Incorporating Equity, Diversity and Inclusion (EDI) into the Education and Assessment of Professionalism for Healthcare Professionals and Trainees: A Scoping Review

doi:10.21203/rs.3.rs-4351429/v1

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Research Article

Incorporating Equity, Diversity and Inclusion (EDI) into the Education and Assessment of Professionalism for Healthcare Professionals and Trainees: A Scoping Review

https://doi.org/10.21203/rs.3.rs-4351429/v1

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published 11 Sep, 2024

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Background

Current definitions of professionalism for healthcare trainees often lack equity, diversity and inclusion (EDI) in the expectations and assessment of professionalism. While professionalism teaching is incorporated in healthcare training, equity-deserving groups still experience discrimination. This scoping review investigates the literature to understand how EDI and associated domains of cultural humility, and advocacy can be incorporated in healthcare trainees’ education and assessment of professionalism.

Methods

MEDLINE, Embase & PsychINFO were searched up to March 2023, with terms surrounding health professionals, professionalism, EDI, cultural humility, and advocacy. Titles and abstracts (n = 3870) and full-texts (n = 140) were independently screened by two reviewers. Articles were included if they focused on EDI, cultural humility, or advocacy among healthcare students/trainees, and had outcomes related to professionalism. Articles lacking discussion of professionalism as an outcome were excluded. Themes were generated by mutual discussion. Risk of bias was assessed using the Cote et al. and Medical Education Research Study Quality Instrument (MERSQI) tools.

Results

48 articles underwent thematic analysis. Studies investigated the disciplines of medicine, nursing, social work, physiotherapy, and dentistry. Most studies were qualitative in methodology (n = 23). Three themes emerged: (1) EDI-associated interventions improve professionalism (n = 21). Interventions employed were either an EDI-associated educational course (n = 8) or an exchange program to promote EDI competencies among trainees (n = 13). (2) Trainee definitions and perceptions of professionalism reveal themes of EDI and cultural humility (n = 12). (3) Current standards of professionalism are perceived as non-inclusive towards historically-marginalized populations (n = 15). Literature investigating advocacy as it relates to professionalism is limited.

Conclusion

The main finding of this review is that EDI and its associated domains of cultural humility and advocacy correlates with professionalism. These findings create a strong impetus to incorporate EDI within professionalism frameworks in healthcare education. Future research should employ standardized tools for professionalism assessment to provide more conclusive evidence. Incorporating patient perspectives of professionalism can inform actionable recommendations for fostering inclusive healthcare environments.

Scoping review

Professionalism

EDI

Cultural humility

Advocacy

Health Professions Education

In the healthcare pedagogical literature, professionalism has often been broadly defined as a set of characteristics, competencies and attitudes that are expected of a healthcare professional or trainee [1]. A 2014 editorial published by the American Board of Medical Specialties (ABMS) Standing Committee on Ethics and Professionalism defines professionalism as “the motivating force for an occupational group to come together and create, publicly profess, and develop reliable mechanisms to enforce shared promises—all with the purpose of ensuring that practitioners are worthy of patients’ and the public’s trust” [2].

Many healthcare training institutions educate and assess their trainees and workers on itemized frameworks of what constitutes professionalism. For instance, the Michael G. DeGroote School of Medicine (MGDSM) at McMaster University in Hamilton, Ontario, Canada, has developed and utilizes the Professionalism in Practice (PIP) framework, which teaches and holds its learners accountable to the following core domains of professionalism: professional responsibility and integrity, pursuit of excellence/insight, personal interactions, as well as EDI and Indigenous reconciliation, with each of these domains including numerous subdomains to further clarify professionalism expectations [3]. However, due to the inherent subjectivity and lack of unison in defining lists of professionalism standards, different institutions’ set of expectations often contain attributes that other institutions’ professionalism frameworks omit. For instance, the National Taiwan University College of Medicine (NTUCM) conducted a study using a nominal group technique (NGT), a methodology relying on contributions from various stakeholders to arrive at a consensus, to define a framework for medical professionalism. Stakeholders included chairs of different hospital departments, residents, attending physicians, different types of nurses, and hospital volunteers. The resultant consensus framework consisted of 8 domains: integrity, humanism, altruism, communication, clinical competence, ethics, excellence, and accountability [4]. Despite some overlap between the healthcare professionalism frameworks of NTUCM and MGDSM, various competencies are not shared across the two frameworks. For example, the NTUCM framework does not explicitly have a domain pertinent to EDI.

The ABMS states that viewing medical professionalism as an itemized list of traits and expectations, while being valuable in making professionalism teaching and assessment more objective, does not adequately reflect the social aspects of professionalism [2]. Amongst the most important social roles physicians serve is upholding values of equity, diversity and inclusion (EDI) in their interaction with patients and learners [6], which is often omitted in professionalism education and assessment curricula as seen in the NTUCM framework [4].

Numerous studies find that EDI, cultural humility and advocacy are beneficial for both patients and healthcare teams. A review paper found that multiple studies suggest patient outcomes are improved by more diverse teams, and that healthcare environments that are identified as diverse are found to be less prone to disputes in times of change [7]. Additionally, despite the efforts of healthcare institutions in teaching, assessing and upholding professionalism expectations from their trainees, discriminatory practices and consequent healthcare disparities still persist. For instance, the prevalence of symptoms of depression in the Black community in Canada was approximately 6 times higher than that of the general population in a 1 year period, and Black patients who experienced higher levels of racial discrimination were 36.4% more likely to exhibit intense depressive symptoms compared to patients with lower reported levels of discrimination [8]. The lack of emphasis on EDI in healthcare professionalism curricula, combined with the continued discriminatory practices and negative healthcare outcome disparities amongst patients of equity-deserving backgrounds, creates a strong impetus for redefining expectations of professionalism from healthcare professionals and trainees to encompass concepts of cultural humility and advocacy.

This scoping review systematically searches the literature to evaluate how EDI and associated domains of cultural humility and advocacy are related to and can be incorporated into the standards, teaching and evaluation of professionalism for healthcare workers and trainees. By shedding light on the interconnectedness of these concepts and the value of incorporating concepts of advocacy, cultural humility and EDI into professionalism frameworks, it is hoped that this paper can inspire healthcare institutions to reframe their professionalism standards to better help diverse patient populations, and consequently, improve health inequities.

Research Question

This scoping review aggregates the existing evidence on the following research question: What literature is available on how principles of equity, diversity and inclusion (EDI) are incorporated in the education and assessment of professionalism for health professions trainees?

Approach to terminology

This paper utilizes the terminology recommended by the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) to guide language, narrative, and concepts as our standard for inclusive language that promotes health equity. For instance, per the AMA and AAMC recommendations, the terms "cultural competency", "minority/minority groups" and "equality" as commonly found in the literature, are substituted with terms such as "cultural humility/safety", "(people from) racial and ethnic groups'' and "equity", respectively [9].

Materials and Methods

Given the extensive scope of literature pertaining to the principles of EDI in professionalism education and assessment, we judiciously opted for a scoping review as the methodological approach for this study. A scoping review is a systematic approach that helps synthesize the literature on emerging topics and analyze knowledge gaps [10]. Our scoping review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist through multiple rounds of feedback and modification by our research team [11].

Eligibility criteria

Studies were included if (1) the population was practicing health professionals and trainees (2) the outcome was related to professionalism within the objectives, methodology, or results sections, and (3) professionalism was linked to EDI, cultural humility, or advocacy. Studies were excluded if they (1) were not in English, (2) did not focus on professionalism outcomes, (3) did not focus on our population of interest, and (4) had an incorrect publication format (i.e. conference abstracts). Considering that both empirical and non-empirical studies have the potential to yield meaningful findings on concepts of EDI and professionalism, no restrictions were placed on study design.

Search Strategy

A preliminary search was conducted to identify keywords and subject headings related to our research question. The final search strategy was developed in consultation among the research team members and a librarian at McMaster Health Sciences Library. Three electronic databases were searched from inception to March 7, 2023: Embase, Medline and PsycINFO. Search terms were designed to capture concepts of “advocacy” AND “cultural humility” AND “healthcare professionals” AND “healthcare trainees” AND “professionalism” AND “professional development.” Search terms were adapted for each database as subject headings or keywords where appropriate (See Appendix S1, Additional File 1). The literature search was supplemented by hand-searching for additional studies. The Covidence software was used to manage citations, including removing duplicates and screening [12].

A revised search was conducted between March 7st 2023 to April 1st 2024 with an identical search strategy to identify advances in the literature. A set of 204 unique records were identified for which abstract and full-text screening were completed. We did not identify any new studies meeting inclusion/exclusion criteria that added substantial evidence to the results of our study.

Screening process

Following a pilot test, two independent reviewers (NA, DS, or NB) screened titles and abstracts to evaluate their eligibility against the inclusion and exclusion criteria. Studies that passed the initial screening process underwent full-text screening by two independent reviewers (NA, DS, or NB). Disagreements at any screening stage were resolved by a third reviewer or consensus-based discussion. A PRISMA-ScR flowchart was used to show the process of study selection (Fig. 1).

Data extraction

A data extraction sheet was developed by the authors and used to organize data from included studies. Data extraction was divided among three members (NA, DS or NB) and was conducted using the Excel software. All extracted data was reviewed by another member. The final extraction table included (1) study characteristics (i.e., authors, publication year, country), (2) sample characteristics (i.e., number of participants, population description), (3) methodological characteristics (i.e., study design, program description/recruitment), and (4) study outcomes related to professionalism (See Appendix S2, Additional File 1).

Quality appraisal

One reviewer (NA, DS or NB) assessed the quality of studies using tools for qualitative and quantitative data. This consisted of the Medical Education Research Study Quality Instrument (MERSQI) for quantitative studies, and a qualitative study grid published by Côté et al [13, 14].

Data analysis

This review qualitatively analyzed the data following the thematic analysis approach [15]. Three reviewers (NA, DS & NB) independently categorized data according to their meaning and content. Subsequently, key themes were independently identified and formulated. These themes were then compared and any disagreements were resolved with discussion-based consensus, arriving at three main themes.

Literature scope and characteristics

Results of the initial search are presented in Fig. 1, including rationales for excluded articles. The data searches yielded 4194 unique records, with 125 selected for full-text review. After screening against eligibility criteria, 34 articles were included for data extraction. Included articles spanned publication between 2005 and 2023. An additional 24 articles were identified from hand-searching of included studies, of which 14 met eligibility criteria, producing a total of 48 articles included in our analysis.

Literature scope and characteristics

Most studies involved medical trainees or physicians (n = 18). Other professions examined in the literature included nursing, social work, dentistry, midwifery, and physical therapists. Most studies were based in the United States (n = 19) among other countries such as Australia, the United Kingdom, Canada, and Turkey. The majority of studies were qualitative in nature (n = 23) followed by mixed-methods (n = 10), commentaries (n = 8), and quantitative (n = 7). Among qualitative studies, methods of evaluating professionalism were predominantly based on participant narratives and interviews (n = 15). Quantitative measures included Likert scales to measure participants’ perspectives (n = 14). A summary of quality appraisal is presented in the supplementary material (See Appendix S3, Additional File 1).

Theme 1: EDI-associated interventions improve professionalism

Most studies investigated outcomes after an EDI-oriented intervention on professionalism outcomes among participants (n = 21). Similar to the whole set of articles, studies within this theme employed mainly qualitative methodologies (n = 13), followed by mixed-methods (n = 5), and quantitative (n = 3). Studies within this theme are divided based on their intervention of an educational course (n = 8) or an exchange clinical placement (n = 13). Topics of the educational courses included health advocacy, cultural humility, and spirituality/religion [16–23]. All eight studies reported an improvement in professionalism or professional identity formation. Four of the eight studies explicitly link professionalism and EDI concepts [16, 17, 19, 23]. In one study, first-year medical students completed a 10-month community health elective course aimed to expand cultural humility and advocacy in the context of adolescent care [19]. Reflective essays completed at the end of the course revealed that 90% of students noted an increase in knowledge and skills of professionalism [19]. These findings are seen across healthcare disciplines including nursing, pharmacy, social work, and other allied health. A 10-week interprofessional course aimed at developing cultural humility induced professional growth in addition to improved cultural proficiency [23]. These studies demonstrate improved professionalism as a common outcome for EDI-promotion through healthcare education.

Studies employing clinical placement interventions as methods of EDI-training revolved around either rural community or international placements. Assessment of professionalism development was assessed by a combination of self-reported surveys [24–29], written reflections [30, 31], and semi-structured interviews [18, 31, 32]. All thirteen studies report improvement in domains of professionalism secondary to exchange programs within different cultural settings [24–36]. A 4-week exchange between Japanese and UK medical students was associated with professionalism outcomes including social justice and resource stewardship [35]. Five of the thirteen studies explicitly connect domains of EDI to professionalism or professional development [25, 26, 30, 33, 34]. In these cases, cross-cultural experiences directly improve professionalism in participants [28, 30, 33]. Remaining studies describe parallel improvements in cultural humility and professionalism as outcomes of the intervention with implicit associations between the two concepts [24, 36]

Theme 2: Operationalization of professionalism revealed themes of EDI

A second subset of studies assessed trainee conceptualization of health professionalism within their respective field of practice. Seven studies employed qualitative methodologies with a mixture of self-report surveys, interviews, and literature searches [37–43]. Two studies relied on quantitative assessment with standardized questionnaires [44, 45]. Finally, three studies used a combination of quantitative and qualitative techniques to assess concepts of professionalism [46–48]. Hamdan Alshammari and Alboliteeh applied a structural equation model to questionnaire responses of 587 nurses in Saudi Arabia. They find significant correlations between dimensions of professional and cultural competency [47]. Similarly, practitioner perceptions of cultural competency are closely related to perceptions of professional development rather than formal health professional education [40]. A bidirectional relationship between professionalism and themes of EDI is demonstrated in the literature. Topics of EDI including cultural humility and health advocacy are often cited as core components of professional development [44, 48]. Alternatively, medical trainees, physicians, and researchers identify a need to integrate professionalism assessment within the development of an effective cultural humility curricula [43].

Theme 3: Current standards of professionalism are perceived as non-inclusive

The final set of studies explored the perspectives of trainees and practitioners from equity-deserving groups. Specifically, researchers investigated perceptions of professionalism in the workplace with reference to gender identity, sexual orientation, race/ethnicity and other EDI-associated demographic factors [49, 50]. These outcomes were primarily assessed by means of interviews [50–54] followed by self-reported surveys [49, 54, 55]. Participants from equity-deserving groups routinely experience professionalism as culturally and ethnically restrictive [50]. A stereotyped definition of professionalism underlines difficulties for trainee progression from further professional development [51]. This literature is also surrounded by a handful of recent commentaries by physicians on the current inequities faced by equity-deserving populations [56–62]. International medical graduates highlight the unique challenges of adapting to professionalism norms due to the inherent interconnectedness of professional identity and cultural schemata [62]. A common theme remains a sense of rigidity in definitions of professionalism with limited ethnic expression afforded to practitioners [58, 61]. Accordingly, there is increasing support for the existing definitions of professionalism to include measures of equity, diversity, and cultural humility [49, 52, 53]. Advocacy is proposed as a valuable tool for trainees to induce changes in institutional professionalism standards [50].

The aim of this scoping review was to characterize existing literature surrounding EDI, cultural humility, and advocacy principles in professionalism education, assessment, or experiences for healthcare trainees and practitioners. EDI and professionalism are explored in three predominant modalities. EDI-interventions such as educational courses improve professionalism outcomes among learners (Fig. 2) [16, 19, 21]. In the present studies, rural and foreign exchange programs are intended to produce improvements in cultural hum. Previous research supports the beneficial outcomes of short-term overseas programs in cultural humility [62, 63]. The present studies extend this finding by demonstrating concurrent improvements in professionalism [29, 31, 35]. Furthermore, there is a direct and positive correlation between professional and cultural competencies measured among practitioners [47]. These findings further support an interconnected model of professionalism and cultural humility.

Interventions promoting advocacy as a domain of professionalism were more limited in the literature [17]. While there is a strong agreement for advocacy as a professional responsibility, the scope of the healthcare practitioner as an advocate remains unclear and may contribute to the lack of organized interventions in this area [64–67]. Nevertheless, Peluso and colleagues (2013) discuss the success of a four-week “advocacy and activism” module as a component of medical students’ professionalism education. Advocacy is frequently cited within the scope of professional competencies of healthcare trainees [68, 69]. Therefore, structured assessment of advocacy education in professionalism remains an area requiring further investigation.

Development and revision of professionalism frameworks rely on values expressed by trainees and practitioners [70, 71]. Studies in the first and second domains of our findings cumulatively express an inherent relationship between EDI and professionalism. Furthermore, commentaries around this topic in the literature signify the disparity faced by individuals from equity-deserving groups due to the lack of EDI integration in current professionalism standards. The coin model of privilege and critical allyship elegantly highlights the disparity in power to reform systems of inequity disproportionately given to populations of historic domination [72]. In our context, the coin signifies existing standards of professionalism by which health professionals are trained and held accountable. The path towards critical allyship requires efforts from those in positions of privilege to reshape these frameworks, incorporating greater awareness of domains of EDI as core competencies of the health professional. Greater emphasis on the values of EDI in the professionalism standards will help bridge health disparities, reflected in improved patient outcomes and higher quality care [73, 74].

Limitations of the literature

Most studies assessed changes in professionalism or measures of EDI with self-reported techniques such as questionnaires, written reflections, or interviews. A few studies use validated tools for assessment of professional development [18] while most rely on the interpretation of student feedback or internally constructed questionnaires [22, 23]. Over the last three decades, an increasing number of validated professionalism tools have been developed based on existing frameworks of professionalism [75, 76]. Increased use of these tools would support more valid assessments of professionalism in the context of EDI-associated interventions. Studies present in this review engaged solely health trainees and professionals with self-assessment of professionalism. Perspectives from patients are a valuable, and often underutilized, source for gauging professionalism in clinical settings [77]. Studies investigating patient perception of professionalism in the context of EDI training may serve as a valuable measure for the integration of these concepts.

Limitations of our study

The literature search was developed according to the starting framework of the professionalism-in-practice (PIP) developed at McMaster University [3]. The framework provides guidance towards query terms related to domains of EDI. Therefore, the conceptualization of the present literature is within the context of the applied framework. Other frameworks may have informed a different strategy to investigate literature on professionalism [70, 78]. Secondly, our study aims to promote more equity-oriented language according to the AAMC guide to language promoting health equity [79]. In this context, we opted to use terms such as “cultural humility” in place of “cultural competency”. However, we acknowledge that those terms are not interchangeable in all contexts [80].

To our knowledge, our study is the first to review literature around EDI and professionalism in the healthcare setting. We demonstrate that a significant body of research supports the integration of domains of EDI into professionalism education and assessment across interdisciplinary programs. Interventions aimed to improve measures of EDI concordantly improved measures of professionalism. Domains of EDI, cultural humility, and advocacy correlate with professionalism noted both by self-reported measures and quantitative surveys of health professionals. Current models of professionalism are viewed as non-inclusive to practitioners of equity-deserving groups. These juxtaposing findings suggest an increasing need for the revision of definitions of professionalism to better address competencies of EDI across healthcare disciplines.

We expect this study to drive future research and serve as a support for the development and revision of professionalism frameworks with domains of EDI, cultural humility, and advocacy. The Michael G. DeGroote school of Medicine from which our work is based recently revised its internal model of professionalism to include a domain of EDI [3]. This revision aims to further address the disparities faced by patients and practitioners of equity-deserving backgrounds. Similarly, we hope our work drives the evidence-based design of professionalism frameworks guiding health professional education and standards of assessment.

EDI: Equity, Diversity and Inclusion

MERSQI: Medical Education Research Study Quality Instrument

MGDSM: Michael G. DeGroote School of Medicine

NGT: Nominal Group Technique

NTUCM: National Taiwan University College of Medicine

PIP: Professionalism in Practice

PRISMA-ScR: Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews

Ethics approval and consent to participate:

Not applicable.

Consent for publication:

Not applicable.

Availability of data and materials:

The authors confirm that all relevant data, including the search strategy, databases used, and the papers used in data extraction and analysis are included in the article, or can be found in the supplementary files.

Competing interests:

The authors declare no competing or conflicting interests.

Funding:

The authors conducted this study without external funding.

Authors’ contributions:

MS defined the research topic and study design, and as a more experienced researcher in the team, provided mentorship and constructive feedback throughout the research process. MS also guided the team in journal selection. DS, NB and NA were responsible for the development of the search strategy, devising inclusion and exclusion criteria, screening titles, abstracts and full-text articles, conducting thematic analyses and manuscript writing, with MS providing continued guidance throughout all these steps. All authors thoroughly reviewed the manuscript and provided edits and constructive feedback. The final version of the manuscript was approved by all authors. We would like to declare DS, NB and NA all as first authors with equal contributions and division of tasks throughout the research process.

Acknowledgments:

We would like to express our gratitude to Dr. Dorothy Bakker and other members of the Michael G. DeGroote School of Medicine Professionalism Education Committee for their guidance in the development of a scoping search strategy and journal selection.

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Incorporating Equity, Diversity and Inclusion (EDI) into the Education and Assessment of Professionalism for Healthcare Professionals and Trainees: A Scoping Review

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Abstract

Background

Methods

Results

Conclusion

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Introduction

Methods

Research Question

Approach to terminology

Materials and Methods

Eligibility criteria

Search Strategy

Screening process

Data extraction

Quality appraisal

Data analysis

Results

Literature scope and characteristics

Literature scope and characteristics

Theme 1: EDI-associated interventions improve professionalism

Theme 2: Operationalization of professionalism revealed themes of EDI

Theme 3: Current standards of professionalism are perceived as non-inclusive

Discussion

Limitations of the literature

Limitations of our study

Conclusion and Future Directions

Abbreviations

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