory”, where knowledge needs to be presented in authentic contexts (Lave & Wenger 1991; Cruess & Cruess 2006; Zink et al. 2009; Birden et al. 2013). A set of scenarios (or vignettes) to describe professionalism dilemmas, can be used to trigger discussion and reflection that facilitate learning professionalism (Hatem 2003; Boenink et al. 2005; Hill-Sakurai et al. 2008). Professionalism vignettes reflect the complexities of medical practice and offer opportunities in an open and safe forum to guide students’ learning on un/professional behaviour (Bernabeo et al. 2013). Self-reflection and reflection among peers is fundamental to the understanding and development of professionalism (Horlick et al. 2006).

Unfortunately, faculty members are not competent in teaching professionalism as a content area and they are unable to articulate the attributes and behaviours within their courses (Steinert et al. 2005). Furthermore, there is a literature gap on faculty development for teaching professionalism and the few available scholarly reports in the area have been written from a Western perspective (Steinert et al. 2005). Faculty development is fundamental to empower educators to teach professionalism and promote institutional agreement on definitions and characteristics of professionalism (Steinert et al. 2007; Adkoli et al. 2011). This study has two aims: (1) to design a faculty development programme in learning and teaching professionalism in the Arabian context, and (2) to evaluate the “structure” of this programme in view of educational guiding principles for teaching professionalism and evaluate the “outcomes” of the programme on the reaction, learning, and behaviour of faculty members.

Programme development

The programme was planned and delivered by the Department for Medical Education and it was approved by the Deanship for Educational Development at the University of Dammam, Saudi Arabia. The preparation and implementation of the study extended from September 2013 to May 2014. The programme was developed with two guiding principles in mind related to culture-sensitivity and situated learning. It has to embody professionalism in Arabian context and present the core values of professionalism as operationalised in behaviours of health practitioners in selected situations. The programme intended to achieve five learning outcomes, as listed in Table 1.

Table 1. Learning outcomes of the faculty development programme.

By the end of the programme, teachers should be able to:

1. Identify relevant key attributes of professionalism in their specialties

2. Develop vignettes that demonstrate professionalism dilemmas to be used for teaching professionalism

3. Use pre-set questions/triggers to guide students’ reflection on the given vignettes

4. Report students’ learning experiences

5. Act as advocate to teaching professionalism in their departments and institutions

Methods

Two groups shared the responsibility for programme development, namely: authors and teachers in a participatory design approach. Authors reviewed the literature in three tracks: professionalism in Arabian context, educational principles for teaching professionalism, and faculty development programme planning and evaluation. The programme was designed in a three-step process, as demonstrated in Figure 1.

1. Orientation workshop

Figure 1. Developing a programme for faculty development for learning and teaching professionalism in a three-step process. A: Author; T: Teacher; S: Student.

Teachers of different health professions colleges were invited to a full-day faculty-wise workshop on professionalism that encompassed short presentations and interactive discussions in seven topics, as listed in Table 2.

Table 2. Topics for presentations and activities of the workshop.

• The growing significance of professionalism

• Why professionalism must be taught?

• The cultural basis of professionalism and its domains in the Arabian context

• The guiding principles to inculcate professionalism in health professions education curricula

• Teaching professionalism in clinical sciences

• The neglected opportunity to teach professionalism in basic sciences

• Using vignettes for guided reflection on professionalism issues

Teachers were invited to share their experiences on professional lapses or moments of deep reflection in their actual clinical practice.

1. Vignettes development

After the workshop, authors helped teachers in private meetings to describe critical situations and professionalism dilemmas with relevance to their specialities. Authors and teachers, together, developed multi-dimensional professionalism vignettes that describe real-life scenarios of conflicting interests between practitioners, patients, and colleagues.

1. Teaching professionalism

Teachers presented the developed vignettes (in written format) to students in their classes and clinical rounds. Teachers and authors, agreed on a preferred learning setting, where the class was divided in small groups of five to seven students. Each group discussed the different aspects of the professionalism dilemma in a particular vignette for 15 minutes. During reflection, their students were encouraged to carefully consider the different aspects of the professionalism dilemma, express their feelings, debate on the possible decisions to be taken with justification, and anticipate the consequences of each course of action on different stakeholders in the scenario, namely, on themselves, patients and colleagues. Ten minutes were allocated for a student leader from each group to present and defend the argument of his/her peers and seek feedback from members of the other groups and instructors.

Results

A total of 28 teachers attended the workshop from a variety of backgrounds of health professions education in medicine (n = 13), nursing (n = 10), applied medical sciences (n = 3), and dentistry (n = 2). After the workshop, authors, and teachers developed a total of 32 vignettes in various clinical aspects, portraying a blend of professionalism dilemmas. Sample vignettes are narrated in Table 3.

Table 3. Sample vignettes on professionalism.

Vignette 1: While you are examining a patient in the outpatient clinic, an old lady opens the door suddenly without an appointment and asks you to order two sophisticated investigations for her and renew her prescription. The lady is a patient of another colleague who went to vacation and will be back to his clinic after 3 weeks. The nurse attending your clinic complained that the old lady has shouted at her.

Vignette 2: A patient enters your office and shouted: “Doctor, I want to leave the hospital now”. You asked: “Why?” Suddenly the patient moved a chair with anger and seems as if he is about to hit you.

Vignette 3: You are a nurse at the family planning clinic. A patient was examined by Dr. X and he asked you to insert an intrauterine device (IUD). You examined her and successfully inserted the IUD. When you started educating her on the common problems of IUD, you discovered that she has a history of ectopic pregnancy, which is a clear contraindication to IUD.

Vignette 4: Your kids ranked top in their schools. You promised them an exceptional outing this weekend. When you were planning to leave the hospital after the end of your shift, a friend of yours arrived at the ER and requested you to stay to care for his wife, who was in a critical condition. You have already singed out to one of your competent and conscientious colleagues. You know he is capable of managing the case. You decided to meet your friend to assure him then proceed with your personal plans with your family. Your friend, however, pleads you to stay.

Teachers and authors suggested a battery of seven questions/triggers to guide students’ reflection on professionalism vignettes, as listed in Table 4.

Table 4. Triggers/questions to guide reflection on professionalism vignettes.

○ Describe your feelings, if you were in that situation.

○ What is the professionalism dilemma of the given scenario?

○ What would you do in that situation? and why?

○ What are the expected consequences of your decision?

○ What if you were in the shoes of the colleague or the patient? (swapping roles)

○ What did you learn from discussing this scenario?

○ Do you feel more prepared in case if you encounter a similar situation in reality?

Teachers piloted the developed vignettes on 126 students in clinical years. Students reported their feedback on the new learning experience in response to a four-item questionnaire in five-point Likert scales. Students agreed that learning experience was enjoyable (Mean = 4.28, SD = 0.81), reflection followed a logical sequence (Mean = 4.11, SD = 0.91), vignettes were authentic to real practice (Mean = 4.17, SD = 0.82), and the time was properly allocated throughout the session (Mean = 3.81, SD = 1.17).

Programme evaluation

Our faculty development programme on learning and teaching professionalism can be evaluated with regard to its “construct” and its “outcomes”, as in Figure 2.

Figure 2. Programme evaluation for its construct (in three principles) and its outcomes (in four levels.

Construct evaluation

Evaluation of programme construct was planned in view of three main guiding principles in professionalism education: (1) professionalism has to emerge from a context-specific foundation that fits the Arabian culture, (2) programme design should acknowledge the situated learning theory, and (3) the participatory design approach has to be manifested by the shared responsibilities between authors and teachers in programme development.

There are indications to confirm that our programme has already fulfilled the above three guiding principles. First, the domains of professionalism have emerged from local studies that addressed professionalism in Arabian context (Adkoli et al. 2011; Al-Eraky & Chandratilak 2012; Al-Eraky et al. 2013, 2014). In the Four-Gates model (Al-Eraky et al. 2014), eight professional traits were shortlisted and coupled in four themes (Gates), namely: dealing with self, dealing with tasks, dealing with others, and dealing with God. The forth gate (Dealing with God) is pertinent to societies, where “faith” represents a cornerstone in communication and the basis for social values for a majority of the health-care professionals. In the Arabian context, self-accountability and self-motivation were interpreted as “taqwa’’ and “ehtesab’’, respectively, in Arabic (Al-Eraky et al. 2014). These studies were used to establish the foundation of the cognitive base of the faculty development programme for teaching professionalism. Second, the program used situated learning theory, where these attributes and values were operationalised in real-life situations to stimulate reflection among students on professionalism dilemmas. Third, teachers contributed with authors throughout programme by: sharing their personal experiences on professionalism lapses during the orientation workshop (step 1), developing the vignettes (step 2), designing an appropriate learning setting, and propose triggers to guide students’ reflection (step 3), as demonstrated in Figure 1.

Outcomes evaluation

Evaluation of programme outcomes was planned as per the Kirkpatrick’s model (1994). The model describes four levels of outcomes: (1) Reaction (of teachers to the educational experience); (2) Learning (which refers to changes in attitudes, knowledge, and skills of teachers); (3) Behaviour (which refers to the change of their teaching practice); and (4) Results (which refers to impact of the programme on students learning and organisational change). We attempt to evaluate the programme in the four levels, as follows:

1. Reaction

Participating teachers actively contributed to the three steps of programme development. The workshop inspired teachers to reflect on and express a number of stories portraying un/professional behaviours of themselves, students, and colleagues in real practice with respect to their specialities. Teachers’ engagement in the discussion was an indicator of their satisfaction about the quality of workshop and reflected their interest in the topic.

1. Learning

The programme produced more knowledgeable teachers on the complexity of professionalism and how it can be taught. Gain in cognitive knowledge of the teachers was manifested by (1) the quality of vignettes they developed, as reviewed by content experts in professionalism and colleagues of the same specialities, (2) the developed battery of questions/triggers for reflection, (3) teachers’ ability to plan the appropriate learning setting and allocate proper time for reflection and discussion.

1. Behaviour

Teachers learned about professionalism and they transferred their learning to their workplace. The change of behaviour was measured by the self-reported gain in instructional design skills in teaching professionalism in classes using the developed vignettes. Teachers expressed that they were empowered to pass their tacit knowledge on professionalism to their students in a structured manner.

1. Results

Results or the impact of the programme can be measured in two directions: the improvement in students’ learning and a wider change in the system or organisational practice. Students’ feedback on their learning experiences was promising as indicated in the results of the questionnaire. We admit that a longer period is required to evaluate our programme at this advanced level, but we, as authors, are optimistic that our study is expected to promote an organisational change in the nearest future for two reasons. First, teachers who have voluntarily contributed to this study can act as professionalism advocates to call for curriculum reform and mentor their peers in different specialities to teach this relatively complex content area. Second, the 32 developed vignettes can be a nucleus for a professionalism vignette bank, where dilemmas can be sorted out by their domain, discipline, learning outcomes, and educational level.

General discussion

This study aimed to design and evaluate a faculty development programme for learning and teaching professionalism. The programme used genuine Arabian framework on professionalism as indicated in local scholarly reports. The design follows the educational principles for teaching professionalism using situated learning theory, where professional attributes were embedded in situations or vignettes. The engagement of teachers in interactive discussion during the orientation workshop and afterwards in the subsequent phases of vignettes development along with students’ feedback on their learning experiences indicated that the programme was feasible, constructive, and productive.

Context-specific remarks

From our experience, we would like to reflect on some context-specific issues related to teaching professionalism in an Arabian context from the perspective of both teachers and students. We noticed that teachers of traditional educational systems, that is based on information provision, like to be in control of their sessions. They plan to impart knowledge in a classical approach, for example, by using PowerPoint or a whiteboard. Teachers are keen to cover the materials in hand and they usually plan a limited period for discussion or clarification, usually at the end of the session. That’s why some teachers admitted that they felt unsecure at the beginning; because they were not familiar with teaching this content area and they could not anticipate the sequence of the discussion. But, when enough time was allocated for reflection, the session turned out to be exciting for both teachers and students. Professionalism education can drive a more student-centred approach to learning, because there is not much content to be presented, but professional values are contextualised in situations which stimulate discussion and reflection.

On the other side, students also felt unprepared for the session, because they were not familiar with that form of highly interactive learning experience. Students have to build a rationale to advocate their decisions in each professionalism dilemma. Students listed a number of benefits they learned during sessions regarding critical thinking, being accountable for own actions, feeling empathy to patients, integrity and honour, prompt decision making, respecting the scope of service, and collaboration with other members of the health team. Students also reported that they felt better prepared to manage similar situations, if they would encounter them in real life practice.

The use of vignettes was particularly valuable to teach professionalism in Arabian context. Arab students have been raised in an educational environment that fosters competition and they usually seek the “single” best answer, as the only truth (Frambach et al. 2012). Medical practice, however, is not that straightforward, but it is full of uncertainty and ambiguity. We advised teachers not to turn professionalism teaching into “preaching” on what should or should not be done. Alternatively, teachers should help students to explore different views and elements on each professionalism dilemma, because in reality, professionals are not supposed to find the absolute correct answer, but develop professional judgement skills and advocate what they think “most appropriate and feasible” action in each situation (Coles 2002).

Lessons learned

We would like to indicate three lessons that we learned from planning, conducting, and evaluating our faculty development intervention for learning and teaching of professionalism. First, developing vignettes on professionalism is not an easy job. It has to reflect the complexity of real situations. For instance, in Vignette 1 (Table 3), learners have to acknowledge the conflict of interest of four stakeholders, namely the doctor (self), the patient, the absent colleague, and the nurse.

Second, some vignettes can help learners prioritise their roles to enjoy balanced life. For instance, Vignette 4 (Table 3) demonstrates the typical tension between duties and family responsibilities. It was a learning opportunity to decide the “limits” of professionalism values. All virtues are midway between two non-virtues. For instance, extreme altruism can lead to burn-out with the consequences of impairment and lack of conscientiousness. Students, particularly residents, should create a balance between their professional duties and personal commitments.

Third, we recognised that different versions may evolve from a single vignette by fine-tuning some contextual details. For instance, in Vignette 1 (Table 3), what if the absent doctor will stay away for three months, instead of three weeks? What if the patient is asking to just renew a routine monthly prescription for her chronic illness? Also swapping the roles among characters may offer different perspectives of the same vignette. For instance, if you were the absent doctor, how would you react to a colleague who dares to examine “your” patient in your absence? And what if you were in the shoes of the nurse who has been abused by the angry patient? It is amazing to identify different learning objectives with each of the above questions that emerged from the same scenario.

We also realised the implication of transforming faculty development from the classical formal standalone events (mainly workshops) to informal meetings and collaborative learning among teachers to create a move towards mentorship and learning participation in “communities of practice” in faculty development for professionalism (Steinert et al., 2006).

Strengths and limitations

The growing interest in teaching, learning, and assessment of professionalism was not supplemented with scholarly initiatives for faculty development to train teachers in that important content area (Steinert et al. 2005). This study adds to the scarce evidence available on the feasibility and impact of faculty development on professionalism on teachers and students. With the recent national framework of competencies that focuses on professionalism as a salient outcome of medical education in Saudi Arabia (Zaini et al. 2011), we expect other initiatives to be materialised in the nearest future. We intentionally submitted a detailed manual including outcomes, topics for presentations, sample vignettes, and triggers for reflection. We hope our report would help educators to design similar, and even better, programmers in their institutions.

The study is not without limitations. The selection of participating faculty members was based on their personal interest to learn and teach professionalism in their courses. An alternative approach may engage chairpersons of departments to define a strategy to officially inculcate professionalism as an explicit outcome and then define tools for teaching and assessment. We admit that our programme represents an ad-hoc initiative, but Steinert et al. (2005) advocated that faculty development on professionalism can bring about curricular change, which we desperately hope.

Conclusion

Professionalism can be taught and learned by vignettes that describe professionalism dilemma in different specialities. A three-step approach (orientation workshop, vignettes development, and teaching professionalism) proved effective for faculty development on professionalism. Teaching professionalism is a shared responsibility between educationists and teachers. Teachers, who contributed to this study, can be professionalism advocates to motivate their peers for teaching professionalism in their specialities. Future efforts should be synchronised with the curriculum committee and departments to transform the individual experiences of teachers into an institutional reform to explicitly teach professionalism across all specialties.

Notes on contributors

Dr MOHAMED M. AL-ERAKY, MBBCh, MSc, MMedEd, is a lecturer of medical education at the University of Dammam, Saudi Arabia. He was also a founding member of Medical Education Development Center at Zagazig University, Egypt. Dr Al-Eraky has been awarded his master degree in medical education from Dundee University (UK) and is currently a PhD fellow at the University of Maastricht (NL).

JEROEN DONKERS, PhD, is an assistant professor, at the Department of Educational Development and Research, Faculty of Health, Medicine, and Life Sciences, Maastricht University, the Netherlands.

GOHAR WAJID, PhD, Assistant Professor of Medical Education, University of Dammam, Saudi Arabia. He is consultant to the Master in Health Professions Education Programs at Khyber Medical University and the University of Lahore, Pakistan.

JEROEN J. G. VAN MERRIENBOER, PhD, is a Full Professor of Learning and Instruction at the Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University. He is a Research Programme Director of the School of Health Professions Education and Scientific Director of the Interuniversity Center for Educational Research.

Acknowledgements

The authors would like to appreciate the efforts of all faculty members and colleagues for their invaluable contribution to the planning and implementation of the reported model for faculty development for medical professionalism. Special thanks to: Prof. Khalid Al-Umran, Dr Mona Al-Sheikh, Dr Eman Rashad, Dr Neama Fouad and Dr Hesham F. Marie.

The publication of this supplement has been made possible with the generous financial support of the Dr Hamza Alkholi Chair for Developing Medical Education in KSA.

Declaration of interest: The authors have no conflict of interest.