Perception and engagement in unprofessional behaviors of medical students and residents: a mixed-method study

BACKGROUND: The present study aimed to investigate perception and engagement in unprofessional behavior of residents and medical interns and explore the factors affecting their engagement in unprofessional behavior. METHOD: This study has an explanatory (quantitative-qualitative) mixed-method design. This study was conducted at Shahid Sadoughi University of Medical Sciences in 2022–2023. Participants, including residents and medical interns (n = 169), were entered by stratified random sampling. A survey was conducted in the quantitative step. A by an unprofessional behavior in clinical practice questionnaire (29 items) was used. For each behavior, the participants were asked to report whether they (a) participated in the behavior and (b) stated that the behavior Is unprofessional. In the qualitative step, 17 participants contributed. The qualitative data were collected by semi-structured interviews and analyzed according to the conventional content analysis approach Graneheim and Lundman introduced. RESULTS: The highest ratio of participants’ engagement in unprofessional behavior was reported in ‘failure to introduce yourself and nurses and physician assistants to the patient and his family’ (n = 145 (85.8%)). The results showed the proportion of participants who engaged in unprofessional behavior more than those who did not participate. There were associations between participants’ engagement in each behavior and their perception of that particular behavior as unprofessional. (p = 0.0001). In the following behaviors, although the participants acknowledged that these behaviors were unprofessional, those who participated in the unprofessional behaviors were significantly more than those who did not participate: failure to comply with clinic regulations and policy (p = 0.01), eating or drinking in the hallway of the clinic (p = 0.01), medical negligence in duties in the clinic setting (p = 0.04) and failure to perform duties in teamwork (p = 0.04). The qualitative results were explored in a theme entitled “internalized unprofessional culture,” including three categories “encouraging contextual risk factors towards unprofessionalism,” “suppressing of unprofessionalism reporting,” and “disbelieving professionalism as a key responsibility.” CONCLUSION: The results indicated that most participants engaged in unprofessional behaviors. The findings resulted from the internalized unprofessional culture in the workplace. The findings showed that engagement in unprofessional behaviors resulted from personal and systemic factors. The weakness of responsibility recognition and identity formation as a professional facilitated the engagement in unprofessional behaviors at the personal level. Furthermore, systemic factors including the contextual risk factors (such as deficiency of explicit and hidden curriculum), and the suppression of unprofessionalism reporting mechanism as a hidden factor played an important role in normalizing unprofessional behavior and promoting engagement in unprofessional behaviors among the participants. Recognition of the nature and extent of students’ unprofessional behaviors facilitates educational discussion among teachers and students in this field. The results might assist to establish an assessment system and feedback mechanism to solve the problem of the “failure to fail” problem. In addition, these results provide medical educators insights into the development of professional courses that equip learners with adherence to professionalism and coping skills to deal with unprofessionalism in the healthcare system.