Professionalism dilemmas in work based learning: personal incident narratives of dental, nursing, pharmacy and physiotherapy students
N.B. The information below is authored by the mini-project applicants, not by staff of the subject centre. This text represents the views and opinions of the mini-project team only, not those of the subject centre or its affiliates.
Principal investigator
Dr Lynn Monrouxe (Formerly Knight), Cardiff University
Full list of project partners
Researchers - 1: Professor Charlotte Rees, Centre for Medical Education, Institute of Health, Skills & Education, College of Medicine, Dentistry & Nursing, University of Dundee, Scotland; email crees@med.usyd.edu.au Co-Applicant 2: Ms Uma Madhav, Dental Student, School of Dentistry, Cardiff University 3: Ms Laura Rees-Davies, Research Assistant, Division of Medical Education, School of Medicine, Cardiff University. Clinical Reference Group - 4: Professor Ruth Endacott, Professor in Clinical Nursing (Critical Care), School of Nursing and Midwifery, University of Plymouth; 5: John Gibson, Consultant and Honorary Senior Lecturer in Oral Medicine at Dundee Dental Hospital & School, NHS Tayside; 6: Dr Rola Ajjawi (trained physiotherapist), Office of Postgraduate Medical Education, University of Sydney.
Topic
Education in Practice and Work-based LearningBackground
Aims/Objectives:
The professional development of dental, nursing, pharmacy and physiotherapy students is paramount in health sciences education. Although students are taught good professional practice throughout their education, they are commonly exposed to professionalism dilemmas in work based learning, such as witnessing the physical and emotional maltreatment of patients (Erdil & Korkmaz 2009). Professionalism dilemmas cause students grave distress and can also impact negatively on their developing professional attitudes and behaviours (Kushner & Thomasma 2001).
Although research has begun to explore students’ explanations of professionalism dilemmas within health sciences education (particularly nursing and dental education) these studies have methodological and theoretical limitations: mostly single-site, typically employing questionnaires (so lack ‘richness’), or are analyses of students’ written ethics assignments (so ‘crafted confessions’). We aim to address these limitations by exploring personal incident narratives (PINs) about professionalism dilemmas narrated by dental, nursing, pharmacy and physiotherapy across three sites in different countries (Wales, England, Scotland). Our work adopts an inter-subjective perspective, focusing on the personal, experiential and cognitive aspects of individuals’ narratives. Research questions include aspects of what is told (the events) and how it is narrated: (1) what professionalism dilemmas do health sciences students encounter during work based leaning? (2) What do students claim to do within dilemma situations? (3) How do students explain their behaviours within dilemma situations?
Methodology:
We will employ focus group methodology. Eight groups (comprising 4-8 participants; total n=32-64). Groups will be homogeneous in terms of the type of student: 2 focus groups (one final year students, one penultimate year students) with each of the following - dental, nursing, pharmacy and physiotherapy students. Groups will be recorded and last 1-2 hours, beginning with an exploration about participants’ understanding of professionalism. Narrative interviewing techniques will be employed, encouraging participants to articulate PINs of professionalism dilemmas. Anonymised transcriptions will be analysed using framework analysis (Ritchie & Spencer 1994) to determine content- and process-related themes i.e. what participants say and how they say it respectively. We will also analyse our data using Malle’s (2004) theory of behavioural explanations. This social cognitive theory enables the exploration of individuals’ reasons for intentional and unintentional behaviours and encourages the examination of how individuals articulate those reasons. This methodology is consistent with that already employed by us in a British Academy funded study exploring medical students’ professionalism dilemmas.
Learning/Teaching:
We will address professionalism learning in dental, nursing, pharmacy and physiotherapy education, collecting numerous PINs covering a variety of professionalism dilemmas. These narratives could be used as trigger materials to facilitate students’ ethical reasoning within teaching/learning of professionalism and to guide the continuing professional development of educators.
Timetable
January-March 2010: Obtain ethical approval at each site. Conduct further literature review.
March-May 2010: Recruit participants. Conduct group discussions. Transcription.
June-Sept 2010: Data analysis.
Oct-Dec 2010: Disseminate findings.
Dissemination:
Findings will be disseminated locally (study report to all schools at the three sites), nationally and internationally though publications in international journals (e.g. Advances in Health Sciences Education), and national (e.g. Festival of Learning) and international conferences (e.g. AMEE Glasgow).
Proposed activities
We have recently conducted a study examining medical students’ explanations of their own and others’ behaviours during professionalism dilemmas [British Academy LRG-45505]. Students across all years from three schools in England, Wales and Australia were invited to participate in either group or individual interviews (22 interviews, 32 groups, total n=200). Over 1,000 personal incident narratives of dilemma situations were collected. Thematic analysis revealed a broader range of situations than previously recognized including students witnessing superiors behaving unprofessionally and experiencing abuse or humiliation by superiors or patients. Students provided detailed descriptions of their behaviours within these situations and the factors that influenced those behaviours. Furthermore, the emotional impact of these dilemmas was apparent: students described a range of emotions from uncomfortable feelings during the dilemmas, to stronger feelings of stress and anxiety remaining with them after the dilemmas. This study has already resulted in 7 international conference presentations, one report to the General Medical Council in response to their consultation exercise for Tomorrow’s Doctors and a book chapter (see below). Furthermore, we are currently writing a book proposal for Oxford University Press to disseminate the findings of this research (including students’ narratives) to medical students, medical educators, and interested social scientists. Should the current study proposal be successful, we hope to include narratives from dental, nursing, pharmacy and physiotherapy students, so that the book has wider appeal to other health sciences students and educators (in addition to medics).
References (in chronological order)
Knight LV & Rees CE (2008) Medical students’ explanations of their own and others’ behaviours within professionalism dilemma situations: implications for the assessment of professionalism. Presented at the ASME workshop ‘Medical students: professional behaviour and fitness to practise’, 5th June, RIBA, London.
Knight LV & Rees CE (2008) Medical students’ professionalism dilemma situations: The whats and hows of behaviour explanations. Presented at AMEE 2008, 30th August – 3rd September, Prague, Czech Republic.
Rees-Davies L, Knight LV & Rees CE (2008) ‘It doesn’t matter if you kill the patients ha ha:’ Medical students’ explanations of behaviour of professional dilemma situations during overseas electives. Presented at “Quality Counts: Developing Theory and Practice in Medical Education Research”, 18th November 2008, Cardiff University, UK.
Rees CE, Monrouxe LV & Rees-Davies L (2009) “He couldn’t move his legs ha ha ha ha ha”: The function of laughter in medical students’ accounts of professionalism dilemmas. Presented at the ASME Annual Scientific Meeting 2009, 15-17th July, The Royal College of Physicians, Edinburgh, UK.
Monrouxe LV, Rees CE, Rees-Davies L & Sweeney K (2009) “Oh I’d better wash my hands because you’re there”: effects of medical students’ acts of resistance during medical workplace learning encounters. Presented at the ASME Annual Scientific Meeting 2009, 15-17th July, The Royal College of Physicians, Edinburgh, UK.
Monrouxe LV, Neve H, Rees CE, Sweeney K & Rees-Davies L (2009) Medical students’ explanations of professionalism dilemmas experienced whilst overseas: Who do I think I am? A preliminary report for the Tomorrow’s Doctors consultation in the UK. Presented to the General Medical Council, London.
Monrouxe LV, Rees CE, Rees-Davies L & Sweeney K (2009) “Come here. I want you to feel a normal rectum. Do it.”: medical students’ explanations of their behaviours during consent dilemmas involving intimate examinations. Paper to be presented at the ABSAME 39th Annual Meeting. 7th-10th October 2009, Santa Fe, New Mexico, USA.
Monrouxe LV & Rees CE (2009) “I’ve got one! I’ve got one! When I was…” Medical students sharing narratives of professionalism dilemmas. Paper to be presented at ASME Researching Medical Education Conference 2009, 16th November 2009, RIBA, London, UK.
Rees C & Monrouxe LV (in press) “Oh my God uh uh uh”: Laughter for coping in medical students’ personal incident narratives of professionalism dilemmas. In: CR Figley, P Huggard & C Rees, First do no self-harm: Understanding and promoting physician stress resilience. New York: Oxford University Press.
Proposed outcomes
We anticipate the study findings informing recommendations for the development of professionalism curricula in dental, nursing, pharmacy and physiotherapy education.
As with our previous research we anticipate that the personal incident narratives collected as part of this study could also be used as part of students’ professionalism curricula and as part of educators’ continuing professional development.
Furthermore, we anticipate employing Laura Rees-Davies as the research assistant. Laura is a new researcher who joined us in June 2008 as a Research Assistant on our British Academy funded study investigating medical students’ professionalism dilemma situations (her post comes to an end Feb 2010 so this will give her an opportunity to continue to work with the team at Cardiff). Her main duties involved obtaining ethical approval, conducting a literature search, organising focus groups and transcribing data. Since joining us she has begun to develop research skills and working on this project will enable her to develop further by taking a more active role in the analysis of the data.
Finally, Uma Madhav (4th year Dental student at Cardiff University) is part of the team and will also be developing her research skills within this project.
Expertise of grant holder and project team
Similar work
Although there is a growing body of literature exploring the professionalism dilemmas experienced by medical students (e.g. Kushner & Thomasma 2001), there is a relative dearth of research examining dilemmas encountered by other health sciences students. Research has begun to explore such dilemmas in nursing and dentistry in particular, with some notable similarities and differences in comparison with medical students. Like medical students, nursing students have been found to witness the physical and psychological maltreatment of patients, ignoring patient’s privacy, and violations of confidentiality and consent by nurses and doctors (Cameron et al. 2001; Erdil & Korkmaz 2009; Killen 2002; Park et al. 2003). However, the nursing literature tends to lay greater emphasis on the disempowerment of nursing students (and nurses) within the medical hierarchy and the relationship between that disempowerment and professionalism dilemmas (Killen 2002; Peter et al. 2004). Such conflicts in hierarchy have also been reported by hospital pharmacists when discussing their interactions with doctors, such as their difficulties trying to challenge inappropriate prescriptions by doctors (Kalvemark et al. 2004). Like medical students, dental students reported professionalism dilemmas related to conflict between clinicians, clinicians not following standards of care, belittling patients, and capacity to consent dilemmas (Modifi et al. 2003; Sharp et al. 2005; Wilson & Ayers 2004). However, dental students also report professionalism dilemmas related to patient’s (in)ability to pay, and dilemmas around treating friends and family (Modifi et al. 2003; Sharp et al. 2005; Wilson & Ayers 2004). Finally, physiotherapists have reported confidentiality dilemmas due to curtained areas, lack of facilities, departmental layouts, lack of privacy, time pressures, computerised notes and multidisciplinary team working.
While studies are beginning to explore the professionalism dilemmas encountered by health science students, they all employ samples from single sites, some use questionnaire surveys so lack the ‘richness’ of narratives about dilemmas (Erdil & Korkmaz 2009, Killen 2002) and those capturing narrative do so using written essays so can be seen as ‘crafted confessions’ (Cameron et al. 2001, Modifi et al. 2003; Park et al. 2003, Sharp et al. 2005; Wilson & Ayers 2004). Two studies do employ focus groups but both analyse the data in a fragmentary rather than holistic fashion (Kalvemark et al. 2003; Cross & Sim 2000). Therefore, the current study aims to address these methodological shortcomings and extend the health sciences education literature by exploring the verbal personal incident narratives of professionalism dilemmas encountered by dental, nursing, pharmacy and physiotherapy students.
References (in alphabetical order)
Cameron ME, Schaffer M & Park H-A (2001) Nursing students’ experience of ethical problems and use of ethical decision-making models. Nursing Ethics 8(5), 432-447.
Cross S & Sim J (2000) Confidentiality within physiotherapy: perceptions and attitudes of clinical practitioners. Journal of Medical Ethics 26, 447-453.
Erdil F & Korkmaz F (2009) Ethical problems observed by student nurses. Nursing Ethics 16(5), 589-598.
Kalvemark S, Hoglund AT, Hansson MG, Westerholm P & Arnetz B (2004) Living with conflicts-ethical dilemmas and moral distress in the health care system. Social Science & Medicine 58, 1075-1084.
Killen AR (2002) Stories from the operating room: moral dilemmas for nurses. Nursing Ethics 9(4), 405-415.
Malle BF. (2004) How the Mind Explains Behavior. Folk Explanations, Meaning, and Social Interaction. Cambridge, MA: MIT Press.
Mofidi M, Strauss R, Pitner LL & Sandler ES (2003) Dental students’ reflections on their community-based experienced: the use of critical incidents. Journal of Dental Education 67(5), 515-523.
Park H-A, Cameron ME, Han S-S, Ahn S-H, Oh H-S & Kim K-U (2003) Korean nursing students’ ethical problems and ethical decision making. Nursing Ethics 10(6), 638-653.
Peter E, Lunardi VL & Macfarlane A (2004) Nursing resistance as ethical action: literature review. Journal of Advanced nursing 46(4), 403-416.
Sharp HM, Kuthy RA & Heller KE (2005) Ethical dilemmas reported by fourth-year dental students. Journal of Dental Education 69(10), 1116-1122.
Wilson HJ & Ayers KMS (2004) Using significant event analysis in dental and medical education. Journal of Dental Education 68(4), 446-435.
Contact details
Grant holder: monrouxelv@cardiff.ac.uk,
Cardiff University
Amount awarded: 5000