Teaching Professionalism: Comparing Written and Video Case-Studies.

PURPOSE: Professionalism is a difficult concept to teach to healthcare professionals. Case-studies in written and video format have demonstrated to be effective teaching tools to improve a student's knowledge, but little is known about their impact on student behaviour. The purpose of this research study was to investigate and compare the impact of the 2 teaching tools on a student's behaviour during a simulation.
METHOD: A 3-stage mixed method study was conducted with senior Medical Laboratory Science (MLS) undergraduate students. All students were randomly divided into a Written Group or Video Group to attend a mandatory professionalism workshop focused on bullying and gossip. Twenty-six students completed the voluntary assignment and 21 students participated in the voluntary group simulations. Thematic analysis was performed on the assignments and simulation. Frequencies of themes were calculated. A Group Simulation Assessment Rubric was used to score simulations and calculate an adjusted group performance average (AGPA).
RESULTS: The assignment demonstrates that students from both groups obtained a theoretical understanding of how to resolve gossip and bullying. From the Written Group and Video Group, 70%/18% of students discouraged/resolved gossiping and 80%/63% prevented bullying. The mean AGPA for the Written Group and Video Group was 5.4 and 4.9 respectively (t (5) = 1.5, P = .2). DISCUSSION: Students can successfully apply knowledge they have gained in written and video case-studies focused on the professionalism topics of bullying and gossip to a hypothetical situation. However, a discrepancy in their actions was found during the simulations. The data from the study suggests that written and video case-studies do not have different impacts on a student's behaviour.

Introduction

Professionalism is the judicious use of communication, technical, and clinical reasoning skills, knowledge, emotions, values, ethics and reflection on one’s attitude, character and practice.[1,2] Professionalism guides health care providers in delivery of high quality patient care and maintaining a positive work environment.[3-5] Unfortunately, high stress situations can cause professionalism lapses that lead to decreased workplace psychological safety. Support, guidance and training should begin early in the education of health care professionals.

Professionalism is most often learned through the hidden curriculum and is a multidimensional construct making it difficult for educators to accurately assess. While traditional assessment approaches encourage students to memorize material, which results in poor performance outcomes and reduced knowledge retention, case-based learning (CBL) narrates real-life situations to encourage student engagement and practice of problem-solving skills. CBL is a well-documented approach to teach professionalism to health care students.[9-12] Both written and video case-studies have been used to increase students’ understanding and ability to link psychosocial and humanistic variables to professionalism as well as use reflective discussions to improve critical thinking skills.[10,11] However, there is a lack of data that demonstrates if either written or video case-study can effectively impact a student’s professional behaviour in a simulated clinical setting.

Based on current studies, students have reported that case studies presented in a written format can provide them a sense of role-playing, promotes reflection and improves their critical thinking. Nadeau et al.’s study suggests that the written case-studies not only provides a fun way to learn and is interesting to students but can successfully teach students multiple professional competencies. Similarly, video case-studies have demonstrated increased student knowledge in different professional competencies. Through videos, students can recognize how social and anthropological influences affect professional practice and have the opportunity to identify with characters in the film – which creates a more impactful learning experience.[11,12] Students have self-reported that video case-studies have helped improve their critical thinking, moral reasoning skills and reflection.[11,16] In addition, students have found that material presented in video format is also interesting, entertaining and engaging.

Our study aimed to investigate if teaching professionalism to Medical Laboratory Science (MLS) students in an undergraduate bachelor’s program at the University of Alberta through written or video case-studies impacted a student’s behaviour and if the 2 groups behaved differently.

Material and Methods

Study design

A mixed study comprising 3 stages was conducted and is summarized in Figure 1.

Figure 1.

Summary of study timeline and design.

In Stage 1, MLS students were randomly divided into 2 groups for participation in a 1-hour mandatory professionalism case-study based workshop that used the same scenario but was presented in either a written or video format. Identical case-studies focused on gossip, respect, empathy, communication skills, teamwork, bullying and accountability. One group was presented the case-studies as a video and the other group received them in writing.

The case-study involved many health care professionals working in a busy emergency room. The story began with, several residents socializing when 1 resident began to gossip about their supervisor’s past. Each resident responded to the gossip differently. In a second scene, a resident displayed bullying behaviour towards a colleague during a high stress situation. In the final scene, the resident and colleague worked through their conflict and displayed empathy and compassion for each other. Case study discussion questions explored workplace gossip, conflict resolution, teamwork and responding to bullying and gossip. Students were encouraged to reflect on their skills and how to respond to similar situations in the future. Details of the workshop learning objectives can be found in Appendix A.

In Stage 2 the students were given an optional assignment to explore their professionalism knowledge by responding to a hypothetical workplace scenario.

In Stage 3 students from the same workshop cohort voluntarily participated in group simulations. The simulation scenario presented an opportunity to practice the professional competencies taught in the workshops and was used to assess a student’s professional behaviour and gather quantitative data.

Participants

The study included 28 Bachelor of Science students in the MLS Program at the University of Alberta. Students were in their senior year of the program and had completed all clinical practicums, ensuring exposure to health care workplace experiences.

Data collection and analysis

Assignment

A fictional narrative that focused on the topics of accountability, conflict management, gossip and bullying placed the student as a working Medical Laboratory Technologist (MLT) who had made a major error. While trying to correct the mistake, an innocent co-worker (the victim) publicly received the blame from a supervisor (the bully). Two bystander MLTs overheard the supervisor’s complaints and began gossiping about the coworker.

Students were required to reflect on the narrative and develop a plan-of-action to address the key professional issues. Answers were de-identified and coded by a third-party member. Thematic analysis was performed to provide insight on how students planned to resolve a professional issue and apply their knowledge. Two researchers analysed the assignments together to agree on common themes found; subthemes were determined by 1 researcher. The results were coded into Microsoft Office Excel 2013 to generate frequency data.

Simulation

Each simulation was comprised of 3 parts: a prebrief, simulation scenario and facilitated debrief. The simulation scenario focused on workplace conflict management, gossiping and bullying. All simulation scenarios and debriefs were video recorded for subsequent analysis by 2 researchers.

Simulation rubric

Students’ professional behaviour were graded on a rubric (Appendix B) based on demonstration of: effective communication skills; teamwork skills; ability to respect others’ dignity, values and/or beliefs; desire to discourage workplace gossip; and ability to prevent and/or resolve workplace bullying. One point per student was noted each time an attitude or skill from the rubric was exhibited; allowing for calculation of the percentage of students displaying that competency. Individual student scores were not obtained in order to reduce student anxiety associated with performance within the simulation, instead scores were collected for the group. The final score was tallied based on the entire group. Final scores were adjusted for varying group size by calculating the adjusted group performance average (AGPA). The AGPA was determined by dividing the total group score by the number of participants. Mean AGPA was calculated and an independent test performed to determine statistical significance.

Noteworthy aspects of the simulations were documented, and a thematic analysis was performed on the simulation observations to detect trends and patterns amongst the students’ behaviour and practice.

Simulation debrief

Immediately after each simulation scenario, the group debriefed the simulation in a focus group format. During the simulation debrief, the simulation facilitator asked students predetermined opened-ended questions to further investigate the rationality behind their choice of actions during the simulation and the impact of each teaching method. Student answers were recorded by the simulation facilitator and by video and thematic analysis was performed.

Ethic approval and participant consent

Ethical approval for this research has been granted from the University of Alberta Research Ethics Office for research involving human participants. (December 18, 2018, Pro00085272). Written informed consent forms were signed by participants of the study.

Results

Assignments

Ninety-three percent of students completed the Stage 2 optional assignment (N = 26). The students’ responses to the narrative’s professional issues were categorized into the following major themes: fixing gossip, approaching an individual about the gossip, apologizing to the victim, showing empathy, being accountable, telling the supervisor (bully) what to do, influencing others’ opinions and quality improvement. Two of the themes were further divided into subthemes. Occurrence of each theme and subtheme is summarized in Table 1.

Table 1.

Key themes and subthemes found in assignments and number of students displaying each theme in the written and video case-study group.

Theme / Subthemes	Written group (N = 13)	Video group (N = 13)
Fixing gossip	13	10
Tells the truth	5	7
Shows empathy	4	4
Helps the victim	3	1
Informs individual of inappropriate actions	5	5
Praises victim	1	0
Other (example: providing education on gossiping)	2	2
Approaches an individual about gossip	13	10
Coworker	11	8
Supervisor	1	1
Victim	1	1
Apology to victim	12	12
Show empathy	10	11
Be accountable	13	13
Telling the supervisor (bully) what to do	6	3
Influencing other’s opinion	4	3
Quality improvement	7	5

Fixing the gossip

Hundred percent (n = 13) of students from the Written group and 77% (n = 10) of the students from the Video group displayed interest in fixing the gossip that had occurred in the assignment narrative. The 2 most popular methods described by students was to directly tell the supervisor the truth and to point out the inappropriateness to the gossips.

‘I would try to stop the negative gossip about [the victim]. I would explain the incident to the other coworkers, so they know what truly happened, and kindly remind them to gather all facts before gossiping about an individual.’

Being accountable

All students identified that it was important to own up to the error and be accountable to the consequences of their actions.

‘[I would] proceed to the supervisor’s office and explain how it was my mistake first. . .I would say that if there were any repercussions to this incident that I would take full blame and that it wasn’t [the victim’s] fault.’

In addition, 92% (n = 12) of students from both groups indicated that it was important to them to apologize to the victim for taking the blame of the error they made in the narrative.

‘I would apologize to [the victim] as it was my fault for dragging him into this mess.’

Demonstrating empathy

Seventy-eight percent (n = 10) of the Written group and 84% (n = 11) of the Video group demonstrated empathy by indicating that they were concerned for the victim’s emotional state and would provide them support.

‘I would ask [the victim] how he was doing. . .and see if there was anything [they] could do to help regain [his] emotional stability.’

Only 2 students from each workshop group demonstrated empathy towards the bully.

‘I would ask how [the bully’s] day is going and offer her support if needed.’

Providing critique/feedback

Forty-six percent (n = 6) of the Written group and 23% (n = 3) of the Video group indicated they would directly confront the bully and express their concerns.

‘I would then try to politely suggest to the [bully] that the way she handled things caused a bit of a disruption in the lab. . .’

In addition, students planned to provide the bully with advice on how they should behave and how they could negate the negative consequences of their actions.

‘I would suggest that [the supervisor / bully] apologize to [the victim] as well. It might be also be useful to offer the [bully] advice for how to handle mistakes in the future, such as approaching the individual with more of a gentle tone and playing the role of a mentor. Additionally, in future situations, she should ask questions before assuming who made the mistake to begin with.’

However, 1 student realized that approaching the bully, who was a supervisor with more experience and knowledge, could be an imitating task. Therefore, they would only provide the supervisor with advice under the right circumstances which allowed the student to feel safe to share their concerns.

‘I’m not sure if I would bring up that I thought her behaviour was unprofessional. I think that part would depend on my relationship with the supervisor and previous experience, and the general work environment in the lab.’

Influencing an individual’s opinion

Sixty-two percent (n = 8) of the Written Group and 23% (n = 3) of students from the Video Group were uncomfortable critiquing the bully’s actions. These students planned on a more passive solution to address the bullying. By admitting the truth of what had happened and commenting on the victim’s current emotional state to the bully, students hoped that the bully’s opinion of the victim would change for the better and feel compelled to apologize to the victim after the conversation.

‘After I explain the situation, I would tell the supervisor that [the victim] was quite upset. . . I would do this in hope that the supervisor would apologize to [the victim] about the interaction.’

Quality improvement

Several students from both groups (46%, n = 12) mentioned they would complete correcting the laboratory error and help develop a contingency plan to prevent their mistake from occurring again.

‘I would try to have a constructive conversation about how to avoid this situation in the future. . .This would turn a difficult situation into a learning opportunity.’

Another suggestion made by students was to improve the victim’s competency, through additional training and resources in order to improve the victim’s reputation and discourage workplace gossiping.

Simulation

Student behaviour demonstrated in the simulation

Ten students from the Written and 11 from the Video Group (N = 21) voluntarily participated in the simulations. A total of 9 simulations were completed. The average length of each simulation scenario was 11 minutes (excluding the prebrief and debrief).

All students demonstrated the ability to effectively and respectfully communicate with other simulation participants and actors. In addition, all students displayed respect for other’s dignity, values and beliefs throughout the simulation scenario.

Seventy percent (n = 7) of students from the Written Group successfully demonstrated the ability to discourage and/or resolve gossiping, while only 18% (n = 2) of students from the Video Group could. Students who attempted to discourage the bully from gossiping tried to calm the bully’s emotions with statements such as ‘it [had] been a stressful day/long day/busy day’, that ‘[the victim] deserves a breather’ and that ‘accidents happen’. Students also indirectly encouraged empathy for the victim by suggesting that the ‘[victim was] maybe just tired’, ‘maybe had a bad day’, or that ‘these things happen’; a passive method to discourage bullying.

When challenged with bullying, most students from both the Written and Video Group attempted to resolve and/or prevent further bullying from occurring (80% and 63% respectively). Even when the victim expressed reluctance and fear, students shared their concerns about the bully’s treatment towards the victim and reassured the victim that the bullying must be addressed. To support the victim, students mentioned that they were willing to accompany the victim as a witness if they wanted to confront the bully or another supervisor.

Overall simulation performance mark

Based on the rubric results (Table 2), the AGPA was 5.4 for the Written Group and 4.9 for the Video Group (t(5) = 1.5, P = .2), but the Null hypothesis was rejected. Therefore, the results suggest that there was no significant difference between the behaviours demonstrated by the students from the Written and Video Group in the simulation.

Table 2.

Total group simulation points and adjusted group performance average.

	Total simulation score	Number of simulation participants	Adjusted group performance average (AGPA)
Written group simulations
Simulation 1	9	2	4.5
Simulation 2	18	3	6
Simulation 3	11	2	5.5
Simulation 4	17	3	5.7
Average AGPA = 5.4
Video group simulations
Simulation 1	13	3	4.3
Simulation 2	10	2	5.5
Simulation 3	9	2	4.5
Simulation 4	10	2	5
Simulation 5	10	2	5
Average AGPA = 4.9

Debrief

Professional issues in the simulation observed by students

The students recognized: poor coworker relationships, poor work environment, and the lack of professional laboratory skills. In addition, students noticed the abnormal behaviours of the 2 actors by describing one as ‘harsh’ and ‘condescending’ and the other as ‘sheepish’, ‘nervous’, ‘stressed’, ‘very uncomfortable in the situation’ and ‘abused by [the bully].’ Only a few students used the labels gossip and bullying.

The student’s initial thoughts vs reality

In response to the simulation’s professional issues of gossip and bullying, some students initially thought of confronting the bully respectfully to ‘think of solutions’ or to ‘speak up about [their] inappropriate behaviour’. However, many students were unable to follow through with their plan to do so because of 2 main reasons. Firstly, students did not confront the bully because their plan was to talk to the bully privately later, this opportunity was not available for students due to the design of the simulation scenario. Secondly, students did not confront the bully during the simulation because the students felt too uncomfortable critiquing a superior due to power-differentials.

A few students initially planned to avoid the professional issues by not engaging in the coworker’s interaction and ignoring the situation by occupying themselves with other activities but eventually did act.

Influencers on student behaviour in the simulations

When asked if the workshops had any impact on the student’s behaviour and actions in the simulations, students from both groups claimed that they gained theoretical knowledge on the various professionalism topics covered during the workshop and a better understanding on how they should respond to issues. Student comments on the teaching methods are summarized in Table 3.

Table 3.

Summary of student comments on written and video case-studies.

Teaching method	Student comments
Written case-study	Prefer practical learning
Video case-study	Engaging
	Useful for visual learners
	Opportunity to learn about empathy through seeing body language and hearing different tones of voices

Further inquiry discovered that students from both groups also pulled from experiences external to the workshops. Students credited some of their behaviour and actions in the simulations to theory and practical experiences they encountered from the following sources: university level courses about interprofessional relationships, learning modules and practical courses outside of school, life experiences gained from jobs and their clinical practical training, their personality and personal values and beliefs.

Student answers to debrief questions

Students believed the focus of the simulation was: workplace conflict and management, professionalism or conflict resolution. Students reported that they most enjoyed the thought provoking and informative debrief and receiving feedback from the actors on the student’s actions, behaviour and interactions which was valuable to their learning. In addition, students enjoyed having the opportunity to practice interpersonal skills in the simulation scenario.

Discussion

Learning outcomes uncovered from the assignment data

The results from the assignment provided evidence that both the written and videos case studies successfully delivered the didactic content since all the solutions that students explored in their assignments correlated closely to the methods suggested to them during the workshop. Ways to prevent and/or deal with gossip and bullying presented during the workshop is displayed in Table 4.

Table 4.

Methods to prevent and/or deal with gossip and bullying presented in the workshop.

Professional issue	Method to prevent/deal with the professional issue
Gossip	Talk to the individual (the gossiper) without attacking them
	Take the time to gather facts
	Ask others to stop gossiping
	Change the topic of the conversation (focus on the positives)
	Approach a supervisor and/or HR member
Bullying	Learn more about bullying
	Do not ignore the behaviour
	Get help/support from people you trust
	Document every incident
	Address the situation by approaching the bully
	Be willing to examine your own behaviour/feelings
	Report the incident to your manager/HR

All the solutions that students explored in their assignments correlated closely to the methods suggested to them during the workshops. The results from the assignment provided evidence that both the written and videos case studies successfully delivered the didactic content.

Based on the assignments, students demonstrated an understanding of accountability, honesty and responsibility for mistakes. To prevent future gossiping and bullying, students claimed that they would either directly confront the gossipers/bully or utilize a more passive solution by trying to sway the opinions and feelings of the bully and gossipers. These responses parallel the findings of van Heugten who proposed that there are 3 types of bystanders in scenarios of bullying: the follower of the bully, the defender of the victim and the silent or passive bystander. Results from the assignment also demonstrated that many students had the ability to practice empathy for the victim. This finding further supports the observation that the students who participated in the study are defending and passive bystanders based on the findings of Gini et al who suggests that these types of bystanders tend to demonstrate high levels of empathy.

Assignment results versus simulation behaviour

The simulations demonstrated the students’ ability to identify behaviours of bullying and gossiping. The ability to feel empathy, console and support the victim seen among students during the simulation paralleled the actions described by students in the assignments. When supporting the victim during the simulation, students would encourage the victim to approach the bully, report the incidents to Human Resources or keep a record of the events as evidence. The actions the students demonstrated and advice they gave to the victim followed the best practice outlined by the Canadian Center for Occupational Health and Safety and the Canadian Society of Medical Laboratory Science (CSMLS).

However, there were discrepancies between students’ interaction with the bully in the simulation versus their hypothetical actions from the assignment. In the assignment, most students stated they would confront the bully/gossiper directly. Likewise, during simulation debrief, some students shared they wanted to confront the bully; however, no students did. Instead, most students attempted to influence the bully’s perception and feelings towards the victim through empathetic statements about the victim. Some students choose to ignore and avoid the conflict. Students admitted that they were unable to provide feedback to the bully because they felt uncomfortable criticizing a superior. Unfortunately, workplace bullying is often committed by superiors and there are numerous known barriers that prevent victims and bystanders from standing up. Individuals may fear that nothing would change if they spoke up or that adverse outcomes could occur to them. This same fear was observed in students who mentioned that they were fearful that ‘[the bully] would trash talk about [them] too’.

Performance difference between the written and video groups

Based on the results of the simulation rubric, students from both groups were able to demonstrate effective communication and teamwork skills and were able to respect other’s dignity, value and beliefs. Although most students from both workshop groups demonstrated the potential to prevent future bullying, there was a difference seen between the groups relating to gossip. Only 18% of students from the Video group were able to behave appropriately during the simulation and defend the victim, as opposed to 70% of students in the Written Group. Even though the mean AGPA between the 2 groups is not statistically significant, the data still may suggest that students from the Written group demonstrated a higher level of professional competence in gossiping situations. There is literature with student self-reported evidence that learning was better with videos;[11,16,23,24] however, our study supports the findings of Pardi et al who used an assessment tool to demonstrate that student learning was greater with text based resources compared to videos.

Impact of written and video case-study teaching methods on student behaviour and other influencers

Although the simulation rubric scores suggest the Written Case-Studies had a more positive impact on student behaviour, this information must be reviewed carefully by considering outside sources of knowledge and experience. During the debrief, some students from both groups self-reported that the workshops allowed them to expand their theoretical understanding of solutions available for resolution of professional issues such as gossiping and bullying. However, most students believed that their performance during the simulation was also influenced by other factors: previous customer-based jobs, university courses, workshops, and online modules provided them with opportunities to practice interpersonal and conflict resolution skills. Additionally, some students believed that their values and belief systems influenced their actions. Thornberg et al suggested that a person’s motivation to intervene on scenarios of bullying depend on their moral evaluation of bullying and belief that they are morally responsible to act. Finally, a small number of simulation participants from both workshop groups, admitted they had forgotten most of the case-studies. However, these simulations occurred several weeks after the workshops and these groups relied more heavily on other sources of information to demonstrate professional skills and attitudes during the simulation.

Limitations

This study has several limitations. First, the study design did not allow for direct comparison of a student’s assignment data to their simulation performance; leading to only generalized conclusions about the groups. Second, other sources of education and knowledge outside of the study affected student performance in the simulations which could lead to a misrepresentation of how written and video case-studies impact student behaviour. Third, students admitted to learning loss. Fourth, this study only investigated the impact of written and video-case studies on communication, teamwork, gossiping, bullying and respect. It is uncertain if the 2 teaching tools would have different impacts on other types of professional student behaviour. Finally, only students from the senior year of 2018/2019 were included in this study. Further studies will need to be conducted to test the validity of the results provided from this research.

Conclusions

Written and video case-studies can be used to teach MLS students the didactic aspects of professional competences relating to conflict management, gossiping and bullying. Students can successfully apply didactic knowledge to develop a hypothetical defender resolution to bullying and gossiping, they are able to articulate what they ‘should’ do; however, in a high fidelity gossip and bullying simulation the majority of video students reacted as bystanders to the gossiping, it is harder to ‘do’ the right thing. Students’ history and memory loss may have affected the simulation outcome. Our results suggest no statistical difference in students’ demonstration of professional skills and attitudes between the written and video case based learning; however, there are interesting nuances as the outcome indicate students from the written CBL appear to be more able to defend bullying and gossip.

Skill/behaviour	Number of participants that demonstrate	Number of participants that do not demonstrate	Comments
Communicates respectfully and effectively to facilitators and other participants in the simulation.
Able to contribute to the team.
Able to discourage negative gossip from occurring in the workplace.
Able to help prevent/resolve workplace bullying.
Able to respect another’s dignity.
Able to respect others values and/or beliefs.
Additional Group Comments:Total Points: _____________ Number of Participants:_____________Group Time (min:sec): _____________Total Points/Number of Participants: _____________