Quantitative Results
Table 1 below gives an overview of clinical and PBL tutor (n=17) demographics.
Table 1: Clinical Tutor Demographics Overview
|
N
|
%
|
Gender
|
Male
|
5
|
29.4%
|
Female
|
12
|
70.6%
|
Total
|
17
|
100.0
|
Age
|
Under 35
|
1
|
5.9%
|
35-44
|
8
|
47.1%
|
45-54
|
3
|
17.6%
|
55-64
|
4
|
23.5%
|
65 plus
|
1
|
5.9%
|
Total
|
17
|
100.0%
|
Nationality
|
Irish
|
15
|
88.2%
|
EU
|
2
|
11.8%
|
Total
|
17
|
100.0%
|
How long have you been a tutor at your present institution?
|
<5 years
|
8
|
47.0%
|
>5 years
|
9
|
53.0%
|
Total
|
17
|
100.0%
|
Who do you tutor?
|
Year 1 student
|
3
|
17.6%
|
Year 2 student
|
4
|
23.5%
|
Year 3 student
|
2
|
11.8%
|
Year 4 student
|
1
|
5.9%
|
Year 1 & Year 2 students
|
5
|
29.4%
|
Year 2 & Year 3 students
|
1
|
5.9%
|
Year 3 & Year 4 students
|
1
|
5.9%
|
Total
|
17
|
100.0%
|
What is your clinical background (i.e. speciality)?
|
GP
|
13
|
76.5%
|
Paediatrics
|
2
|
11.8%
|
Anesthesiology
|
1
|
5.9%
|
Community Health
|
1
|
5.9%
|
Total
|
17
|
100.0%
|
Where have you undertaken undergraduate and postgraduate medical training?
|
UK
|
1
|
5.9%
|
Ireland
|
11
|
64.7%
|
Ireland & Other
|
1
|
5.9%
|
UK & Ireland
|
4
|
23.5%
|
Total
|
17
|
100.0%
|
How long is it since you completed your undergraduate medical training?
|
5-9 years
|
3
|
17.6%
|
10-19 years
|
8
|
47.1%
|
20 years or more
|
6
|
35.3%
|
Total
|
17
|
100.0%
|
Educational level - Student versus trainee
Tutors described differences in their reporting of and responses to unprofessional behaviour when the individual concerned was a medical student versus a qualified intern / trainee. 58.87% (n=10) reported that the action they would take upon witnessing an unprofessional behaviour would differ if the individual was a student / intern / trainee.
Open-text comments alluded further as to tutor’s reasons for this response:
Participant 2: “As someone has progressed through their training it would be expected that they have attained a standard of professional behaviours. You would probably be more lenient with a student than an intern or postgraduate trainee”.
Participant 3: “I think we are more tolerant of students in years 1 and 2….due to their lack of experience”
Participant 4: “They (students) are still learning”
Medical students / interns / trainees were viewed differently and as separate roles, each with their own responsibilities. The majority of tutors agreed that as medical students were still learning, any unprofessional behaviour would be dealt with more leniently, compared to a trainee who had finished their training. This may be seen as an opportunity for a ‘learning moment’ for the student.
Interventions with students / trainees on professionalism issues
Most tutors indicated that they had intervened with a student / trainee in a professional issue (88%, n=15). Of those that had, the majority had only done so ‘Once in a while’ (53%, n=9). The most common reason for triggering an intervention with a student / trainee was a ‘Single unprofessional incident’ (52.9%, n=9). Ninety-four percent (n=16) of participants also noted that they had an informal conversation with a student / trainee to address the issue raised. 47% found the student / trainee to be ‘Moderately receptive’ to the discussion and 29% ‘Quite receptive’. 100% of tutors felt that it was their responsibility to address lapses in professionalism with students / trainees.
Feedback and Reporting to students / trainees
Participants were asked about how often they acknowledged good professional behaviours in students / trainees by explicitly telling the student / trainee. Responses varied from ‘Once in a while’ (29.4%), ‘Sometimes’ (23.5%), ‘Often’ (29.4%) and ‘Almost always’ (17.6%). This explicit acknowledgment however was not always recorded for future feedback or as a log of behaviours for students / trainees.
Table 2: Log of behaviours recorded by tutors
Do you routinely record professional behaviours that you observe in students/trainees for feedback to student/supervisor or as a log of behaviours?
|
|
N
|
%
|
Almost Never
|
7
|
41.2%
|
Once in a while
|
3
|
17.6%
|
Sometimes
|
3
|
17.6%
|
Often
|
2
|
11.8%
|
Almost Always
|
2
|
11.8%
|
Total
|
17
|
100%
|
The majority of tutors (41%, n=7) ‘Almost never’ routinely recorded professional behaviours for feedback to students / trainees or as a log of behaviours (Table 2). Of those that did record these behaviours, most were recorded at least four times (53%), with only 5.9% (n=1), recording after each session (Table 3).
Table 3: Frequency of log of behaviours recorded by tutors
If yes, how frequently do you routinely record professional behaviours that you observe in students/trainees for feedback to student/supervisor or as a log of behaviours?
|
|
N
|
%
|
After each session
|
1
|
5.9%
|
Twice
|
6
|
35.3%
|
Three times
|
1
|
5.9%
|
Four times
|
9
|
52.9%
|
Total
|
17
|
100%
|
A majority of tutors noted that they were ‘Quite confident’ however in providing feedback to students / trainees (71%, n=12).
Training Needs of Tutors
Almost a third of tutors (29%) stated that a reason for not addressing lapses in professional behaviour amongst students / trainees was due to their lack of training. Only 18% (n=3) of tutors noted having received any training in recognising and assessing professional behaviours in students / trainees.
This highlights a significant overlap and calls for further training to be provided. When asked what type of assistance would help tutors intervening with unprofessional behaviour, the majority (82%, n=14) noted case-based reference examples. Where tutors oversaw substantive behaviour change in students, the majority (47%, n=8) felt ‘Quite supported’, similarly when asked on delivering consequences on lapses in professional behaviour to students / trainees.
Qualitative Results
Seven core themes were highlighted as part of qualitative analysis with a number of minor themes (Table 4). Appendix F in supplementary material provides a description of our coding tree / thematic roadmap.
Table 4: Themes Overview- Factors that influence identifying / managing unprofessional behaviours in medical students
1. Student
|
a) Stages of education
|
|
b) Remediating knowledge and skills versus behaviour
|
|
c) Insight of student
|
2. Issues related to an unprofessional incident (s)
|
a) Formally / Informally
|
|
b) Level of severity of issue
|
3. Time
|
a) Lack of time to determine ongoing issues
|
|
b) Pattern of behaviours
|
|
c) Remediation
|
4. Student / Trainee Outcomes
|
a) Lack of knowledge on outcome
|
5. Reluctance to report
|
a) Perceived consequence for student
|
|
b) Perceived consequence for tutor
|
6. Oversight
|
a) Lack of a clear feedforward practice
|
|
b) Independent Oversight
|
7. Culture
|
a) Peer influence / culture
|
|
b) Institutional culture
|
1. Student
Participants spoke to their approach in dealing with unprofessionalism issues with students and trainees. These issues were discussed as part of several minor themes, relating to their approach taken dependent on the training stage of a student / trainee, the nuances between remediation and the insight of students.
a) Stages of Education
Tutors outlined how they would address lapses in professionalism, which was dependent on the stage of medical training the student / trainee. These lapses as a medical student were seen as training moments, whereas lapses by qualified interns / trainees were viewed more seriously.
CP2 (Group 2): “I think once you’ve qualified I mean there are still things to be learnt, but I think there is a different measurement value attached to that, because you affect the team in clinical practice, it affects the patient”
b) Remediating knowledge and skills versus behaviour
In reviewing lapses in professionalism, tutors discussed the difference in relation to remediating knowledge and skills rather than behaviours in students / trainees. Issues relating to knowledge and skills were distinctly outlined differently compared to poor behaviour.
CP3 (Group 2): “…with the junior trainee I've had less concerns with professionalism but more concerns with competence and ability.”
CP2 (Group 2): “Competence is easy to assess and poor competence doesn’t make someone a bad doctor, you know… so I think competence we need to assess and that’s important but that’s far more changeable.”
c) Insight of student
Tutors also discussed addressing professionalism lapses with students / trainees with many highlighting that for the most part, students / trainees do acknowledge and accept ownership when an issue is highlighted to them.
CP3 (Group 2): “they just have a lack of insight... so when you draw it to their attention then they are… appreciative, but it’s very rare that you would get someone who would get their back up by what you say”
2. Issues related to an unprofessional incident(s)
a) Formally / Informally
Tutors discussed how they had previously managed professionalism issues with students / trainees, often were done informally. Tutors noted that formal complaints were only done when informal discussions has failed to address issues.
CP3 (Group 2): “I don’t think I've a formally reported anyone for professionalism issues, I've come across, I guess a couple of students… which I might have discussed informally with colleagues and with them. But, not fundamentally ever to the extent whether I've made a formal complaint”
b) Level of severity of issue
Tutors often chose to report professionalism issues depending on the level of severity of the issue, determined by the tutor. Where tutors felt there might be a higher level of risk or where patient safety was being affected, issues would then be escalated. Whilst tutors often dealt with more minor issues, they were cognisant that in not addressing these that it could potentially escalate over time to more serious.
CP1 (Group 2): “I think it’s when you identify somebody who you have brought up an issue with and the message hasn’t clearly gotten through to them and that’s usually when you, or I would consider, you know, moving at a step up I think”
3. Time
a) Lack of time to determine ongoing issues
One of the significant challenges faced by tutors was not having enough time; limited time on rotations to spend with students / trainees to identify lapses in professionalism.
CP2 (Group 2): “there are certainly undergraduate students where you see behaviours that you would like to ameliorate and yet you kind of really don’t have the opportunity because you see them briefly”
b) Pattern of behaviours
Another time related issue highlighted by tutors was lack of time to identify if these lapses in professionalism by students / trainees were part of a pattern of behaviours, or a single incident. Tutors felt that having such limited time potentially allowed poor behaviours to go unrecognised, thus under reporting of such behaviours which could have an effect in the long term.
CP2 (Group 2) “there’s occasions where people have not performed well, and that’s not quite the same and it’s usually across several aspects rather than just one.”
c) Remediation
Tutors also noted that in having limited time with students / trainees, they found it difficult, particularly with students, to see if remediation for poor / unsatisfactory behaviours had made any difference to unprofessional behaviours.
GP3 (Group 1): “It is difficult to know (if students have remediated poor behaviours) because we only have them for a short period of time.”
CP2 (Group 2):“…there are certainly undergraduate students where you see behaviours that you would like to ameliorate and yet you kind of really don’t have the opportunity because you see them briefly and you have no ‘pre’ or ‘post’, because to be fair we all have bad weeks”
4. Student / Trainee Outcomes
a) Lack of knowledge on outcome
Tutors discussed how they often felt that they had a lack of knowledge on outcomes following the reporting of a lapse in professionalism with students / trainees. Tutors felt that if they were more aware of the reporting and assessment process then this would provide them with the confidence in reporting.
CP4 (Group 2): “we had one episode last year where there was actually a problem with aggressive behaviour with a consultant on a ward round and that was escalated to the CEO, but I never had to bring (it) any further than escalating it, but often I didn’t necessarily see the resolution or what the outcomes were.”
CP2 (Group 2): “So, the biggest barrier is knowing or confidence I guess that being an accurate fair assessment as part of the process, and I think that encourages reporting for me… “
CP2 (Group 2): “…everybody’s right in saying that if you are going to report you do want to have some confidence that the input is going to be taken seriously…but it has to be properly accessed in a valid and a structured way and a consistent way…you have to be very clear what is and what is not happening then there has to be an opportunity to remediate and to access that and to see what change there is.”
5. Reluctance to report
a) Perceived consequences for the student
Tutors explored what they believed to be the consequences for students if reported for unprofessional conduct. Many felt that reporting should also have supportive actions rather than punitive for students, allowing a learning opportunity for students.
CP1 (Group 2): “if you suspect that this (reporting) might be more putative rather than supportive. You might end up thinking maybe I will give this person extra chance, because if it’s a case of where the focus is more on making a note of this person as unprofessional rather than actually trying to educate that person as to where they went wrong.”
GP1 (Group 1): “…like …was is that bad, or when I think about it or maybe it wasn’t that bad, how, you know, do they need to be punished. But, then when you read the medical council guidelines for a student it is very clear, they are very clear, it is just that maybe we are not, but they are very clear and what is that we might chose”
b) Perceived consequences for the tutor
Tutors identified potential consequences for themselves in escalating and reporting lapses in professionalism. A lack of knowledge of an outcome and feedback led to frustration and tutors questioning whether their report was valued and held to the same level of severity by superiors.
CP4 (Group 2) “…very frustrating that if you bring something up and it doesn’t go any further, it’s kind of ‘a’ it shows that there is no repercussion for the person. And ‘b’ – you are then brought out to be kind of a trouble maker”
6. Oversight
a) Lack of a clear feedforward practice
Tutors discussed at length the lack of a clear feedforwarding process of information on students who may have been remediated or could potentially need remediation. This perceived lack of knowledge on reporting processes impacted tutor confidence.
GP1 (Group 1): “how do we informally notify each other as well, you know, and part of that I suppose is confidence on our side as well”
CP2 (Group 2): “I think it’s a big problem because we see people and there’s very good examples for over last few years…in both those cases it was impossible to change, and yet, kind of as we discovered everybody knew about it, but there wasn't a system in place to take X and move him forward as an undergraduate”
b) Independent Oversight
Whilst tutors discussed lack of a feedforwarding practice, several suggestions were made that might address this. One proposed solution was the appointment of an academic liaison/pastoral support role that would be independent of training and assessment.
CP2 (Group 2): “I think it would help have somebody outside my own department who was picking up on systematic recurrent long standing issues and you know and they can say I will look into that and address that from my view point what I would like you do is keep an attendance record… without necessarily breaching confidentiality”
CP3 (Group 2): “essentially like an academic welfare officer… if you have concerns about someone you can say that, look I’m worried about this person’s performance and then also they can proactively contact specialties that they are now in and say how is this person doing”
7. Culture
a) Peer influence / culture
The importance of peer influence and culture was discussed by tutors in relation to addressing professionalism issues within student groups. Tutors highlighted the value of positive group interactions and peer influence on the overall student / trainee culture.
GP4 (Group 1): “I know sometimes the group, there’s more accountability within the group, so that sometimes the group can almost take care of situations because if someone is being rude or obnoxious the group kind of, you know, doesn’t allow it”
CP3 (Group 2): “…they get influenced maybe by their peers and if that’s the culture within”
b) Institutional culture
Tutors outlined how the role of institutional culture impacted medical students and trainees, hence future doctors. Institutional culture was also acknowledge as a potential barrier in reporting unprofessional behaviours.
CP4 (Group 2): “I think the culture is very important, because it’s kind of like what you permit, you promote?”
CP2 (Group 2): “I think there are barriers to reporting and the institution, the culture, and the progression of it”