PROfessionalism in Partnership for Education Research (PROPER) study: A Novel Online Initiative Approach to Professionalism Education

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Guraya, Grainne P. Kearney, Aine Ryan, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8132875/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Medical education must ensure medical students graduate with the appropriate values, attitudes, and behaviours that allow them to work collaboratively with patients and families from a range of diverse cultural backgrounds. The PROfessionalism in Partnership for Education Research (PROPER) study aimed to assess the impact of an online educational intervention on medical professionalism for undergraduate medical students in two jurisdictions, focusing on behaviours and cultural sensitivity. Methods The PROPER study employed a quasi-experimental, mixed-methods design underpinned by the Theory of Planned Behaviour (TPB). The intervention comprised four online workshops, using scenario analyses and reflective practices, addressing confidentiality, raising concerns, self-care, and cultural awareness. Quantitative survey data were collected at three time points (pre- and post- workshop and three months follow-up) and qualitative data were obtained through focus group discussions (FGDs). Quantitative analyses included paired and independent t-tests, while qualitative data were analysed thematically. Results Forty-one participants (intervention = 31, control = 10) were included. The most notable change was observed in perceived behaviour control for self-care, which significantly improved from pre- to post-workshop ( P < 0.05). For other constructs, improvements were observed but did not reach statistical significance. Other TPB items showed similar directions of change, where decreases or no improvements were observed. FGDs (n = 5, 24 participants) analysis identified four key themes across the combined workshops: perspective enhancement, enabling self, dialogic reflection, and strengthening axiology. These themes highlighted evidence in increased self-awareness, confidence, and the early development of professional values among participants. Discussion Despite limited statistical evidence, qualitative insights suggest PROPER intervention may be a promising model for online undergraduate professionalism education, combining a structured programme and reflection to enhance collaboration and cultural competence. Challenges such hierarchical norms, structural barriers and participants’ relative lack of clinical experience were perceived to limit long-term behaviour change. More evidence is needed in this area, focusing on incorporating experiential learning and addressing contextual barriers at a larger sample size to sustain professionalism alongside supporting professional identity formation. Clinical trial number: Not Applicable Medical Ethics Medical Professionalism Educational interventions e-learning theory of planned behaviour professional behaviour mixed methods cultural sensitivity undergraduate students Figures Figure 1 Background Doctors work in increasingly diverse environments, encountering professionally challenging situations ( 1 ). Students also have professional obligations like qualified doctors during clinical learning, underscoring the importance of early professionalism teaching ( 1 – 3 ). Unprofessional behaviour in medical school is associated with subsequent disciplinary action by medical regulatory boards during clinical practice, further justifying this focus ( 4 ). Therefore, medical educators must prepare students with the values, attitudes, and behaviours needed to navigate professionalism dilemmas and collaborate with culturally diverse patients and families ( 2 , 3 , 5 ). The mission for medical education is to ensure patients will receive the same degree of medical professionalism (MP) practice irrespective of where their doctor graduated. MP is a vital competency for patient safety and care quality, forming a core competency in undergraduate medical students ( 6 ). While most institutions incorporate professionalism teaching into curricula, challenges remain in aligning taught values with practices ( 7 ). Professional behaviours (PB) reflect professional values (i.e., cultural sensitivity, ability to raise concerns, etc) and are often formally assessed ( 7 – 10 ). The value of curriculum interventions to foster developing PB have been questioned when students witness a dissonance between the design of a certain educational programme and what is taught in school versus teachers as role models ( 11 ). This tension, fuelled by the hidden curriculum- informal learning shaped by institutional, cultural influences- can hinder professional identity formation ( 11 , 12 ). Despite globalization and adoption of international concepts, the hidden curriculum impact varies across medical institutions ( 13 ). For instance, research has investigated strategies to minimize the effects of the hidden curriculum using reflective practice, support groups, guided experimental workshops and scenario-based analysis ( 14 , 15 ). Nevertheless, evidence on theory-based interventions, validated tools and long-term sustainability with focus on cultural sensitivity remains limited. This gap is particularly relevant on the island of Ireland, which includes the separate political jurisdictions of Northern Ireland, United Kingdom (UK) and the Republic of Ireland; these have different medical-education and regulatory frameworks, and yet share medical training, people and geography. This creates a unique challenge and provides a unique opportunity for studying the benefits of culturally aware online MP education. Thus, PROfessionalism in Partnership for Education Research (PROPER) study addresses this by developing a best-practice model for MP education across borders. Using online curated workshops with scenario analysis, PROPER aims to (i) co-educate medical students from two institutions in two regions; and (ii) assess the potential impact of an online educational intervention on MP for undergraduate medical students in the two jurisdictions, focusing on behavioural change and cultural sensitivity. Methods Design PROPER is a quasi-intervention mixed-methods design, designed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement ( 16 ). Underpinned by social cognitive theory and the theory of planned behaviour (TPB) as detailed in a prior publication ( 17 ), PROPER comprises three components: Workshops and scenario analysis: Four online workshops on Microsoft (MS) Teams® on key professionalism competencies. TPB-based surveys: measured at three time points: pre-workshop, post-workshop, and three-month follow-up, with a comparator group. TPB-based focus group discussion (FGD): semi-structured, conducted virtually using MS Teams post workshop. Participants Eligibility criteria included pre-clinical undergraduate medical students (year 2–3) from Royal College of Surgeons in Ireland (RCSI), Republic of Ireland and Queen’s University Belfast (QUB), UK, before they commence clinical education. The intervention and data collection were conducted online from September 2023 to February 2024; with PROPER workshops held between September and October 2023. Participants were required to complete a 10-minute survey(s), attend a 90-minutes workshop(s) and engage in an online FGD, where applicable. Ethical approval was sought and obtained from the Research Ethics Committee of the RCSI (REC202205007) and QUB (MHLS 22_184) prior to commencement. Clinical trial number: Not applicable. Recruitment Convenient sampling was employed, and recruitment was conducted via email through the Quality Enhancement Office in RCSI. An invitation was emailed to all years 2 and 3 medical students at both institutions (RCSI = 750, QUB = 540) outlining study details, providing a participant information leaflet and a consent form. Participants could select either the intervention route (involving pre and post workshop surveys, attendance at one workshop, one post workshop FGD, and a three-month follow up survey) or the control route (completing only pre-workshop and follow up surveys). To encourage retention, participants were rewarded with a certificate of completion and €25 Amazon voucher at the end of data collection. PROPER intervention PROPER workshops : four bespoke educational workshops addressing key MP themes: 1. Maintaining confidentiality; 2. Raising concerns and whistle-blowing; 3. Self-care and wellbeing and 4. Exercising cultural sensitivity. Experts from Ireland, UK, Bahrain, and the United Arab Emirates informed the workshop design using educational theories. Each workshop included a 40 minute group scenario analysis utilising Rolfe’s reflection model ( 18 )(Table 1 ). The scenarios were informed by experts and student panel, with full details provided in our previous publication ( 17 ). Table 1 PROPER workshop structure Stages Duration Virtual Online Room Details Introduction 5 minutes Main room (All participants) Welcome, introductions and overview of workshop objectives Didactic lecture 10 minutes Main room (All participants) Summary of pre-workshop materials and theme Scenario- analysis 40 minutes Breakout rooms (4–5 students; 2 facilitators/room) Scenario deliberation using Rolfe’s reflective model, problem-solving, and clinical reasoning. Working through four scenarios/ workshop theme Case-feedback & discussion 25 minutes Main room (All participants) Reflecting on hidden curriculum challenges, sharing insights, and discussing lessons learned. Wrap up 5 minutes Main room (All participants) Feedback, conclusion and preview future practice. Quantitative design The PROPER study survey was adapted from Medisauskaite et al. , ( 19 ) and validated for relevancy and clarity ( 20 ). The validated survey assesses participants attitude, subjective norms (SN), perceived behaviour control (PBC) and intentions. The survey also collected demographic data including participant’s age, gender, ethnicity and year of study, and was administered online using Survey Monkey®. PROPER impact on PB was assessed by analysing changes within the intervention group from pre-workshop to post-workshop. Change from the pre-workshop to three months follow-up were compared between intervention and control group. Qualitative design A TPB-based semi-structured guide was developed, piloted, and refined by the research team. Virtual FGDs, audio-recorded with consent, were auto-transcribed, and examined prior to analysis. Outcomes The primary outcomes were the average scores for attitudes (8 items), SN (12 items), PBC (4 items) and intentions (4 items), which were rated on a 7-point scale. Data collection Each participant received a unique ID. One week before the workshops, all consenting participants were sent a pre-workshop survey. Intervention participants received an MS Teams invitation and educational resources related to the workshops. Post-workshop, they completed the post workshop survey and received a FGD invitation. Three months later, all participants received a follow-up survey, following GDPR guidelines ( 21 ) . Analysis Quantitative analysis Demographic information was summarised using descriptive statistics. The average score of each TPB construct was calculated at each time point. Sample t-tests were originally planned for analyses, however given the small sample size and statistical power, differences within the intervention group between pre and post intervention were assessed using non-parametric sign test, while comparisons of pre-workshop to three-months follow-up scores between intervention and control groups utilised Mann-Whitney U test. Statistical analyses were performed using Stata v18 and a p-value ≤ 0.05 indicated statistical significance. Qualitative analysis Thematic analysis followed Braun and Clark’s Six stages approach ( 22 ). Three researchers (AS, SSG and GK) analysed the FGDs using a multi-layered approach, applying a deductive TPB-based coding process. SSG and GK independently coded the first two transcripts before resolve discrepancies with AS. A second inductive analysis followed the same process, ensuring nuances insights during an in-depth analysis. Triangulation Qualitative and quantitative results were triangulated using the Cathkin et al. , triangulation method ( 23 ). This methodology allowed for comparison and contrast of the findings to uncover convergence (agreement), complementarity (providing additional insights), or dissonance (contradictions). Sample size For the quantitative arm, power calculations (Cohen’s d = 0.5, 90% power, and a significance level of 0.05) ( 24 ) recommended 40 participants per group and adjusted to 60 for attrition and clustering. However, the final sample was smaller than expected, limiting the study’s power to detect small-to-medium effects. For the qualitative arm, a target of 5–8 participants per session was set to ensure interactive discussions ( 25 ). Notably, blinding was not implemented as this was a quasi-experimental study. Results Participant characteristics As presented Table 2 , 41 participants took part in the study (Intervention = 31, Control = 10). Participants were recruited from two institutions located in the Republic of Ireland (RCSI: n = 27, 65.8%) and UK (QUB: n = 14, 34.1%). Equal participation was observed from Years 2 and Year 3 students, predominantly female (n = 22, 70.7%) and aged 19–24 years (n = 34, 89.9%). Ethnic backgrounds, including Asians (n = 24, 58.5%), White (n = 12, 29.3%) and Africans (n = 5, 12.2%). Table 2 Table of demographics Category Intervention group (N = 31) Control group (N = 10) Total participants (N = 41) p -value* Institution n (%) RCSI 20 (64.5%) 7 (70.0%) 27 (65.8%) 0.99 QUB 11 (35.5%) 3 (30.0%) 14 (34.1%) Academic year n (%) Year 2 18 (58.1%) 5 (50.0%) 23 (56.1%) 0.72 Year 3 13 (41.9%) 5 (50.0%) 18 (43.9%) Gender n (%) Female 22 (71.0%) 7 (70.0%) 29 (70.7%) 0.99 Male 8 (25.8%) 3 (30.0%) 11 (26.8%) Non-binary 1 (3.2%) 0 (0.0%) 1 (2.4%) Age n (%) 19 7 (22.6%) 3 (30.0%) 10 (24.4%) 0.82 20 11 (35.5%) 3 (30.0%) 14 (34.1%) 21 7 (22.6%) 3 (30.0%) 10 (24.4%) > 21 6 (19.4%) 1 (10.0%) 7 (17.1%) Ethnicity n (%) Asian 20 (64.5%) 4 (40.0%) 24 (58.5%) 0.25 White 7 (22.6%) 5 (50.0%) 12 (29.3%) African 4 (12.9%) 1 (10.0%) 5 (12.2%) RCSI: Royal College of Surgeons, South of Ireland, Ireland; QUB: Queen’s University Belfast, North of Ireland, United Kingdom *Chi-square test used for larger sample sizes and Fisher’s Exact Test when any expected cell count was less than 5. Quantitative results In the intervention group, participants were distributed according to preference across four workshops addressing themes of MP: confidentiality (n = 11), cultural awareness (n = 6), raising concerns (n = 6) and selfcare (n = 8). The most notable change was observed in PBC for self-care, which significantly improved from pre- to post-workshop (median (IQR): 3.7 (3.2–4.0) to 5.2 (4.9–5.3); p < 0.01). For other constructs, improvements were observed but did not reach statistical significance. For example, PBC for cultural awareness increased (5.8 (4.5–6.0) to 6.5 (6.3–6.8); p = 0.06), and intentions to raise concerns rose slightly (5.2 (4.7–5.5) to 5.5 (5.0–6.0); p = 0.06). Other TPB items showed similar directions of change, except for attitudes to cultural awareness, subjective norms for raising concerns and self-care, and intentions for cultural awareness, where decreases or no improvements were observed (Additional File 1). Other items show positive trends although interpretation is limited by sample size. There was no evidence of a difference from pre-workshop to three-month follow-up when comparing intervention and control groups (Additional File 1). Qualitative results Twenty-four participants from the intervention group engaged in 5 online FGD post-workshop, unaware of quantitative results. Each FGD included 4–5 participants and one facilitator and was approximately 60 minutes in duration. Using the four TPB constructs, analysis revealed four themes. Attitude: perspective enhancement Participants reported enhanced perspectives on MP, enabling them to challenge previous assumptions and beliefs. Participants repeatedly conveyed that PROPER prompted them to re-examine preconceptions about MP’s role in students' lives and in clinical practice. This reflected a contextual understanding of MP that evolves with learning. “I think also just being aware of the kind of scenarios where I used to think that professionalism didn't matter, but realizing that it does matter.., definitely it's helped me be a lot more aware of how I act" Student_23 This shift suggested a deeper, context-dependent understanding of MP as a phenomenon requiring ongoing reflection. "Once you scratch the surface, you realized how much there is below… There's so much to this!" Student_11 Subjective norms: Strengthening axiology SNs reflected as strengthened axiology, a deepening understanding of values. Participants articulated a strengthened sense of their professional values, enhancing their decision-making abilities in professional contexts. “I just feel like as long as I have my views and my views are in charge and I still believe in them, I'll be able to be more professional" Student_04 They emphasised the importance of having clear professional beliefs for building patient trust. “If hidden curriculum is shared with patients and they understand that we are working on it and trying to improve it, it will make them feel safer and build more trust in the medical professional in a way" Student_22 However, some concerns were raised about how certain peers’ attitudes towards professionalism could undermine their axiological belief growth or their practice development. “Older generations who are not open minded to changes in how the medical professional is perceived or people think professionalism is a waste of time…and some professors who really don't agree with professionalism" Student_03 Perceived behaviour control: Enabling Self From PBC analysis emerged ‘enabled self’ which was characterised by increased confidence in handling future professional dilemmas. Many participants felt reassured about their knowledge and abilities post-workshop. Small group discussions further solidified these understandings. “You're getting reassurance that you know what's right to do and that you can put it into practice because you've thought through those experiences…. And I think that I was aware of what to do before, but I think the workshop reiterated that and consolidated my like knowledge" Student_20 However, some participants expressed the need for continued reinforcement of the newfound self-efficacy. “ I feel a bit more confident than prior to the study, but I'm still not 100% confident in myself and my ability… But hopefully I guess by the time that would be 100%” Student_16 Participants feared medical hierarchical practices could undermine confidence, influencing their PB practices. "I could look at the guidelines of the PROPER study and try to do something, but if my superior is not OK with that, even if I want to do the change and I'm unable to do the change" Student_22 Intentions: Dialogic reflection Intentions manifested as dialogic reflections, demonstrating improved risk assessment capabilities and ability to reflect critically on their actions. "I think I've already applied at least some of them while being in clinical practice and kind of noticed the bias and the differences in my thinking that I've noticed after doing one of the workshops" Student_14 Participants articulated their improved confidence in rationalising the right approaches, and consider translating acquired theoretical insights to future professional practices. "Overall, my confidence has increased, but I think it'll increase as I actually have to deal with real life situations and I take the initiative to use them to use the PROPER study hidden curriculum" Student_23 Dialogic reflections also revealed that participants felt empowered to express their views and challenge the existing hierarchy constructively. “I think I'm more vocalizing now. I'm trying to tell them [seniors] in the politest way and raise concerns when needed even in work or anywhere out of work.…. Before I used to not say anything" Student_23 Triangulation Quantitative and qualitative results were triangulated using O’Cathain et al.’s framework , summarising themes in a table to compare results interpretable for convergence, complementarily and discrepancies. This method facilitated deeper understanding and interpretation of the combined results (Table 3 ). Table 3 Triangulation Theme Quantitative Qualitative Attitude No significant improvement in attitudes towards raising concerns Enhanced perspectives and understanding of MP attitudes Subjective norms No significant improvement in subjective norms across MP theme Strengthened values and beliefs within social structures, alongside barriers and facilitators, were recorded. PBC Significant improvement in PBC related to selfcare and some evidence of improvement towards cultural awareness Increased confidence in engaging in professional practices, though hierarchical practices were seen as a threat to the confidence and newly acquired MP understandings. Intentions Some evidence of improvement in intentions to raising concerns Dialogic reflections showed improved ability to assess benefits and threats of actions in professionalism in practice. Behaviour change Sustainability No significant sustained impact on behaviour change over time compared to control group Participants emphasized the need for iterative efforts to maintain self-efficacy and confidence. MP: Medical professionalism; PBC: Perceived behaviour control Discussion MP education is an essential component of undergraduate teaching. PROPER workshops resulted in some evidence of improvements in a number of behaviour constructs towards raising concerns, self-care and cultural awareness. Qualitative findings revealed four emergent themes that provided further details to the improvement journey in PB, these included: perspective enhancement , strengthening axiology , enabling self , and dialogic reflection . These findings emphasize the impact of PROPER on personal growth and readiness of medical students to act professionally. However, contextual barriers ( e.g. , hierarchy), were reported to have hindered the students’ significant improvement and the perceived readiness for long-term translation of intentions into behaviour changes. Moreover, PROPER demonstrates the feasibility of delivering professionalism-focused education online across two institutions. While attitudes scores showed no statistical improvements towards raising concerns but rather a positive trend using the sign test, qualitative evidence revealed participants' expanded understanding of MP and its clinical importance. Perspective enhancement evidenced a revaluation of MP’s significance in clinical practice, mirroring emerging research that highlights the importance of cognitive understanding in shaping professional identity formation ( 26 ). This shift reflects a deeper cognitive evolution beyond surface-level understanding. These results resonate with findings from previous systematic reviews emphasising the benefits of structural educational frameworks and reflective practices ( 15 , 27 ). Johnsen et al., ( 28 ) also suggested that similar interventions can ease inner conflict in raising concerns, emphasizing the complexity of attitudes and the need for targeted strategies to ensure patient safety. PROPER workshops have contributed to enabling undergraduate students’ ability to internalize professional values by emphasizing professionalism learning. This targeted approach fosters deeper reflection, ethical awareness, and behavioural integration of core professional standards. While quantitative analysis showed no significant changes in SNs, qualitative data indicated a notable development in participants' professional values, particularly through external validation from peers and patients. This observation aligns with the intervention’s design, which is grounded in social constructivist theory ( 17 ). This approach emphasises learning within the zone of proximal development, where social interactions, shared experiences and cultural/social context facilitate the assimilation of sociocultural behaviours and transformation of learner identities ( 29 – 31 ). Additionally, participants recalibrated their moral compasses, reflecting strengthened axiology, where learners construct understanding through social engagement ( 32 ). However, the lack of quantitative change of SNs may reflect measurement limitations, which might not capture the nuanced shifts more observable through qualitative methods. Literature suggests that SNs are context-dependent, and challenging to quantify effectively ( 33 ). PROPER results reveal these challenges in form of traditional professionalism perspectives which students reported to be held by senior healthcare professionals, which can act as a barrier to student’s PB developments. Medical students often model their behaviours on their supervisors’, adopting their values and behaviours, despite undergoing attitudinal shifts ( 34 , 35 ). This can suppress the evolution of professional identity aligned with modern professional standards ( 36 , 37 ). This highlights the need to promote evidence-based PBs that reflect current ethical standards, inclusivity, and patient-centred care rather than hierarchical norms. PROPER aims to integrates these values into educational curricula, allowing students to internalize PBs consistent with evolving societal expectations ( 38 , 39 ). This alignment creates a supportive learning environment where students can challenge traditional perceptions, prioritise collaboration and ensure patient safety. Quantitative findings revealed statistically significant and potentially meaningful improvements in PBC, particularly in self-care and cultural awareness. These results were reinforced by qualitative insights, where participants expressed increased potential confidence in applying the professional behaviours acquired during the clinical stage of education and practice. The PROPER workshops validated existing knowledge taught on professionalism topics embedded within other courses within RCSI participants, strengthening participants' belief in their professional abilities. However, confidence was perceived as context-dependent, potentially threatened by hierarchical environments that undermine PBC. This suggests that increased PBC may not drive behaviour change if barriers are present ( 40 ). These findings suggest the necessity for parallel interventions to mitigate hierarchical norms in clinical settings, fostering an environment where professionals can express their behaviours without structural limitations. This observation is consistent with the TPB framework, which suggests that increased PBC does not always lead to behaviour change when situational constraints exist ( 41 ). The literature identifies PBC as a challenging construct due to its complexity ( 33 , 40 ). Research on PBC within medical education remains scarce and while some interventions (i.e., workshops) aimed at modifying PBC have inconsistent results, comprehensive strategies remain limited ( 42 – 44 ). The novelty of our PROPER intervention lies in its design, incorporating collective reflections using Rolfe’s model, and expert guidance to address real-world scenarios ( 18 ). This approach fostered self-efficacy, psychological safety and PB. Aligning with Mann et al., our findings on reflective processes deepens professional awareness, examine assumptions and readiness for professionalism in practice ( 45 ). Additionally, large group discussions in PROPER workshops helped reinforce new insights, challenges, and strengthen PBC among participants. In a similar manner, potential improvements in intention to raising concerns scores were reinforced by qualitative insights, revealing participants' engagement in dialogic reflections. The correlation between intentions and behaviour within our framework, is well-documented; for instance, Henderman et al. , highlighted TPB-based intentions reliably predict behaviour change ( 46 ). PROPER workshops have the potential to foster this introspection among medical students; however challenges remain in students’ perception of sustaining PB and duration of intervention. Contextual and cultural barriers, particularly hierarchical norms and fears of repercussions for raising concerns, further impeded potential behavioural shifts, despite gains in knowledge, confidence and self-reflection in our cohort ( 47 – 49 ). Addressing these barriers alongside educational interventions is crucial to create an environment where PB can be enacted without fear of negative consequences thus supporting the translation of professionalism learning into practice. Strengths and limitations PROPER is a theory-based project, designed to enhance MP education for culturally diverse students from two different institutions in Northern and Southern Ireland, employing mixed method, quasi-experimental design. Experts and students co-developed PROPER workshops to ensure relevance, and validated questionnaires to accurately assess behaviour change. The virtual format of the intervention had improved accessibility and engagement of students from geographically diverse regions. The study faced several limitations. First, recruitment challenges led to a limited quantitative sample size, which constrained statistical power and precluded advanced analyses such as sustainability comparisons and structural equation modelling. On reflection, embedding the study within the formal curriculum with optional consent to participate in research may have enhanced both recruitment and retention, but was not considered logistically possible across two separate institutions. Second, the self-selection of participants into intervention and control groups may have introduced selection bias due to unmeasured baseline differences. Third, the lack of a control group at immediate post-intervention (Time 2) for comparison. Forth, issues related to data sufficiency and the potential loss of subthemes were noted in both the quantitative and qualitative analyses. While these constraints are acknowledged, the integration of qualitative and quantitative data through methodological triangulation was intentionally employed to enhance the credibility and depth of the results. Triangulation does not eliminate the limitations associated with sample size but provides complementary insights that strengthen the internal validity and contextual understanding of the intervention’s effects. However, the study provides meaningful insights into the intervention’s impact within a naturally occurring, self-directed educational context. Furthermore, the qualitative findings offer rich, contextualized perspectives that may inform a blueprint for future MP educational interventions at different institutions and geographics. Future research with larger and more diverse samples is warranted to confirm and extend these findings. Conclusion PROPER offers a promising blueprint for online professionalism education, combining structured learning and reflection to foster collaboration and cultural competence. While improvements in PB were noted, hierarchical norms and limited clinical experience may have constrained long-term change. Future interventions should target barriers via faculty development and experiential strategies to translate professional identity formation and foster behaviour change in clinical practice Abbreviations PROPER Professionalism in Partnership for Education Research MP Medical professionalism PB Professional Behaviour TPB Theory of Planned Behaviour SN Subjective norms PBC Perceived Behaviour Control Declarations Ethical approval was sought and obtained from the Research Ethics Committee of the RCSI (REC202205007) and QUB (MHLS 22_184) prior to commencement and the study adhered to the Declaration of Helsinki to this effect. Informed consent obtained from all the participants prior to any data collection. Consent for publication: Not applicable, this manuscript does not contain identifiable data from an individual participant. All authors have reviewed and approved consent to participate and publication of the manuscript. Competing of interest The authors declare that they have no competing interests Asil Sadeq Asil Sadeq, is the funded researcher for the PROPER study, RCSI University of Medicine and Health Sciences. Funding: The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This project is funded by the Higher Education Authority, North–South Research program granted to the RCSI [PI (DH), grant number 21578A01]. Author contribution: All authors (AS, SSG, GPK, AR, EC, MS, AB, SH, SYG, FD, FB, MH, DWH) confirm their contribution to the study inception, design, execution, data collection, analysis and interpretation, manuscript writing and reviewing. Acknowledgement: We thank the Quality Enhancement Office at the RCSI, Dublin and students at the RCSI, Dublin and QUB for their contribution and support. Clinical trial number : Not applicable. 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SLACK Incorporated Thorofare, NJ, pp 183–184 Guraya SS, Guraya SY, Doubell F-R, Mathew B, Clarke E, Ryan Á et al (2023) Understanding medical professionalism using express team-based learning; a qualitative case-based study. Med Educ Online 28(1):2235793 Passi V, Doug M, Peile E, Thistlethwaite J, Johnson N (2010) Developing medical professionalism in future doctors: a systematic review. Int J Med Educ 1:19 Ajzen I, Perceived Behavioral, Control, Self-Efficacy (2002) Locus of Control, and the Theory of Planned Behavior. J Appl Soc Psychol 32(4):665–683 Ajzen I (1991) The theory of planned behavior. Organ Behav Hum Decis Process 50(2):179–211 Wang CX, Pavlova A, Boggiss AL, O’Callaghan A, Consedine NS (2023) Predictors of medical students’ compassion and related constructs: a systematic review. Teach Learn Med 35(5):502–513 Steinert Y, Mann K, Anderson B, Barnett BM, Centeno A, Naismith L et al (2016) A systematic review of faculty development initiatives designed to enhance teaching effectiveness: A 10-year update: BEME Guide 40. Med Teach 38(8):769–786 Archer E, Bitzer E, Van Heerden B (2017) Interrogating patient-centredness in undergraduate medical education using an integrated behaviour model. South Afr Family Pract 59(6):219–223 Mann K, Gordon J, MacLeod A (2009) Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ 14:595–621 Hardeman W, Johnston M, Johnston D, Bonetti D, Wareham N, Kinmonth AL (2002) Application of the theory of planned behaviour in behaviour change interventions: A systematic review. Psychol health 17(2):123–158 O'Donovan R, De Brún A, McAuliffe E (2021) Healthcare professionals experience of psychological safety, voice, and silence. Front Psychol 12:626689 Jones A, Kelly D (2014) Whistle-blowing and workplace culture in older peoples' care: qualitative insights from the healthcare and social care workforce. Sociol Health Illn 36(7):986–1002 Rees CE, Monrouxe LV, Ajjawi R (2014) Professionalism in workplace learning: understanding interprofessional dilemmas through healthcare student narratives. Exploring the dynamics of personal, professional and interprofessional ethics. Policy, pp 295–310 Additional Declarations The authors declare no competing interests. Supplementary Files Additionalfile1.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Education\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eDoctors work in increasingly diverse environments, encountering professionally challenging situations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Students also have professional obligations like qualified doctors during clinical learning, underscoring the importance of early professionalism teaching (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Unprofessional behaviour in medical school is associated with subsequent disciplinary action by medical regulatory boards during clinical practice, further justifying this focus (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Therefore, medical educators must prepare students with the values, attitudes, and behaviours needed to navigate professionalism dilemmas and collaborate with culturally diverse patients and families (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The mission for medical education is to ensure patients will receive the same degree of medical professionalism (MP) practice irrespective of where their doctor graduated. MP is a vital competency for patient safety and care quality, forming a core competency in undergraduate medical students (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). While most institutions incorporate professionalism teaching into curricula, challenges remain in aligning taught values with practices (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eProfessional behaviours (PB) reflect professional values (i.e., cultural sensitivity, ability to raise concerns, etc) and are often formally assessed (\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The value of curriculum interventions to foster developing PB have been questioned when students witness a dissonance between the design of a certain educational programme and what is taught in school versus teachers as role models (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This tension, fuelled by the hidden curriculum- informal learning shaped by institutional, cultural influences- can hinder professional identity formation (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Despite globalization and adoption of international concepts, the hidden curriculum impact varies across medical institutions (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). For instance, research has investigated strategies to minimize the effects of the hidden curriculum using reflective practice, support groups, guided experimental workshops and scenario-based analysis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Nevertheless, evidence on theory-based interventions, validated tools and long-term sustainability with focus on cultural sensitivity remains limited.\u003c/p\u003e\u003cp\u003eThis gap is particularly relevant on the island of Ireland, which includes the separate political jurisdictions of Northern Ireland, United Kingdom (UK) and the Republic of Ireland; these have different medical-education and regulatory frameworks, and yet share medical training, people and geography. This creates a unique challenge and provides a unique opportunity for studying the benefits of culturally aware online MP education. Thus, PROfessionalism in Partnership for Education Research (PROPER) study addresses this by developing a best-practice model for MP education across borders. Using online curated workshops with scenario analysis, PROPER aims to (i) co-educate medical students from two institutions in two regions; and (ii) assess the potential impact of an online educational intervention on MP for undergraduate medical students in the two jurisdictions, focusing on behavioural change and cultural sensitivity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003ePROPER is a quasi-intervention mixed-methods design, designed in accordance with the Consolidated Standards of Reporting Trials (CONSORT) statement (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Underpinned by social cognitive theory and the theory of planned behaviour (TPB) as detailed in a prior publication (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), PROPER comprises three components:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWorkshops and scenario analysis: Four online workshops on Microsoft (MS) Teams\u0026reg; on key professionalism competencies.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTPB-based surveys: measured at three time points: pre-workshop, post-workshop, and three-month follow-up, with a comparator group.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eTPB-based focus group discussion (FGD): semi-structured, conducted virtually using MS Teams post workshop.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEligibility criteria included pre-clinical undergraduate medical students (year 2\u0026ndash;3) from Royal College of Surgeons in Ireland (RCSI), Republic of Ireland and Queen\u0026rsquo;s University Belfast (QUB), UK, before they commence clinical education. The intervention and data collection were conducted online from September 2023 to February 2024; with PROPER workshops held between September and October 2023. Participants were required to complete a 10-minute survey(s), attend a 90-minutes workshop(s) and engage in an online FGD, where applicable. Ethical approval was sought and obtained from the Research Ethics Committee of the RCSI (REC202205007) and QUB (MHLS 22_184) prior to commencement. Clinical trial number: Not applicable.\u003c/p\u003e\n\u003ch3\u003eRecruitment\u003c/h3\u003e\n\u003cp\u003eConvenient sampling was employed, and recruitment was conducted via email through the Quality Enhancement Office in RCSI. An invitation was emailed to all years 2 and 3 medical students at both institutions (RCSI\u0026thinsp;=\u0026thinsp;750, QUB\u0026thinsp;=\u0026thinsp;540) outlining study details, providing a participant information leaflet and a consent form. Participants could select either the \u003cem\u003eintervention route\u003c/em\u003e (involving pre and post workshop surveys, attendance at one workshop, one post workshop FGD, and a three-month follow up survey) or the \u003cem\u003econtrol route\u003c/em\u003e (completing only pre-workshop and follow up surveys). To encourage retention, participants were rewarded with a certificate of completion and \u0026euro;25 Amazon voucher at the end of data collection.\u003c/p\u003e\n\u003ch3\u003ePROPER intervention\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003ePROPER workshops\u003c/em\u003e: four bespoke educational workshops addressing key MP themes: 1. Maintaining confidentiality; 2. Raising concerns and whistle-blowing; 3. Self-care and wellbeing and 4. Exercising cultural sensitivity. Experts from Ireland, UK, Bahrain, and the United Arab Emirates informed the workshop design using educational theories. Each workshop included a 40 minute group scenario analysis utilising Rolfe\u0026rsquo;s reflection model (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)(Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The scenarios were informed by experts and student panel, with full details provided in our previous publication (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePROPER workshop structure\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStages\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDuration\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eVirtual Online Room\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDetails\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMain room\u003c/p\u003e\u003cp\u003e(All participants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWelcome, introductions and overview of workshop objectives\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDidactic lecture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMain room\u003c/p\u003e\u003cp\u003e(All participants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSummary of pre-workshop materials and theme\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eScenario- analysis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBreakout rooms (4\u0026ndash;5 students; 2 facilitators/room)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eScenario deliberation using Rolfe\u0026rsquo;s reflective model, problem-solving, and clinical reasoning. Working through four scenarios/ workshop theme\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCase-feedback \u0026amp; discussion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMain room\u003c/p\u003e\u003cp\u003e(All participants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReflecting on hidden curriculum challenges, sharing insights, and discussing lessons learned.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWrap up\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 minutes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMain room\u003c/p\u003e\u003cp\u003e(All participants)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFeedback, conclusion and preview future practice.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQuantitative design\u003c/strong\u003e\u003cp\u003eThe PROPER study survey was adapted from Medisauskaite \u003cem\u003eet al.\u003c/em\u003e, (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and validated for relevancy and clarity (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The validated survey assesses participants attitude, subjective norms (SN), perceived behaviour control (PBC) and intentions. The survey also collected demographic data including participant\u0026rsquo;s age, gender, ethnicity and year of study, and was administered online using Survey Monkey\u0026reg;.\u003c/p\u003e\u003c/p\u003e\u003cp\u003ePROPER impact on PB was assessed by analysing changes within the intervention group from pre-workshop to post-workshop. Change from the pre-workshop to three months follow-up were compared between intervention and control group.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQualitative design\u003c/strong\u003e\u003cp\u003eA TPB-based semi-structured guide was developed, piloted, and refined by the research team. Virtual FGDs, audio-recorded with consent, were auto-transcribed, and examined prior to analysis.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were the average scores for attitudes (8 items), SN (12 items), PBC (4 items) and intentions (4 items), which were rated on a 7-point scale.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eEach participant received a unique ID. One week before the workshops, all consenting participants were sent a pre-workshop survey. Intervention participants received an MS Teams invitation and educational resources related to the workshops. Post-workshop, they completed the post workshop survey and received a FGD invitation. Three months later, all participants received a follow-up survey, following GDPR guidelines (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) .\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative analysis\u003c/strong\u003e\u003cp\u003eDemographic information was summarised using descriptive statistics. The average score of each TPB construct was calculated at each time point. Sample t-tests were originally planned for analyses, however given the small sample size and statistical power, differences within the intervention group between pre and post intervention were assessed using non-parametric sign test, while comparisons of pre-workshop to three-months follow-up scores between intervention and control groups utilised Mann-Whitney U test. Statistical analyses were performed using Stata v18 and a p-value\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;0.05 indicated statistical significance.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eQualitative analysis\u003c/strong\u003e\u003cp\u003eThematic analysis followed Braun and Clark\u0026rsquo;s Six stages approach (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Three researchers (AS, SSG and GK) analysed the FGDs using a multi-layered approach, applying a deductive TPB-based coding process. SSG and GK independently coded the first two transcripts before resolve discrepancies with AS. A second inductive analysis followed the same process, ensuring nuances insights during an in-depth analysis.\u003c/p\u003e\u003c/p\u003e\n\u003ch3\u003eTriangulation\u003c/h3\u003e\n\u003cp\u003eQualitative and quantitative results were triangulated using the Cathkin \u003cem\u003eet al.\u003c/em\u003e, triangulation method (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This methodology allowed for comparison and contrast of the findings to uncover convergence (agreement), complementarity (providing additional insights), or dissonance (contradictions).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eSample size\u003c/h2\u003e\u003cp\u003eFor the quantitative arm, power calculations (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5, 90% power, and a significance level of 0.05) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) recommended 40 participants per group and adjusted to 60 for attrition and clustering. However, the final sample was smaller than expected, limiting the study\u0026rsquo;s power to detect small-to-medium effects. For the qualitative arm, a target of 5\u0026ndash;8 participants per session was set to ensure interactive discussions (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Notably, blinding was not implemented as this was a quasi-experimental study.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eParticipant characteristics\u003c/h2\u003e\u003cp\u003eAs presented Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, 41 participants took part in the study (Intervention\u0026thinsp;=\u0026thinsp;31, Control\u0026thinsp;=\u0026thinsp;10). Participants were recruited from two institutions located in the Republic of Ireland (RCSI: n\u0026thinsp;=\u0026thinsp;27, 65.8%) and UK (QUB: n\u0026thinsp;=\u0026thinsp;14, 34.1%). Equal participation was observed from Years 2 and Year 3 students, predominantly female (n\u0026thinsp;=\u0026thinsp;22, 70.7%) and aged 19\u0026ndash;24 years (n\u0026thinsp;=\u0026thinsp;34, 89.9%). Ethnic backgrounds, including Asians (n\u0026thinsp;=\u0026thinsp;24, 58.5%), White (n\u0026thinsp;=\u0026thinsp;12, 29.3%) and Africans (n\u0026thinsp;=\u0026thinsp;5, 12.2%).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTable of demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntervention group (N\u0026thinsp;=\u0026thinsp;31)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eControl\u003c/p\u003e\u003cp\u003egroup (N\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003eparticipants (N\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value*\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eInstitution \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRCSI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (64.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (70.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27 (65.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQUB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (35.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (34.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcademic year\u003c/b\u003e \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e18 (58.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (56.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYear 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (41.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (43.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (71.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (70.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (70.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (25.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (26.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-binary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1 (3.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (2.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (22.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (24.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (35.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (34.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (22.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (30.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (24.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (19.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (17.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e \u003cb\u003en\u003c/b\u003e \u003cb\u003e(%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20 (64.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (40.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24 (58.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7 (22.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (50.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (29.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfrican\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (12.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (12.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eRCSI: Royal College of Surgeons, South of Ireland, Ireland; QUB: Queen\u0026rsquo;s University Belfast, North of Ireland, United Kingdom\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Chi-square test used for larger sample sizes and Fisher\u0026rsquo;s Exact Test when any expected cell count was less than 5.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eQuantitative results\u003c/h2\u003e\u003cp\u003eIn the intervention group, participants were distributed according to preference across four workshops addressing themes of MP: confidentiality (n\u0026thinsp;=\u0026thinsp;11), cultural awareness (n\u0026thinsp;=\u0026thinsp;6), raising concerns (n\u0026thinsp;=\u0026thinsp;6) and selfcare (n\u0026thinsp;=\u0026thinsp;8). The most notable change was observed in PBC for self-care, which significantly improved from pre- to post-workshop (median (IQR): 3.7 (3.2\u0026ndash;4.0) to 5.2 (4.9\u0026ndash;5.3); p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). For other constructs, improvements were observed but did not reach statistical significance. For example, PBC for cultural awareness increased (5.8 (4.5\u0026ndash;6.0) to 6.5 (6.3\u0026ndash;6.8); p\u0026thinsp;=\u0026thinsp;0.06), and intentions to raise concerns rose slightly (5.2 (4.7\u0026ndash;5.5) to 5.5 (5.0\u0026ndash;6.0); p\u0026thinsp;=\u0026thinsp;0.06). Other TPB items showed similar directions of change, except for attitudes to cultural awareness, subjective norms for raising concerns and self-care, and intentions for cultural awareness, where decreases or no improvements were observed (Additional File 1). Other items show positive trends although interpretation is limited by sample size. There was no evidence of a difference from pre-workshop to three-month follow-up when comparing intervention and control groups (Additional File 1).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eQualitative results\u003c/h2\u003e\u003cp\u003eTwenty-four participants from the intervention group engaged in 5 online FGD post-workshop, unaware of quantitative results. Each FGD included 4\u0026ndash;5 participants and one facilitator and was approximately 60 minutes in duration. Using the four TPB constructs, analysis revealed four themes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eAttitude: perspective enhancement\u003c/h2\u003e\u003cp\u003eParticipants reported enhanced perspectives on MP, enabling them to challenge previous assumptions and beliefs. Participants repeatedly conveyed that PROPER prompted them to re-examine preconceptions about MP\u0026rsquo;s role in students' lives and in clinical practice. This reflected a contextual understanding of MP that evolves with learning.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think also just being aware of the kind of scenarios where I used to think that professionalism didn't matter, but realizing that it does matter.., definitely it's helped me be a lot more aware of how I act\" Student_23\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis shift suggested a deeper, context-dependent understanding of MP as a phenomenon requiring ongoing reflection.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Once you scratch the surface, you realized how much there is below\u0026hellip; There's so much to this!\" Student_11\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSubjective norms: Strengthening axiology\u003c/h2\u003e\u003cp\u003eSNs reflected as strengthened axiology, a deepening understanding of values. Participants articulated a strengthened sense of their professional values, enhancing their decision-making abilities in professional contexts.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I just feel like as long as I have my views and my views are in charge and I still believe in them, I'll be able to be more professional\"\u003c/em\u003e Student_04\u003c/p\u003e\u003cp\u003eThey emphasised the importance of having clear professional beliefs for building patient trust.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If hidden curriculum is shared with patients and they understand that we are working on it and trying to improve it, it will make them feel safer and build more trust in the medical professional in a way\"\u003c/em\u003e Student_22\u003c/p\u003e\u003cp\u003eHowever, some concerns were raised about how certain peers\u0026rsquo; attitudes towards professionalism could undermine their axiological belief growth or their practice development.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Older generations who are not open minded to changes in how the medical professional is perceived or people think professionalism is a waste of time\u0026hellip;and some professors who really don't agree with professionalism\" Student_03\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePerceived behaviour control: Enabling Self\u003c/h2\u003e\u003cp\u003eFrom PBC analysis emerged \u0026lsquo;enabled self\u0026rsquo; which was characterised by increased confidence in handling future professional dilemmas. Many participants felt reassured about their knowledge and abilities post-workshop. Small group discussions further solidified these understandings.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;You're getting reassurance that you know what's right to do and that you can put it into practice because you've thought through those experiences\u0026hellip;. And I think that I was aware of what to do before, but I think the workshop reiterated that and consolidated my like knowledge\"\u003c/em\u003e Student_20\u003c/p\u003e\u003cp\u003eHowever, some participants expressed the need for continued reinforcement of the newfound self-efficacy.\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI feel a bit more confident than prior to the study, but I'm still not 100% confident in myself and my ability\u0026hellip; But hopefully I guess by the time that would be 100%\u0026rdquo;\u003c/em\u003e Student_16\u003c/p\u003e\u003cp\u003eParticipants feared medical hierarchical practices could undermine confidence, influencing their PB practices.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I could look at the guidelines of the PROPER study and try to do something, but if my superior is not OK with that, even if I want to do the change and I'm unable to do the change\"\u003c/em\u003e Student_22\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eIntentions: Dialogic reflection\u003c/h2\u003e\u003cp\u003eIntentions manifested as dialogic reflections, demonstrating improved risk assessment capabilities and ability to reflect critically on their actions.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I think I've already applied at least some of them while being in clinical practice and kind of noticed the bias and the differences in my thinking that I've noticed after doing one of the workshops\"\u003c/em\u003e Student_14\u003c/p\u003e\u003cp\u003eParticipants articulated their improved confidence in rationalising the right approaches, and consider translating acquired theoretical insights to future professional practices.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"Overall, my confidence has increased, but I think it'll increase as I actually have to deal with real life situations and I take the initiative to use them to use the PROPER study hidden curriculum\"\u003c/em\u003e Student_23\u003c/p\u003e\u003cp\u003eDialogic reflections also revealed that participants felt empowered to express their views and challenge the existing hierarchy constructively.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think I'm more vocalizing now. I'm trying to tell them [seniors] in the politest way and raise concerns when needed even in work or anywhere out of work.\u0026hellip;. Before I used to not say anything\"\u003c/em\u003e Student_23\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eTriangulation\u003c/h2\u003e\u003cp\u003eQuantitative and qualitative results were triangulated using O\u0026rsquo;Cathain \u003cem\u003eet al.\u0026rsquo;s framework\u003c/em\u003e, summarising themes in a table to compare results interpretable for convergence, complementarily and discrepancies. This method facilitated deeper understanding and interpretation of the combined results (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTriangulation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuantitative\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualitative\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttitude\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo significant improvement in attitudes towards raising concerns\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEnhanced perspectives and understanding of MP attitudes\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo significant improvement in subjective norms across MP theme\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrengthened values and beliefs within social structures, alongside barriers and facilitators, were recorded.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePBC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSignificant improvement in PBC related to selfcare and some evidence of improvement towards cultural awareness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncreased confidence in engaging in professional practices, though hierarchical practices were seen as a threat to the confidence and newly acquired MP understandings.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntentions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSome evidence of improvement in intentions to raising concerns\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDialogic reflections showed improved ability to assess benefits and threats of actions in professionalism in practice.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBehaviour change Sustainability\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo significant sustained impact on behaviour change over time compared to control group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eParticipants emphasized the need for iterative efforts to maintain self-efficacy and confidence.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eMP: Medical professionalism; PBC: Perceived behaviour control\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eMP education is an essential component of undergraduate teaching. PROPER workshops resulted in some evidence of improvements in a number of behaviour constructs towards raising concerns, self-care and cultural awareness. Qualitative findings revealed four emergent themes that provided further details to the improvement journey in PB, these included: \u003cem\u003eperspective enhancement\u003c/em\u003e, \u003cem\u003estrengthening axiology\u003c/em\u003e, \u003cem\u003eenabling self\u003c/em\u003e, and \u003cem\u003edialogic reflection\u003c/em\u003e. These findings emphasize the impact of PROPER on personal growth and readiness of medical students to act professionally. However, contextual barriers (\u003cem\u003ee.g.\u003c/em\u003e, hierarchy), were reported to have hindered the students\u0026rsquo; significant improvement and the perceived readiness for long-term translation of intentions into behaviour changes. Moreover, PROPER demonstrates the feasibility of delivering professionalism-focused education online across two institutions.\u003c/p\u003e\u003cp\u003eWhile attitudes scores showed no statistical improvements towards raising concerns but rather a positive trend using the sign test, qualitative evidence revealed participants' expanded understanding of MP and its clinical importance. Perspective enhancement evidenced a revaluation of MP\u0026rsquo;s significance in clinical practice, mirroring emerging research that highlights the importance of cognitive understanding in shaping professional identity formation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). This shift reflects a deeper cognitive evolution beyond surface-level understanding. These results resonate with findings from previous systematic reviews emphasising the benefits of structural educational frameworks and reflective practices (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Johnsen et al., (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) also suggested that similar interventions can ease inner conflict in raising concerns, emphasizing the complexity of attitudes and the need for targeted strategies to ensure patient safety. PROPER workshops have contributed to enabling undergraduate students\u0026rsquo; ability to internalize professional values by emphasizing professionalism learning. This targeted approach fosters deeper reflection, ethical awareness, and behavioural integration of core professional standards. While quantitative analysis showed no significant changes in SNs, qualitative data indicated a notable development in participants' professional values, particularly through external validation from peers and patients. This observation aligns with the intervention\u0026rsquo;s design, which is grounded in social constructivist theory (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). This approach emphasises learning within the zone of proximal development, where social interactions, shared experiences and cultural/social context facilitate the assimilation of sociocultural behaviours and transformation of learner identities (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Additionally, participants recalibrated their moral compasses, reflecting strengthened axiology, where learners construct understanding through social engagement (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). However, the lack of quantitative change of SNs may reflect measurement limitations, which might not capture the nuanced shifts more observable through qualitative methods. Literature suggests that SNs are context-dependent, and challenging to quantify effectively (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003ePROPER results reveal these challenges in form of traditional professionalism perspectives which students reported to be held by senior healthcare professionals, which can act as a barrier to student\u0026rsquo;s PB developments. Medical students often model their behaviours on their supervisors\u0026rsquo;, adopting their values and behaviours, despite undergoing attitudinal shifts (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This can suppress the evolution of professional identity aligned with modern professional standards (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). This highlights the need to promote evidence-based PBs that reflect current ethical standards, inclusivity, and patient-centred care rather than hierarchical norms. PROPER aims to integrates these values into educational curricula, allowing students to internalize PBs consistent with evolving societal expectations (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). This alignment creates a supportive learning environment where students can challenge traditional perceptions, prioritise collaboration and ensure patient safety.\u003c/p\u003e\u003cp\u003eQuantitative findings revealed statistically significant and potentially meaningful improvements in PBC, particularly in self-care and cultural awareness. These results were reinforced by qualitative insights, where participants expressed increased potential confidence in applying the professional behaviours acquired during the clinical stage of education and practice. The PROPER workshops validated existing knowledge taught on professionalism topics embedded within other courses within RCSI participants, strengthening participants' belief in their professional abilities. However, confidence was perceived as context-dependent, potentially threatened by hierarchical environments that undermine PBC. This suggests that increased PBC may not drive behaviour change if barriers are present (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). These findings suggest the necessity for parallel interventions to mitigate hierarchical norms in clinical settings, fostering an environment where professionals can express their behaviours without structural limitations. This observation is consistent with the TPB framework, which suggests that increased PBC does not always lead to behaviour change when situational constraints exist (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). The literature identifies PBC as a challenging construct due to its complexity (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Research on PBC within medical education remains scarce and while some interventions (i.e., workshops) aimed at modifying PBC have inconsistent results, comprehensive strategies remain limited (\u003cspan additionalcitationids=\"CR43\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The novelty of our PROPER intervention lies in its design, incorporating collective reflections using Rolfe\u0026rsquo;s model, and expert guidance to address real-world scenarios (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This approach fostered self-efficacy, psychological safety and PB. Aligning with Mann et al., our findings on reflective processes deepens professional awareness, examine assumptions and readiness for professionalism in practice (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Additionally, large group discussions in PROPER workshops helped reinforce new insights, challenges, and strengthen PBC among participants.\u003c/p\u003e\u003cp\u003eIn a similar manner, potential improvements in intention to raising concerns scores were reinforced by qualitative insights, revealing participants' engagement in dialogic reflections. The correlation between intentions and behaviour within our framework, is well-documented; for instance, Henderman \u003cem\u003eet al.\u003c/em\u003e, highlighted TPB-based intentions reliably predict behaviour change (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). PROPER workshops have the potential to foster this introspection among medical students; however challenges remain in students\u0026rsquo; perception of sustaining PB and duration of intervention. Contextual and cultural barriers, particularly hierarchical norms and fears of repercussions for raising concerns, further impeded potential behavioural shifts, despite gains in knowledge, confidence and self-reflection in our cohort (\u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Addressing these barriers alongside educational interventions is crucial to create an environment where PB can be enacted without fear of negative consequences thus supporting the translation of professionalism learning into practice.\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003ePROPER is a theory-based project, designed to enhance MP education for culturally diverse students from two different institutions in Northern and Southern Ireland, employing mixed method, quasi-experimental design. Experts and students co-developed PROPER workshops to ensure relevance, and validated questionnaires to accurately assess behaviour change. The virtual format of the intervention had improved accessibility and engagement of students from geographically diverse regions.\u003c/p\u003e\u003cp\u003eThe study faced several limitations. First, recruitment challenges led to a limited quantitative sample size, which constrained statistical power and precluded advanced analyses such as sustainability comparisons and structural equation modelling. On reflection, embedding the study within the formal curriculum with optional consent to participate in research may have enhanced both recruitment and retention, but was not considered logistically possible across two separate institutions. Second, the self-selection of participants into intervention and control groups may have introduced selection bias due to unmeasured baseline differences. Third, the lack of a control group at immediate post-intervention (Time 2) for comparison. Forth, issues related to data sufficiency and the potential loss of subthemes were noted in both the quantitative and qualitative analyses. While these constraints are acknowledged, the integration of qualitative and quantitative data through methodological triangulation was intentionally employed to enhance the credibility and depth of the results. Triangulation does not eliminate the limitations associated with sample size but provides complementary insights that strengthen the internal validity and contextual understanding of the intervention\u0026rsquo;s effects. However, the study provides meaningful insights into the intervention\u0026rsquo;s impact within a naturally occurring, self-directed educational context. Furthermore, the qualitative findings offer rich, contextualized perspectives that may inform a blueprint for future MP educational interventions at different institutions and geographics. Future research with larger and more diverse samples is warranted to confirm and extend these findings.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePROPER offers a promising blueprint for online professionalism education, combining structured learning and reflection to foster collaboration and cultural competence. While improvements in PB were noted, hierarchical norms and limited clinical experience may have constrained long-term change. Future interventions should target barriers via faculty development and experiential strategies to translate professional identity formation and foster behaviour change in clinical practice\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePROPER\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProfessionalism in Partnership for Education Research\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedical professionalism\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eProfessional Behaviour\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTPB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTheory of Planned Behaviour\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSubjective norms\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePerceived Behaviour Control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eEthical approval\u003c/h2\u003e\u003cp\u003ewas sought and obtained from the Research Ethics Committee of the RCSI (REC202205007) and QUB (MHLS 22_184) prior to commencement and the study adhered to the Declaration of Helsinki to this effect. Informed consent obtained from all the participants prior to any data collection.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003cp\u003eNot applicable, this manuscript does not contain identifiable data from an individual participant. All authors have reviewed and approved consent to participate and publication of the manuscript.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting of interest\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAsil Sadeq\u003c/h2\u003e\u003cp\u003eAsil Sadeq, is the funded researcher for the PROPER study, RCSI University of Medicine and Health Sciences.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThe author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This project is funded by the Higher Education Authority, North\u0026ndash;South Research program granted to the RCSI [PI (DH), grant number 21578A01].\u003c/p\u003e\u003ch2\u003eAuthor contribution:\u003c/h2\u003e\u003cp\u003eAll authors (AS, SSG, GPK, AR, EC, MS, AB, SH, SYG, FD, FB, MH, DWH) confirm their contribution to the study inception, design, execution, data collection, analysis and interpretation, manuscript writing and reviewing.\u003c/p\u003e\u003ch2\u003eAcknowledgement:\u003c/h2\u003e\u003cp\u003eWe thank the Quality Enhancement Office at the RCSI, Dublin and students at the RCSI, Dublin and QUB for their contribution and support.\u003c/p\u003e\u003cp\u003e\u003cb\u003eClinical trial number\u003c/b\u003e: Not applicable.\u003c/p\u003e\u003ch2\u003eAvailability of data and material:\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMcGurgan P, Calvert KL, Narula K, Celenza A, Nathan EA, Jorm C (2020) Medical students' opinions on professional behaviours: The Professionalism of Medical Students' (PoMS) study. 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Harvard University Press\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuraya SS, Yusoff MSB, Rashid-Doubell F, Harkin DW, Al-Amad SH, Fredericks S et al (2022) Changing professional behaviors in the digital world using the medical education e-professionalism (MEeP) framework\u0026mdash;a mixed methods multicentre study. Front Med 9:846971\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSwick HM, Szenas P, Danoff D, Whitcomb ME (1999) Teaching professionalism in undergraduate medical education. JAMA 282(9):830\u0026ndash;832\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoldie J (2013) Assessment of professionalism: a consolidation of current thinking. Med Teach 35(2):e952\u0026ndash;e6\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGryka R, Kiersma ME, Frame TR, Cailor SM, Chen AM (2017) Comparison of student confidence and perceptions of biochemistry concepts using a team-based learning versus traditional lecture-based format. 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Med Teach 38(8):769\u0026ndash;786\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eArcher E, Bitzer E, Van Heerden B (2017) Interrogating patient-centredness in undergraduate medical education using an integrated behaviour model. South Afr Family Pract 59(6):219\u0026ndash;223\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMann K, Gordon J, MacLeod A (2009) Reflection and reflective practice in health professions education: a systematic review. Adv Health Sci Educ 14:595\u0026ndash;621\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHardeman W, Johnston M, Johnston D, Bonetti D, Wareham N, Kinmonth AL (2002) Application of the theory of planned behaviour in behaviour change interventions: A systematic review. Psychol health 17(2):123\u0026ndash;158\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO'Donovan R, De Br\u0026uacute;n A, McAuliffe E (2021) Healthcare professionals experience of psychological safety, voice, and silence. Front Psychol 12:626689\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJones A, Kelly D (2014) Whistle-blowing and workplace culture in older peoples' care: qualitative insights from the healthcare and social care workforce. Sociol Health Illn 36(7):986\u0026ndash;1002\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRees CE, Monrouxe LV, Ajjawi R (2014) Professionalism in workplace learning: understanding interprofessional dilemmas through healthcare student narratives. Exploring the dynamics of personal, professional and interprofessional ethics. Policy, pp 295\u0026ndash;310\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Royal College of Surgeons in Ireland","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical Professionalism, Educational interventions, e-learning, theory of planned behaviour, professional behaviour, mixed methods, cultural sensitivity, undergraduate students","lastPublishedDoi":"10.21203/rs.3.rs-8132875/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8132875/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMedical education must ensure medical students graduate with the appropriate values, attitudes, and behaviours that allow them to work collaboratively with patients and families from a range of diverse cultural backgrounds. The PROfessionalism in Partnership for Education Research (PROPER) study aimed to assess the impact of an online educational intervention on medical professionalism for undergraduate medical students in two jurisdictions, focusing on behaviours and cultural sensitivity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PROPER study employed a quasi-experimental, mixed-methods design underpinned by the Theory of Planned Behaviour (TPB). The intervention comprised four online workshops, using scenario analyses and reflective practices, addressing confidentiality, raising concerns, self-care, and cultural awareness. Quantitative survey data were collected at three time points (pre- and post- workshop and three months follow-up) and qualitative data were obtained through focus group discussions (FGDs). Quantitative analyses included paired and independent t-tests, while qualitative data were analysed thematically.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eForty-one participants (intervention = 31, control = 10) were included. The most notable change was observed in perceived behaviour control for self-care, which significantly improved from pre- to post-workshop (\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). For other constructs, improvements were observed but did not reach statistical significance. Other TPB items showed similar directions of change, where decreases or no improvements were observed. FGDs (n = 5, 24 participants) analysis identified four key themes across the combined workshops: perspective enhancement, enabling self, dialogic reflection, and strengthening axiology. These themes highlighted evidence in increased self-awareness, confidence, and the early development of professional values among participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite limited statistical evidence, qualitative insights suggest PROPER intervention may be a promising model for online undergraduate professionalism education, combining a structured programme and reflection to enhance collaboration and cultural competence. Challenges such hierarchical norms, structural barriers and participants’ relative lack of clinical experience were perceived to limit long-term behaviour change. More evidence is needed in this area, focusing on incorporating experiential learning and addressing contextual barriers at a larger sample size to sustain professionalism alongside supporting professional identity formation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not Applicable\u003c/p\u003e","manuscriptTitle":"PROfessionalism in Partnership for Education Research (PROPER) study: A Novel Online Initiative Approach to Professionalism Education","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 14:42:42","doi":"10.21203/rs.3.rs-8132875/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c5ee77b-c17f-4dea-8d28-5f8ded527c63","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":58094327,"name":"Medical Ethics"}],"tags":[],"updatedAt":"2025-11-19T14:42:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 14:42:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8132875","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8132875","identity":"rs-8132875","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}