Background

Although a century has passed since the attention to professionalism, no common definition has been reported for it in the literature and it is still considered a complicated issue (1, 2). Professionalism is one of the main behavioral principles in clinical settings and it deals the relationship between physicians and society. These relationships and behaviors are described based on House's Personality and Social Structure Perspective (PSSP) model in three levels of social structure, interactions, and individual personality (3). To be professional, a doctor should have personality traits that match the structure of the environment, and the mutual interactions of these components create professional behavior (4). Imbalance in such interactions can reduce the doctors’ motivation or lead to social structure, both of which can be harmful. These traumatic issues mostly result in insufficient clinical skills, irresponsibility, unpunctuality, invasion of patients’ privacy, disrespectfulness, lack of communication, and breaches of confidentiality (5), which can be prevented by education and preparation of the physicians for clinical settings. Medical education has tried to investigate them through evaluation (6), teaching (7), integration in the curriculum (8), and feedback (9). Among these, the focus of studies over the last decade has been on feedback, and it is recognized as effective in the teaching-learning process (10, 11). Providing feedback is necessary for effective interactions between the two parties. It is so important that the foundation of professionalism is based on interactions (12).

The most important place for these interactions to take place is in the clinical setting for doctors and students, as it also includes the main doctor-patient relationships (13). In addition to education and evaluation, feedback is needed for achieving the best possible clinical interactions (14). Feedback is a reciprocal process including giving specific information about comparing the observed behavior of a student with a standard one to improve functions and operation (15). The real purpose of feedback is to help students and professors participate in a meaningful feedback process and to assist educational institutes develop a constructive feedback culture (16).

There are different types of constructive feedback in medical education. According to Tuma et al. (2020), types of feedback include 1) Feedback based on the setting and structure (formal and informal feedback), 2) Feedback based on their main aim (Constructive, Inspiring, Corrective),
3) Feedback based on their time and breadth (summative or formative), 4) Feedback with different presentation methods (Sandwich, Pendleton) (15). Kleij et al. (2019) have categorized feedback in groups by the role of the students:
1) Feedback in which students have no role (transmission model), 2) Limited role for students (information processing model) 3) Some student roles (communication model) (communication mode) and 4) Feedback with a fully active role of the students (dialogic model) (17). There are some models for standard feedback such as FEEDBACK, a novel feedback tool that encompasses the focus of learning, student self-evaluation (reflection), the encounter with the patient (professionalism), one task that the student should continue to do (reinforcement), one task that they could do better (improvement) and a key take-home message for self-directed learning. In describing the feedback process, they pay attention to the following at
each stage: identifying learning objectives, a
chance to reflect, feedback on communication skills/professionalism, specific suggestions for improvement, clear take-home message, and personalized feedback (18). Sometimes feedback takes place in the educational settings, and it is designed according to the educational conditions, such as feedback based on the homework, university projects, and exams (19). Feedback may also be specified (20) or general (21).

Feedback patterns which were described in the previous paragraphs are too general and there is a need to a specific kind of feedback in every educational situation. Humanistic and social structures form the foundation for teaching and evaluating professionalism (3), which is completely different from other academic settings. There are always some teaching and learning processes going on in a typical academic situation, but clinical context treatments, preventions, social communication, and education are occurring at the same time (22).

In addition to students and educators, health care providers, patients, and their families are present and interact with them. Each of these is in a particular condition that differentiates clinical education from academic one (23). The patient faces symptoms of illness, anxiety, pain, and tension (24), and the patient's family faces stress, anxiety, and worry (25). Care providers also face busy work, anxiety, and job fatigue (26). An essential part of professionalism is evaluation and feedback on learners' professional behavior with others in the clinical setting. Thus, it is necessary to pay attention to feedback on professionalism regarding that the one of the significant differences in giving feedback on professionalism is in clinical education vs. academic. Elliott et al. (2020) (27), Keshmiri et al. (2020) (28), and Duijn et al. (2019) (29) noted the lack of studies in this field. Thus, to fill the knowledge gap in this field and having not found a review study, and for answering the question
of "How to give feedback on professionalism in clinical education", prompted the researchers to conduct this study .

Objectives

This study aimed to investigate giving feedback on professionalism in clinical education.

Methods

"How should be feedback on professionalism is given in clinical education" was the question of this research. The best way to answer such a question based on our goals, context, and resources was to conduct a narrative review. In a narrative review, researchers try to find new aspects of knowledge and solve ambiguities by focusing on a certain subject (30). Therefore, this review was conducted to find what had already been done and to address the existing gaps for future approaches to be planned and filled. Narrative review has been used in different medical education studies such as Klasen M. et al. (2019) (31) and Ross et al. (2021) (32).

The search process consisted of two steps:

At first, a simple non-systematic search was conducted in Google Scholar and PubMed with “professionalism”, “education”, and “feedback” as key terms. Google Scholar and PubMed are popular database and search engines for scholarly publications. Almost all publications can be found with PubMed and Google Scholar. On the other hand, PubMed is the largest database of medical science publications (33). We realized that no narrative review has been written before in this subject (10-19). All review papers were devoted to general feedback in clinical education, and there were no reviews specialized in giving feedback in the field of professionalism in clinical education. With the data collected during this step, a conceptual framework was developed for the second stage of the search.

In the second step, a systematic search was conducted based on the MESH terms and the keywords of the systematic reviews (feedback, professionalism, clinical education) in PubMed and additional records identified through manual search in Google scholar (22 January 2012 to 22 January 2022). Our search strategy was:

((Feedback OR comment* OR response OR evaluat* OR assess*) AND (professionalism OR "Medical Professionalism" OR "Professionalism, Medical" OR "Professionalism Education" OR "Education, Professionalism' OR 'Surgical Professionalism' OR "Professionalism, Surgical") AND ("clinical education" OR "Clinical Clerkship" OR "clinical practicum" OR "Clinical Practice" OR "Clinical Clerkships' OR 'Clerkships, Clinical' OR 'Clerkship, Clinical' OR "Clinical Apprenticeship' OR 'Apprenticeship, Clinical" OR 'Apprenticeship, Clinical' OR 'Apprenticeships, Clinical" OR "Clinical Apprenticeships")).

This strategy was supported by a research librarian. Our search was conducted in PubMed
and Google scholar by exploring the reference lists
of selected articles, whereby we identified additional references.

Inclusion/exclusion criteria

We included all articles in medicine, which used different approaches for feedback on professionalism. The inclusion criteria were the investigation of feedback on professionalism in clinical education. Articles that did not report feedback on professionalism in clinical education in their results section were excluded from the study. Figure 1 summarizes our search and selection process.

Screening stages of articles:

1. Two researchers conducted the search separately.
2. The search results were inputted into Endnote.
3. Duplications were removed.
4. Each individual researcher read the title and abstract.
5. The selected articles were reviewed by two researchers.
6. The full text of the articles was reviewed by two researchers (were the conflict papers marked for the focus group).

The selected articles were entered into the
focus group.

Results

Eight hundred and twelve articles were identified by searching in PubMed and 14 articles by manual search (n=826). According to the title and abstract, 66 articles were selected in the first step. By a full-text review, we removed sixty-six out of 66 articles. Papers that did not report feedback on professionalism in clinical education in their results section or those with mismatched titles and texts were excluded from the list. At last, the focus group chose 15 articles from the 30 remaining ones to discuss, organize, summarize, and answer the question: "What is the best way of giving feedback on professionalism in clinical settings?" The evaluation criteria of articles were based on a checklist that was designed for each article. This checklist included the title of the article, a summary of the methodology, and the results. In the final column, there was yes/no. which indicated whether this article offers a suitable answer to the research question or not. After the introduction of each article, the group members presented their opinions. Articles that were drafted yes were selected for the final report.

The expert panel identified some articles not to be qualified enough to answer the research question (Figure 1).

Note that the review articles in Table 1 are related to the general aspect of giving feedback in clinical education. Thus, no review that specifically assesses the feedback provided on professionalism in clinical education was found.

Articles about feedback on professionalism in clinical settings investigated it from four categories: feedback techniques, feedback in curriculum, scope of feedback, and feedback outcome (Table 1). Of 15 articles, one of them mentioned anonymous feedback through online settings (34); One had used portfolios as a tool for giving feedback (35); Some had pointed out video-based system feedback (36, 48). Feedback given by a preceptor (37) or peers (38, 50) was also mentioned in some Studies. Some had offered to give feedback in a longitudinal form in clerkship (39).

Most studies mentioned Multi Source Feedback (MSF) or 360 degrees as an appropriate feedback method (40-43, 47). In one study, feedback had a specified role in professionalism education in the curriculum (44). According to studies, feedback on professionalism was given both in summative and formative forms (35, 40, 45), with most studies mentioning the formative forms (36). Ten of 15 articles introduced feedback to be effective for educating professionalism (34, 46), curriculum improvements (40), increase in qualifications (36), system support (44), professional behavior in clinical settings (43), student comfort (37), more accurate evaluations (42, 47) and finally better efficiency of professionalism (38). A summary of the results from the articles is provided in Table 2.

Table 1. Conceptual framework of studies about giving feedback on professionalism in clinical settings

Table 2. Articles about feedback in clinical professionalism

Discussion

The results of the studies were placed in four categories: feedback techniques, feedback in curriculum, the scope of feedback, and feedback outcome.

Feedback techniques

Most of the studies had chosen 360-degree for giving feedback on professionalism. Emphasis on the use of one single method does not seem to be effective enough. An effective and accurate approach would be the combination of several different approaches (49). With such an approach, students can have a more realistic view and reflect better on their behaviors (43). Thus, this might be one of the main reasons for the existing emphasis on 360-degree (MSF) feedback. Use of feedback from a variety of sources can help students gain new perspectives about themselves. Further, this approach can improve many aspects such as communication skills, interpersonal skills, professionalism, leadership, and social participation (38). There are some recommendations for improving the quality of the feedback. Feedback should be specific and should be usable quickly (50). It should be given in different settings in longitudinal and different forms (40). Use of role models along with feedback can foster the improvement process (43). For creating an atmosphere without unnecessary pressure, use a standardized patient is recommended. Feedback can be used as a factor for learning and personal development (49), and it can have a role in the personal development of the students in the curriculum (50). Therefore, it is recommended to follow the points mentioned, such as having multiple sources of feedback, attention to different professions in clinical setting, and applying the role model to design a guideline. It is also suggested that the practice of giving feedback in the field of professionalism should be considered in the form of general skills in medical education, and practical research should be done on this matter.

Feedback in curriculum

In a study, feedback was an essential part of the curriculum (42). If feedback finds its way through the organizational culture, then it can become part of their curriculum (38). Personal development is one of the main goals of many medical curricula and such a goal is related to the use of feedback. People working in medical settings should be able to criticize themselves and their co-workers or the medical team members, and when such skills are lacking, constructive feedback is less likely to be given. Further, the ability to give and receive constructive feedback can lead to lower stress levels in workplaces such as clinical settings (52).

Thus, a standard curriculum should provide students with chances for participation in feedback processes and the educational environment should be designed according to this issue, so that the students and professors would be able to improve their functions and behaviors and have chances for personal reflection (38). In a standard curriculum, chances should exit for interactions between teachers and students. Students should be observed directly by their professors and receive instructions according to their functions as well as behaviors (51). According to Burgess et al. (2020), this curriculum should be able to familiarize students with the purpose and nature of various forms of providing feedback, to receive feedback from students and use them, have diverse activities, and challenge students to engage in new activities. (38).

Students and teachers need to develop qualified and improved relationships that are based on trust, which can be accomplished by a carefully designed and clarified curriculum. The difference between evaluation and feedback processes should be completely explained to students and faculty members. The curriculum should include opportunities to give and receive feedback and improve performance in professionalism without any scoring or grading for students (51). We suggest that the process of design, implementation, and assessment should be considered for giving feedback in professionalism in clinical education as in other courses. For this purpose, the best way is to integrate it longitudinally during internships.

Scope of feedback

In most studies, feedback could be given as summative or formative (32, 38, 43) (most of which were formative) (34). The feedback which is given over time (formative) can improve the self-regulation and self-evaluation skills of the students. As a result, students can improve their cognitive and behavioral abilities through this type of feedback (48).

Creating a professional identity is a long-term process and requires time as well as attention. There also should be no contradictions in the formal, informal, and hidden curriculum (53). Some aspects of the curriculum which can support professional development are integrating identity creation into the school curriculum, engaging students in identity improvement plans, and creating a welcoming and supportive society. In addition to the mentioned issues, students should receive help and support in the entire process (54). Further, students should not face any contradiction in educational settings. Sometimes the student learns something and faces the opposite in the clinical setting. For example, a professor insists on interdisciplinary health care but does not seem to consult with others while making clinical decisions. A doctor who teaches communication skills does not look at her patient during a visit. In short, it should be kept in mind that professionalism is not created instantly and requires time and effort from all disciplines (55).

As a way of perfectly approaching the considered goals of summative and formative feedback, students are urged to keep a portfolio, since this will allow them to monitor their progress and they will be able to evaluate the path they have taken. (40). Clinical settings are highly complicated and there is a possibility for clinical professors to be distracted from students while facing problems such as lack of time. Professors should pay close attention to the students' emotions. Because students are often so vulnerable, their emotions need to be considered carefully.

Paying attention to their emotions can also enhance their future performance through the hidden curriculum (56). Hidden curriculum is one of the most vital issues to be considered. Upon receiving wrong feedback, an honest and committed student may totally change to someone who is less likely to communicate, less compassionate, and far from the expected goals (57). Also, successful formative and summative evaluation needs to have educational effects. Educational effects encourage students to learn better. To achieve this goal, it is necessary to involve the student in the evaluation process. Also, peer evaluations in this process have a significant impact, especially for students who are friends and spend time together outside of class hours. In this way, they can see each other's behavior in clinical clerkships and give feedback to each other repeatedly over time. Of course, this method needs careful investigation and appropriate culture.

Feedback outcome

Finally, we review the outcomes of giving feedback in the field of professionalism in clinical education. According to the literature, feedback
can increase learning about professionalism
(31, 44), curriculum improvements (38), system support (42), student comfort (45), quality of professionalism evaluations (40, 45), and efficacy of professionalism (46). Meanwhile, there are some variables that are effective in conveying the feedback message among people, such as facial expression, and body postures, which have not been discussed enough in the literature (58). It can be concluded that all these consequences pass through the lens of professional identity. All of these goals are attained by creating a professional identity (59) and through long-term planning and education (60). Longitudinal terms, workshops, seminars, in-service education, appropriate educational opportunities, and comprehensive planning are the best solutions for forming social identity. According to the long-term nature of the creation of professional skills, there is a need to frequent formative feedback. In order to achieve more outcomes, it is very effective to review feedback results and report them to students, teachers, and educational managers.

Knowledge gap

Feedback in medical education is one of the most important topics and fortunately there are several studies dealing with it. However, there are still some gaps in different parts for example goals of feedback on professionalism such as differences between formal and informal feedback, personal or group feedback, body postures, investigating brand new ways of giving feedback (61), and examining the factors affecting feedback (teacher, student, educational environment etc.) on professionalism, which can be investigated in future studies.

Limitations: The main limitation of our study was the 10-year (2012-2022) period of review of published articles, though it was sufficient to answer our research question.

Conclusion

The main tool used for feedback on professionalism was 360 degree (MSF) and the most popular form was informal - formative feedback. Since professionalism is a multidimensional concept related to personal communication, multi-source tools are mostly used in the literature. Forming professionalism is a time-consuming process and it takes numerous efforts over time.

Most of the time, feedback is provided in an informal form and through the hidden curriculum. Giving and receiving constructive principled feedback on professionalism requires planning in basic and clinical education in the formal, informal, and hidden curriculum.