Promoting Professional Behaviors and Attitudes in Healthcare Students

Headnote

A Systematic Review

PURPOSE/BACKGROUND: The development of professionalism among healthcare students is challenging because these skills are complex concepts rather than technical skills. The purposes of this systematic review were to investigate: 1) the teaching methods used to promote the development of professionalism and 2) the effectiveness of the teaching methods found. METHODS: We searched healthcare and educational databases. Of 4,371 articles identified, we included 54. The variables of interest included teaching methods and professionalism outcomes in physical therapy, medicine, occupational therapy, nursing, dentistry, and pharmacy education. Two reviewers independently screened each title, abstract, and full-text article to determine if inclusion and exclusion criteria were met. RESULTS: The quality appraisal of the studies was performed using the Mixed Methods Appraisal Tool. We identified 12 teaching methods. The 3 most used teaching methods were self-assessment/reflection, group discussion, and lecture. The teaching methods were frequently used in combination. An assessment of study outcomes showed overall, 89% of the studies resulted in positive changes in professional behaviors or attitudes. CONCLUSIONS: Teaching methods promoting the development of professional behaviors and attitudes in healthcare students commonly use a combination of methods. This systematic review offers healthcare educators evidence-based options for facilitating growth of professional behaviors and attitudes in students. J Allied Health 2024; 53(4):308-325.

THE ROLES of state medical boards and other healthcare licensing bodies in the United States are to protect the public and the professions and ensure that healthcare practitioners are qualified to practice. While each profession has a set of values laid out in their Code of Ethics, Standards of Practice, and Core Values, allegations related to professional misconduct remain one of the primary reasons healthcare practitioners are disciplined.1-4 As many healthcare professions are moving to a competency-based educational model, the importance of preparing professional healthcare graduates who have all the necessary skills to provide effective patient care increases in importance.5,6 Healthcare practitioners are responsible for attaining and maintaining the professional knowledge and skills, similarly to the technical ones, necessary to provide effective and highquality patient care. The teaching of professionalism to healthcare students is central to developing ethical and competent practitioners.7 Other investigators have defined professionalism, based on competency and the safe clinical practice as a complex set of behaviors, attitudes, and dispositions that clinicians demonstrate in practice including ethical principles, establishing and maintaining effective relationships with patients and colleagues, being accountable, and developing selfawareness as a learner and practitioner.8 Improving oneself, helping others learn, and teamwork are three additional concepts built into this definition to enhance the growth of professionalism in healthcare students.9

Healthcare students must demonstrate proficiency in the cognitive, psychomotor, and affective learning domains in order to be well rounded and effective practitioners.10 Professionalism goes beyond cognitive and psychomotor skills and is thus more difficult to teach and assess given the abstract and complex nature of attitudes, values, and beliefs. Because professional behaviors are complex, students cannot be taught through explicit instruction only. These developing behaviors must be experienced through demonstration, practice, and reflection. Patients often assume a healthcare practitioner has the requisite knowledge and skills based on licensure.11 However, the effectiveness of the patient-practitioner relationship is reliant on the affective skills the practitioner displays while interacting with the patient.11 Passing a licensure exam does not equate to a practitioner's ability to competently demonstrate professional attitudes and behaviors in a patient- practitioner interaction.12 The concept of professional development has diverged from the thought of professionalism being an innate quality to a concept that can be taught and learned.13 An important setting where the learning of professionalism occurs is in communities of practice. In this network of teachers and learners, which supports contemporary practice, the healthcare student learns the socialized expectations of a healthcare professional.12,14 General agreement exists amongst healthcare professions regarding the importance of teaching professionalism but no consensus on best teaching methods prevails.

A greater emphasis has been placed on the professional development of healthcare students over the last 25 years.15-21 The teaching of professionalism to medical students is the most studied among healthcare professions, with two relevant systematic reviews completed in the last 10 years.22,23 Investigation into the development of professionalism in students in other healthcare disciplines (pharmacy, nursing, dentistry, physical therapy and occupational therapy) has been limited. To date, a unifying model to integrate the teaching of professionalism into the healthcare curriculum has not been consistently described in the literature. Research related to identifying the most effective teaching methods based on the outcomes of teaching professionalism in entry-level professional healthcare education is lacking. The purposes of this systematic review are to investigate: 1) the teaching methods used to promote the development of professionalism and 2) the effectiveness of the teaching methods found.

Methods

We conducted this systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.24 We registered the review with PROSPERO, an international prospective register of systematic reviews.25

Search Strategy

One author conducted a comprehensive literature search in collaboration with a research librarian in the following electronic databases: Medline Complete, CINAHL Plus with Full-text, SPORTDiscus, Professional Development Collection, and ERIC. Search terms used both independently and in combination were healthcare, physical therapy, medicine, occupational therapy, nursing, dentistry, pharmacy, education, student, professionalism, professional behaviors in conjunction with teaching techniques, teaching methods, education, educational intervention and learning, assessment, and outcomes. Prior to our formal literature search for this systematic review, our preliminary search indicated an increase in healthcare professionalism studies published after 2005. When reviewing the included studies for this systematic review, we noticed only 10 of the 54 included studies that occurred prior to 2013 and only 5 prior to 2010. Although the number of articles published between 2005 and 2013 was limited, we elected to include articles published from 2005 to be as inclusive as possible. The detailed search terms and combinations are listedin Table 1.

Study Selection

We uploaded references from the comprehensive literature search to Covidence. Covidence is a web-based collaboration software platform that streamlines the production of systematic and other literature reviews.26 One author screened the Covidence database to remove duplicates. Two authors independently screened the references by title and abstract, and then full-text to determine the eligibility of the studies. Reviewers resolved disagreements by discussion between the two. If agreement could not be reached, a third author was available to review the title/ abstract or full-text to resolve the disagreement.

Inclusion and Exclusion Criteria

Study criteria for inclusion in this review included: 1) randomized controlled trials, non-randomized controlled trials, qualitative studies, cohort studies, case reports, and descriptive studies published in English with full-text available; 2) publication date from 2005 to January 2021; 3) reports of teaching methods and educational interventions on professionalism; 4) healthcare students from physical therapy, medicine, occupational therapy, nursing, dentistry, or pharmacy; and 5) primary outcomes of change in behaviors and/or attitudes related to professionalism. We excluded studies with the following criteria: 1) not published in English; 2) discussed professional education outside of the healthcare disciplines listed above; 3) discussed professionalism in the post-graduate clinical setting; and 4) systematic reviews, dissertations, and abstracts.

Quality Appraisal

We used the Mixed Methods Appraisal Tool (MMAT) for this systematic review. The MMAT was developed to assess the methodological quality of studies included in a systematic mixed studies review (i.e., systematic reviews that include qualitative, quantitative and/or mixed methods studies).27 The MMAT is a validated tool for critically evaluating experimental and nonexperimental studies.27 Two authors independently appraised each included study and performed a quality analysis. The reviewers compared and discussed their independent ratings and consulted a third author to resolve any disagreements that could not be resolved between the primary reviewers. Reviewers categorized each reviewed study as being of a high or low quality based on achievement of the evaluation criteria. This method of categorization was adapted from recommendations made by the developers of the MMAT.28

Date Extraction

Reviewers extracted the following data from each of the included studies and initially organized them in an Excel document: publication details (author name and publication year), study population, study design, curriculum design (including intervention type / modality and frequency/ duration), professionalism topics addressed, and description of outcomes. All four authors reviewed the results of the data extraction for accuracy.

Results

Study Selection

The initial search identified 5,723 studies. After removing 1,352 duplicates, two independent reviewers screened 4,371 studies and included 316 studies for the full-text review. Following full-text review, reviewers included 54 studies in the systematic review. Study selection results are included in the PRISMA flow diagram in Figure 1.

Study Characteristics

Of the 54 included studies, there were 17 qualitative studies, 2 randomized controlled trials, 6 non-randomized controlled trials, 19 quantitative descriptive studies, and 10 mixed methods studies. Studies include healthcare students from the following disciplines: medicine = 30,28 physical therapy = 9,59-67 nursing = 5,68-72 dental = 5,73-77 pharmacy = 4,78-81 and occupational therapy = 1.82

Quality Assessment

Two authors independently assessed the methodological quality of the 54 included studies using the MMAT. The percentage of agreement for the two raters was 87% (47/54). The raters discussed conflicts in the quality assessment and reached consensus. The raters did not need a third team member to serve as a tie breaker. They assessed 44 included studies as high quality31-39,43-56 58-64,66-68,70-73,76-82 and 10 studies as low quality.29,30,40-42, 57,65,69,74,75 A summary of the quality assessment can be found in Table 2.

According to the MMAT results, one qualitative paper lacked sufficient information about the findings being adequately derived from the data.57 For randomized controlled trials, one article lacked appropriate randomization, comparable groups at baseline, and blinded assessors.65 Reasons for lower quality ratings for the quantitative non-randomized studies included lack of participants representing the target population,30 lack of appropriateness of measurements regarding both outcome and intervention,29,30 and lack of accounting for confounders in the design and analysis.30 In the quantitative descriptive group, the sampling strategy for 2 studies was not relevant to address the research question.74,75 The measurements were not appropriate for one study75 and the risk of nonresponse rate was high for 2 studies.40,41 The statistical analysis was not appropriate for 2 studies.40,56 The most common issue for mixed methods studies was lack of the different components of the study adhering to the quality criteria of each tradition of the methods involved.42,57,69 In addition, one study did not effectively integrate the different components to answer the research question, adequately interpret the outputs of the integrated qualitative and quantitative components, or adequately address inconsistencies between quantitative and qualitative results.69 Overall, 44 of the 54 reviewed studies met all the MMAT criteria (high quality).

Teaching Methods

We identified twelve teaching methods that were applied to foster the development of professional behaviors in healthcare students and are represented by proportion of use in Figure 2. The three most frequently used teaching methods were self-assessment/ reflection (n=34),31-33,36, 39,40,43-45,47-49,51,52,54-56,58-65,67,69,71,74,76,77,80-82 Group discussion (n=23),32,35,37-42,44-49,52,55,58,63,71,77,79-81 and lecture (n=19),38,41 42,44-46,49,52,53,58,60,66,69,71,72,75,78-80 followed by service-based learning (n=9),44,49,59,61,64,66,71,73,76 case studies (n=8), 38,40,41,46 55,56,60,81 and role modeling (n=6),33,34,36,50,57,69 (Table 3).83-91 Eleven studies used a single teaching method." 29-31,50, 51,53,67,68,72,73,82 Teaching methods were rarely utilized in isolation but frequently applied in combination (n=43) ranging from two to five methods. 32-49,52,54-66,69-71,74-81 The most commonly use combinations of teaching methods are represented in Figure 3. Self-assessment/reflection was the most frequently utilized teaching method. Self- assessment/ reflection was most often paired with group discussion (n=16),32,39,40,44,45,47-49,52,55,58,63,71,77,80,81 lecture , (n=9),44,45,49,52,58,60,69,71,80 and service-based learning (n-7).44,49,59,61,64,71,76 The other most paired teaching methods were lecture and group discussion in 12 studies 38,41,42,44-46,49,52,58,71,79,80 and case studies with group discussion in 7 studies. 38,40,41,46,55,56,81

Twenty-four studies used a combination of two teaching methods. In studies that applied two teaching methods (n=24),32-37,39,47,48,54,56,57,59,61.66,70,74,76,78,79 self. > assessment / reflection (n=16),32,33,36,39,47,48,54,56,59,61-65,74,76 group discussion (n=8),32,35,37,39,47,48,63,79 and service-based learning (n=5)59,61,64,66,76 were used most frequently. Ten studies used a combination of three teaching methods,38,43,45,46,55,69,75,77,80,81 In studies that applied three teaching methods, self-assessment /reflection (n=7),45,55,69,77,80,81 group discussion (n=7),38,45,46,55,77,80,81 and lecture (n=6)38,45,46,69,75,80 were used most frequently. Nine studies utilized four or five teaching methods,40-42 44,49,52,58,60,71 and group discussion was used 100% of the time. 40-42,44,49,52,58,60,71 Group discussion was utilized in conjunction with lecture in 8 studies, 41,42,44,49,52,58,60,71 and self-assessment / reflection in 7 studies.40,44,49,52,58,60,71 Of note, 14 studies utilized teaching methods that did not fall into any of the above categories and were captured in an "other" category.30,35,41-44,49,52,54,58,60,62,65,70 These teaching methods included video recording of students with feedback, use of telemedicine with patients, an activity challenging academic honesty, grading professionalism in a course, monitoring social media, journal clubs, peer review, question and answer sessions, creating a humanities newsletter, and producing and viewing skits and videos.

Outcomes

This systematic review examined study outcomes to determine the effectiveness of the included teaching methods on developing professional attitudes and behaviors in healthcare students. Two studies measured outcomes related to professionalism judgement and learning of professionalism in addition to changes in either behaviors or attitudes.41,47 Study outcomes were measured using a variety of methods such as validated tools / scales, surveys / questionnaires, and qualitative coding of student and preceptor interviews and reflections (Table 4).

Study outcomes resulting in an improvement in student professional attitudes and/or behaviors were categorized as "positive change." Study outcomes that did not show a difference or showed a regression in professional attitudes and/or behaviors were categorized as "no change" or "negative change," respectively. The outcomes of interest focused on a positive change in behaviors and/or attitudes (Table 5). The percentages following represent the number of studies demonstrating a positive change. Of the studies measuring a change in professional behaviors, 88% had a positive change.29,30,34-37,42-45,47,50,54,55,59,61,64-66,68,70,75,78,80 In the studies measuring a change in professional attitudes, 93% resulted in a positive change.1-5,10-12,14-23,29-34,36-42,44, 48,49,51-54,56-63,67,69-77,79-82,92-97 Five studies demonstrated variable results when measuring attitude or behavior change initially or longitudinally.45,62,65,66,71 Three studies showed either no change or negative change.42,46,55 When used in isolation, the following teaching methods resulted in the highest percentage of positive change in professional behaviors or attitudes: role modeling = 100%,33,34,36,50,57,69 reflection = 95%,31-33,36,39,40,43 45,48,49,51,52, 54,56,58-65,67,69,71,74,76,77,80-82 and service-based learning = 89%,44,49,59,61,64,66,71,73,76 In studies that implemented three of the most used teaching methods, the percentage of positive change in professional behaviors or attitudes was as follows: self-assessment / reflection paired with group discussion = 94%,32,39,40,44,45,47-49,52,58,63,71,77,80,81 Group discussion paired with lecture = 83%,38,41,44,45,49,52,58,71,79,80 self-assessment / reflection paired with lecture = 100%,44> 49,52,58,60,69,71,80 and when all 3 were combined = 100%.

Discussion

The development of professional attitudes and behaviors among healthcare students is important to developing effective healthcare practitioners. The affective domain includes professional attitudes and behaviors and is more difficult to teach because the learning is more than the transfer of knowledge. In answering the first aim of this systematic review, the results demonstrate that several teaching methods are used to develop professionalism in healthcare students. The second aim was to analyze the effectiveness of the teaching methods. Engaging in the teaching of professionalism to healthcare students using any of the included teaching methods resulted in positive outcomes in a surprisingly high percentage of the studies.

One theory that has been applied to the teaching of health professionalism to healthcare students is situated learning theory. Maudsley and Strivens proposed that situated learning theory is the most effective model to teach professionalism and transform healthcare students into effective members of a profession.98 Situated learning theory is an expansion of the constructivism learning theory in which the individual's learning is the focus and is influenced by experience.99 Similarly, in sit- uated learning theory knowledge is actively applied through experiential learning and is context specific. As stated by Steinert, "situated learning is based upon the notion that knowledge is contextually situated and fundamentally influenced by the activity, context, and culture in which it is used,"14(p69) Situated learning theory includes cognitive apprenticeship, collaborative learning, reflection, practice, and articulation of learning skills. Modeling, scaffolding, fading, and coaching are components of cognitive apprenticeship during which the teacher presents information and guides the students to actively apply knowledge to the relevant context.14 Reflection is promoted as an important part of professional competence. Repeated practice is essential to the integration of learning and is closely tied to experiential learning. Articulation refers to both the separating out of individual skills and the ability to clearly apply the skills to a specific environment. Situated learning is the coming together of the cognitive and experiential learning needed to acquire professional behaviors. Additionally, situated learning aids in transforming knowledge from abstract to something concrete and implementable.

The results of this systematic review are in alignment and supportive of situated learning theory (Table 6) and the premise that situated learning allows students to learn from participating and growing in communities of practice formed by members of that healthcare profession. Situated learning theory is suggested to be a teaching model that can explain the transformation of a student from a novice to a professional with a commitment to the profession's core values.14 Most studies included in this systematic review used multiple teaching methods. Situated learning theory emphasizes the use of multiple teaching methods to create meaningful professionalism learning experiences for healthcare students. The most used teaching methods of lecture, group discussion, and self-assessment / reflection are all components of situated learning's steps of cognitive apprenticeship, collaborative learning, and reflection. The knowledge of the profession's expectations must be conveyed first to the students, most often through lectures. The students are then immersed into the community of practice through a variety of activity teaching methods including group discussion, service-based learning, role modeling through observation or interviewing professionals, and case-based learning. Collaborative learning promotes collective problem-solving and learning through group activities. The teaching methods of service-based learning, simulation, role modeling, peer teaching and role playing all contribute a role in application of professional knowledge and often are paired with guided reflection. The later application of professional knowledge using reflection is seen in the steps of practice and articulation of learning skills. Teaching methods that included an active com- ponent to promote experiential learning appeared to have the best overall outcomes.

The method most used to teach professionalism to healthcare students was reflection which appears to be an important piece in the teaching of professionalism to healthcare students. In situated learning's cognitive apprenticeship, the cognitive and meta-cognitive (thinking about thinking) processes and skills that expert rolemodels use as a part of their practice are emphasized and are the focus of teaching activities.100 The teaching method of reflection allows the student to integrate the information from their community of practice into their own professional identity. A systematic review of the use of reflection in teaching medical students found that it was most effective when tied to another teaching method such as group discussion.101 The effectiveness of reflection was improved when the students were taught how to reflect and given feedback upon their reflections.101 Reflective learning leads to the development of a growth mindset enabling the student to apply the knowledge gained during the didactic curriculum to experiential learning within the clinical environment.102

Based on the results of this systematic review and healthcare teaching literature, thoughtfully structured professionalism curricula conveying knowledge of professional expectations followed by using active learning methods and guided reflection appear to be most effective in developing professionalism in healthcare students during the didactic curriculum. This structure results in integration of knowledge using experiential learning experience combined with reflection to result in positive changes in professional attitudes and behaviors in healthcare students. Examples of this professionalism curricular structure include studies by Cooper and O'Toole.'·· Both studies included lecture followed by experiential learning, either service learning or role modeling activities, followed by a reflective activity. The didactic professional activities are the starting community of practice for the professional development of healthcare students. Using these active teaching methods, communities of practice are formed which assist in reinforcing the high expectations of professional attitudes and behaviors. The communities of practice are further developed as the students enter the clinical environment. While experiential learning appears to be important to the changing of professional behaviors in healthcare students, it was not included in all studies reviewed. This may explain why the included studies show a greater change in professional attitudes as compared to behaviors.

Limitations

One of the purposes of this systematic review was to identify the effectiveness of the teaching methods. The complexity of defining professionalism and the lack of clarity on how change in professional attitudes and behaviors was measured did not allow for a direct comparison of the included studies and the determination of the most effective teaching methods. Selecting the most effective methods was difficult due to heterogeneity in the application of the teaching methods and the measurement tools used to determine the outcomes of attitude and behavior change. The concept of professionalism is broad and encompasses different areas of emphasis including a complex set of behaviors and attitudes, that encompass ethical principles, patientpractitioner interaction, professional collaboration, and development of reflective practice. Different methods were used in the teaching and measurement of each of these concepts,31,60,62,72,77,79 Measurement of change in professionalism is difficult and attitude and behavior change require very different measurement tools.103 The variation in the methods used to measure outcomes made it difficult to discuss differences between the outcomes when comparing the changes between the perception of attitude change and/or behavioral change. Therefore, we were not able to identify the most effective teaching methods. The last limitation is the small number of studies including experiential learning methods. The importance of these methods and more investigation into their use and pairings with the teaching methods encompassing situational learning theory would be beneficial. We also chose to exclude training occurring after the didactic coursework including clinical experiences and residency. The experiential learning of professionalism continues into these areas of training but is variable based on the healthcare discipline and individual student pathway and thus hard to measure.

Conclusion

The teaching of professionalism to healthcare students is necessary to develop well-rounded and competent practitioners. There are multiple teaching methods used to effectively develop professionalism in healthcare students. We found that use of these teaching methods, especially in thoughtfully designed combinations, resulted in positive changes in professional attitudes and behaviors in healthcare students. Although we cannot say which are the most effective teaching methods, this systematic review provides further evidence that formal, structured teaching improves professionalism in healthcare students. Methods included in situated learning theory, including guided reflection, and methods involving experiential learning appear important for the teaching of professionalism.

18. Secrest JA, Norwood BR, Keatley VM. "I was actually a nurse": the meaning of professionalism for baccalaureate nursing students. J Nurs Educ. 2003;42(2):77-82.

References

References

1. Hochberg MS, Seib CD, Berman RS, et al. Perspective: Malpractice in an academic medical center: a frequently overlooked aspect of professionalism education. Acad Med. 2011;86(3):365- 8.

2. Physical therapy professional liability exposure claim report: 4th ed. HPSO. Accessed May 19, 2023. https: / / www.hpso.com/ Resources / Legal-and-Ethical-Issues /Physical-Therapy-ClaimReport-Fourth-Edition.

3. Kirk LM. Professionalism in medicine: definitions and considerations for teaching. Proc (Bayl Univ Med Cent). 2007;20(1):13-6.

4. Chaudhry HJ, Gifford JD, Hengerer AS. Ensuring competency and professionalism through state medical licensing. JAMA. 2015;313(18):1791-2.

5. Wynia МК, Papadakis MA, Sullivan WM, Hafferty FW. More than a list of values and desired behaviors: a foundational understanding of medical professionalism. Acad Med. 2014; 89(5):712-4.

6. Holmboe ES, Sherbino J, Englander R, et al. À call to action: The controversy of and rationale for competency-based medical education. Med Teach. 2017;39(6):574-81.

7. Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002;287(2):226-35.

8. Wilkinson TJ, Wade WB, Knock LD. A blueprint to assess professionalism: results of a systematic review. Acad Med. 2009; 84(5):551-8.

9. Ali A, Anakin M, Tweed MJ, Wilkinson TJ. Towards a definition of distinction in professionalism. Teach Learn Med. 2020; 32(2):126-38.

10. Rodgers DL. Beyond the cognitive domain: including all of bloom's learning domains in objective development. Acad Med. 2023;98(3):294-5.

11. Haddad 5, Fournier P, Machouf М, Yatara E. What does quality mean to lay people? Community perceptions of primary health care services in Guinea. Soc Sci Med. 1998;47(3):381-94.

12. Plack MM, Driscoll M, Ebook C. Teaching and Learning in Physical Therapy: from Classroom to Clinic. Slack; 2011.

13. Lesser CS, Lucey CR, Egener B, et al. A behavioral and systems view of professionalism. ЛАМА. 2010;304(24):2732-7.

14. Steinert Y. Educational theory and strategies to support professionalism and professional identity formation. Teaching Medical Professionalism. Cambridge Univ. Press; 2016:68-83.

15. Swick HM, Szenas P, Danoff D, Whitcomb ME. Teaching professionalism in undergraduate medical education. JAMA. 1999; 282(9):830-2.

16. ABIM Foundation; ACP-ASIM Foundation; European Federation of Internal Medicine. Medical professionalism in the new millennium: À physician charter. Ann Intern Med. 2002;136(3): 243-6.

17. Fetzer SJ. Professionalism of associate degree nurses: the role of self-actualization. Nurs Educ Perspect. May-Jun 2003;24(3):139-43.

19. Smith Randolph D. Evaluating the professional behaviors of entry-level occupational therapy students. J Allied Health. 2003; 32(2):116-21. -

20. Mostrom E. Professionalism in physical therapy: A reflection on ways of being in physical therapy education. J Phys Ther Educ. 2004;18(1):2-3.

21. Chisholm MA, Cobb H, Duke L, McDuffie С, Kennedy WK. Development of an instrument to measure professionalism. Am J Pharm Educ. 2006;70(4):85.

22. Berger AS, Niedra E, Brooks SG, et al. Teaching professionalism in postgraduate medical education: a systematic review. Acad Med. 2020:95(6):938-46.

23. Birden H, Glass N, Wilson I, et al. Teaching professionalism in medical education: A Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25. Med Teach. 2013; 35(7):e1252-e66.

24. Moher D, Liberati A, Tetzlaff J, et al. Reprint-Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Phys Ther. 2009;89(9):873-80.

25. Kress SJ, Irwin KE, Campione E, Hall KD. A systematic review: promoting professional behaviors and attitudes in healthcare students. https: / /www.crd.york.ac.uk / prospero /

26. Covidence systematic review software. Veritas Health Innovation. covidence.org

27. Hong QN, Fabregues S, Bartlett G, et al. The Mixed Methods Appraisal Tool (MMAT) Version 2018 for information professionals and researchers. Educ Inf. 2018;34(4):285-91.

28. Hong QN. Revision of the Mixed Methods Appraisal Tool (MMAT): a mixed methods study [dissertation]. Montréal: Dep. of Family Medicine, McGill Univ.; 2018.

29. Alvarez S, Schultz J-H. Professional and personal competency development in near-peer tutors of gross anatomy: a longitudinal mixed-methods study. Anat Sci Educ. 2019;12(2):129-37.

30. Bramstedt KA, Prang M, Dave 5, et al. Telemedicine as an ethics teaching tool for medical students within the nephrology curriculum. Prog Transplant. 2014;24(3):294-7.

31. Braun UK, Gill AC, Teal CR, Morrison LJ. The utility of reflective writing after a palliative care experience: can we assess medical students' professionalism? J Palliat Med. 2013;16(11):1342-9.

32. Butani L, Bogetz A, Plant J. Illuminating exemplary professionalism using appreciative inquiry dialogues between students and mentors. Med Teach. 2019;41(3):325-31.

33. Butani L, Sweeney С, Plant J. Effect of a patient-led educational session on pre-clerkship students" learning of professional values and on their professional development. Med Educ Online. 2020;25(1):1801174.

34. Camp CL, Gregory JK, Lachman N, et al. Comparative efficacy of group and individual feedback in gross anatomy for promoting medical student professionalism. Anat Sci Educ. 2010;3(2):64- 72.

35. Christner JG, Stansfield RB, Schiller JH, et al. Use of simulated electronic mail (e-mail) to assess medical student knowledge, professionalism, and communication skills. Acad Med. 2010;85(10 suppl):S1-4.

36. Cooper CM, Gheihman G. The kind care bundle: a curriculum to teach medical students the behaviors of kind, compassionate care. MedEdPORTAL. 2021;17:11141.

37. Cusimano MC, Ting DK, Kwong JL, et al. Medical students learn professionalism in near-peer led, discussion-based small groups. Teach Learn Med. 2019;31(3):307-18.

38. Geyer E, Irish E, Hagzan A, Wiczulis A. Social media and online professionalism integrated into year 3 OB/GYN clerkship. Med Ref Serv Q. 2020;39(4):359-69.

39. Gomes AW, Butera G, Chretien KC, Kind T. The development and impact of a social media and professionalism course for medical students. Teach Learn Med. 2017;29(3):296-303.

40. Horlick M, Masterton D, Kalet A. Learning skills of professionalism: a student-led professionalism curriculum. Med Educ Online. 2006;11(1):4615.

41. Hultman CS, Connolly A, Halvorson EG, et al. Get on your boots: preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism. J Surg Res. 2012;177(2):217-23.

42. Humphrey HJ, Smith K, Reddy 5, et al. Promoting an environment of professionalism: the University of Chicago "Roadmap". Acad Med. 2007;82(11): 1098-1107.

43. Kasai H, Ito S, Tajima H, et al. The positive effect of student-oriented clinical clerkship rounds employing role-play and peer review on the clinical performance and professionalism of clerkship students. Med Teach. 2020;42(1):73-8.

44. Lee MS, Kaulukukui SK, Smith MS, et al. Professional and cultural development of medical students mentoring adolescents in a predominately native Hawaiian community. Hawaii J Health Soc Welf. 2019;78(12 Suppl 3):35-40.

45. Lie D, Trial J, Schaff P, Wallace R, Elliott D. "Being the best we can be": medical students' reflections on physician responsibility in the social media era. Acad Med. 2013;88(2):240-5.

46. Mostaghimi A, Olszewski AE, Bell SK, et al. Erosion of digital professionalism during medical students" core clinical clerkships. J Med Internet Res. 2017;3(1):e9.

47. Naeimi L, Asghari F, Nedjat S, et al. Turning unprofessional behaviors around using Holmes' reflection approach: a randomized controlled study. J Med Ethics Hist Med. 2020;13:12.

48. Neve H, Lloyd H, Collett T. Understanding students" experiences of professionalism learning: a "threshold" approach. Teach High Educ. 2017;22(1):92-108.

49. O'Toole TP, Kathuria N, Mishra M, Schukart D. Teaching professionalism within a community context: perspectives from a national demonstration project. Acad Med. 2005;80(4):339-43.

50. Passi V, Johnson N. The impact of positive doctor role modeling. Med Teach. 2016;38(11):1139-45.

51. Quaintance JL, Arnold L, Thompson GS. What students learn about professionalism from faculty stories: an "appreciative inquiry" approach. Acad Med. 2010;85(1):118-23.

52. Rivera E, Correa R. Implementation of different initiatives to develop a culture of professionalism in the medical school. PR Health Sci J. 2009;28(2):135-9.

53. Sattar K, Akram A, Ahmad T, Bashir U. Professionalism development of undergraduate medical students: Effect of time and transition. J Med. 2021;100(9):e23580.

54. Singh S, Barua P, Dhaliwal U, Singh N. Harnessing the medical humanities for experiential learning. Indian J Med Ethics. 2017; 2(3):147-52.

55. Spampinato CM, Wittich CM, Beckman TJ, et al. "Safe Harbor": evaluation of a professionalism case discussion intervention for the gross anatomy course. Anat Sci Educ. 2014; 7(3):191-8.

56. Strobel R, Antunez A, De La Rosa K, et al. Medical professionalism: a series of near-peer facilitated workshops for first-year medical students. MedEdPORTAL. 2017;13:10549.

57. Turner SR, White JS, Poth C, Rogers WT. Learning the CanMEDS roles in a near-peer shadowing program: a mixed methods randomized control trial. Med Teach. 2012;34(11):888-92.

58. Wald HS, Davis SW, Reis SP, et al. Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med. 2009;84(7):830-7.

59. Anderson JR, Taylor LF, Gahimer JE. Assessing the impact of a short-term service-learning clinical experience on the development of professional behaviors of student physical therapists: a pilot study. J Scholarsh Teach Learn. 2014;14(4):130-43.

60. Bello-Haas VD, Proctor P, Scudds R. Comparison of knowledge and knowledge application confidence in physical therapist students completing a traditional versus blended learning professional issues course. J Phys Ther Educ. 2013;27(1):10-19.

61. Borstad A, Deubler DC, Appling S, et al. Professional values are implicit in written reflections by DPT students in a short-term international service learning course. J Allied Health. 2018; 47(3):183-9.

62. Brown NA, Luna SE, LaLonde AN. The jar of truthiness: a novel class activity to develop leaders with integrity. J Phys Ther Educ. 2019;33(1):16-22.

63. Cohn RJ, Plack MM. A cloud with a silver lining: helping students learn about professionalism. Teach Learn Med. 2017; 29(3):304-12.

64. Crandell CE, Wiegand MR, Brosky JA Jr. Examining the role of servicelearning on development of professionalism in doctor of physical therapy students: a case report. J Allied Health. 2013;42(1):e25-e32.

65. Kachingwe AF, Phillips B, Beling J. Videotaping practical examinations in physical therapist education: does it foster student performance, self-assessment, professionalism, and improve instructor grading? J Phys Ther Educ. 2015;29(1):25-33.

66. Wise HH, Yuen K. Effect of community-based service learning on professionalism in student physical therapists. J Phys Ther Educ. 2013;27(2):58-64.

67. Youdas JW, Krause DA, Hellyer NJ, et al. Use of individual feedback during human gross anatomy course for enhancing professional behaviors in doctor of physical therapy students. Anat Sci Educ. 2013;6(5):324-31.

68. Aebersold M, Tschannen D, Bathish M. Innovative simulation strategies in education. Nurs Res Pract. 2012;2012:765212-7.

69. Bussard ME, Lawrence N. Role modeling to teach communication and professionalism in prelicensure nursing students. Teach Learn Nurs. 2019;14(3):219–23.

70. Clark CM, Dunham M. Civility mentor: a virtual learning experience. Nurse Educ. 2020;45(4):189–92.

71. Ferrillo H. Measuring professional nursing value development in students participating in international service learning: A quasi-experimental study. Nurse Educ Today. 2020;84:104221.

72. Ozcan CT, Oflaz F, Bakir B. The effect of a structured empathy course on the students of a medical and a nursing school. Int Nurs Rev. 2012;59(4):532–8.

73. Ahmad MS, Mokhtar IW, Khan NLA. Extramural oral health educational program involving individuals with disabilities: impact on dental students’ professionalism. J Int Soc Prev Community Dent. 2020;10(3):323–8.

74. Al-Khalifa KS, Gaffar BO. Dental students’ perception about using videos in teaching professionalism: A Saudi Arabian experience. J Dent Educ. 2021;85(2):197–207.

75. Al-Khalifa KS, Nazir MA. Evaluation of dental students’ responses to roleplay videos in a professionalism course. J Taibah Univ Medical Sci. 2020;15(6):471–8.

76. Behar-Horenstein LS, Feng X, Roberts KW, et al. Developing dental students’ awareness of health care disparities and desire to serve vulnerable populations through service-learning. J Dent Educ. 2015;79(10):1189–1200.

77. Quick KK, Blue CM. Using situated learning theory to build an interactive learning environment to foster dental students’ professionalism: an ignite project. J Dent Educ. 2019;83(3):334–41.

78. Fejzic J, Barker M. Implementing simulated learning modules to improve students’ pharmacy practice skills and professionalism. Pharm Pract. 2015;13(3):583.

79. Okoro RN. Investigation of final-year pharmacy students’ views on professionalism and ethics in pharmacy practice: an interventional study. Int J Pharm Pract. 2020;28(2):130–3.

80. Peeters MJ, Vaidya VA. A mixed-methods analysis in assessing students’ professional development by applying an assessment for learning approach. Am J Pharm Educ. 2016;80(5):77.

81. Smith MG, Dinkins MM. Early introduction to professional and ethical dilemmas in a pharmaceutical care laboratory course. Am J Pharm Educ. 2015;79(10):156.

82. Chien C-W, Chloe Mo SY, Chow J. Using an international rolemodeling pedagogy to engage first-year occupational therapy students in learning professionalism. Am J Occup Ther. 2020; 74(6):7406205060p1-p11.

83. Ng SL. Reflection and reflective practice: creating knowledge through experience. Semin Hear. 2012;33(2):117–34.

84. Nguyen QD, Fernandez N, Karsenti T, Charlin B. What is reflection? A conceptual analysis of major definitions and a proposal of a five-component model. Med Educ. 2014;48(12):1176–1189.

85. Wald HS. Refining a definition of reflection for the being as well as doing the work of a physician. Med Teach. 2015;37(7):696–9.

86. Cai L, Li Y-L, Hu X-Y, Li R. Implementation of flipped classroom combined with case-based learning: a promising and effective teaching modality in undergraduate pathology education. J Med. 2022;101(5):e28782.

87. Cantillon P. ABC of learning and teaching In medicine: teaching large groups. BMJ. 2003;326(7386):437–40.

88. D'Souza UJA, Kadir FbM, Chodankar N, et al. Response to "Learner perception regarding the lecture and the small group discussion as Teaching/Learning methods in Physiology’. Bangladesh Med J. 2020;19(1):174–5.

89. Hood JG. Service learning in dental education: meeting needs and challenges. J Dent Educ. 2009;73(4):454–63.

90. Loh K-Y, Nalliah S. Learning professionalism by role-modelling. Med Educ. 2010;44(11):1123.

91. Tandel M, Kanjiya D, Vedi N, et al. Introduction of group discussion as a teaching—learning method in dissection hall for the first MBBS students. Natl J Clin Anat. 2019;8(2):66–70.

92. Boyle CJ, Beardsley RS, Morgan JA, et al. Professionalism: a determining factor in experiential learning. Am J Pharm Educ. 2007;71(2):31.

93. Christenberry EJ, Frietze GA, Padilla ME, Haines ST. Co-curricular assessment plan for developing pharmacy professionals (RxPro) after the first professional year. Curr Pharm Teach Learn. 2020;12(3):291–6.

94. Hoffman J, Chung E, Hess K, et al. Overview of a co-curricular professional development program in a college of pharmacy. Curr Pharm Teach Learn. 2017;9(3):398–404.

95. Masin H, Tischenko AK. Professionalism, attitudes, beliefs and transformation of the learning experience: cross-cultural implications for developing a Spanish elective for non—Spanishspeaking physical therapist students. J Phys Ther Educ. 2007; 21(3):40–6.

96. Parker M, Luke H, Zhang J, et al. The "pyramid of professionalism”: seven years of experience with an integrated program of teaching, developing, and assessing professionalism among medical students. Acad Med. 2008;83(8):733–741.

97. Rodríguez-Costa I, González-Rivera MD, Ortega C, et al. Professional and personal physical therapist development through service learning in collaboration with a prisoner reinsertion program: a qualitative study. Int J Environ Res Public Health. 2020;17(24).

98. Maudsley G, Strivens J. Promoting professional knowledge, experiential learning and critical thinking for medical students. Med Educ. 2000;34(7):535–44.

99. Almulla MA. Constructivism learning theory: A paradigm for students’ critical thinking, creativity, and problem solving to affect academic performance in higher education. Cogent Educ. 2023;10(1).

100. Stalmeijer RE. When I say . . . cognitive apprenticeship. Med Educ. 2015;49(4):355–6.

101. Uygur J, Stuart E, De Paor M, et al. A best evidence in medical education systematic review to determine the most effective teaching methods that develop reflection in medical students: BEME Guide No. 51. Med Teach. 2019;41(1):3–16.

102. Cleven AJ, Renaud A, Larose-Pierre M, et al. Associating growth mindset with emotional intelligence and why it’s needed for professional identity formation. Am J Pharm Educ. 2023; 87(6):100110. 103. Ferguson RP. Professionalism: hard to measure but you know it when you see it. J Community Hosp Intern Med Perspect. 2014;4(2): 24226.