Dentistry, Faculty of
DSpace
UBCV
Kwon, Jennifer Hye Eun
Doctor of Philosophy - PhD
University of British Columbia
Background: Professionalism in healthcare encompasses clinical competence, effective communication, ethical understanding, and humanistic attributes. It is a key component in dental education mandated by accreditation bodies in Canada and the U.S. However, the lack of a universally agreed-upon definition, inconsistent teaching approaches, and role modelling make it difficult to implement. Additionally, competitive market pressures and shifting social and economic priorities further challenge efforts to instill professionalism, even among experienced practitioners. Professional identity formation (PIF), which emphasizes the process of "becoming" a professional, may offer a potential pathway for fostering consistent and enduring professionalism in oral healthcare practitioners. Objectives: This dissertation explores key factors shaping PIF and its connection to professionalism among dental students and practicing dentists. It further seeks to offer insights into actionable recommendations for enhancing professionalism education through the lens of PIF. Methods: Surveys and semi-structured interviews were conducted with dental students and practicing dentists. Data analysis included descriptive statistics, thematic analysis, template analysis, and axiological analysis. Results: While professionalism is seen as essential, some participants questioned whether values like empathy, honesty, and respect can be fully taught. Key influences on student PIF included domain-specific self-efficacy, role modelling, peer interaction, the learning environment, and reflection. Students recommended embedding professionalism more fully across the curriculum, improving assessment, and promoting professional culture among faculty. For practitioners, PIF was shaped by work experience, personality and upbringing, education, and the title of “doctor.” However, findings suggested a potential disconnect between professional identity and ethical conduct, suggesting that experience alone, without deliberate reflection, may not ensure ethical behaviour. Dentists also noted gaps in ethics and interprofessional education, recommending enhanced professionalism training, stronger institutional oversight, and supportive work environments. Conclusion: While professionalism is highly valued, cultivating core values such as empathy, honesty, and respect may require a more comprehensive approach beyond traditional instruction, which often emphasizes knowledge acquisition and technical skills over the deeper, reflective aspects of professional identity. Integrating professionalism education throughout the curriculum and positioning PIF as a central goal could support ethical and humanistic development.
UNVEILING THE IMPLICIT: EXPLORING PROFESSIONALISM AND PROFESSIONAL IDENTITY FORMATION IN DENTISTRY by Jennifer Hye Eun Kwon B.Sc., The University of British Columbia, 2005 M.A. University of London, 2018 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Craniofacial Science) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) May 2025 © Jennifer Hye Eun Kwon, 2025 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: UNVEILING THE IMPLICIT: EXPLORING PROFESISONALISM AND PROFESSIONAL IDENTITY FORMATION IN DENTISTRY submitted by Jennifer Hye Eun Kwon in partial fulfilment of the requirements for the degree of Doctor of Philosophy in Craniofacial Science Examining Committee: Dr. HsingChi von Bergmann, Professor, Department of Oral Health Sciences, UBC Supervisor Dr. Charles Shuler, Professor, Department of Oral and Biological Medical Sciences, UBC Supervisory Committee Member Dr. Judith Walker, Associate Professor, Department of Educational Studies, UBC Supervisory Committee Member Dr. Jolanta Aleksejuniene, Professor, Department of Oral Health Sciences, UBC University Examiner Dr. David Silver, Associate Professor, Sauder School of Business, UBC University Examiner Dr. Michael Botelho, Professor, Faculty of Dentistry, University of Hong Kong External Examiner iii Abstract Background: Professionalism in healthcare encompasses clinical competence, effective communication, ethical understanding, and humanistic attributes. It is a key component in dental education mandated by accreditation bodies in Canada and the U.S. However, the lack of a universally agreed-upon definition, inconsistent teaching approaches, and role modelling make it difficult to implement. Additionally, competitive market pressures and shifting social and economic priorities further challenge efforts to instill professionalism, even among experienced practitioners. Professional identity formation (PIF), which emphasizes the process of "becoming" a professional, may offer a potential pathway for fostering consistent and enduring professionalism in oral healthcare practitioners. Objectives: This dissertation explores key factors shaping PIF and its connection to professionalism among dental students and practicing dentists. It further seeks to offer insights into actionable recommendations for enhancing professionalism education through the lens of PIF. Methods: Surveys and semi-structured interviews were conducted with dental students and practicing dentists. Data analysis included descriptive statistics, thematic analysis, template analysis, and axiological analysis. Results: While professionalism is seen as essential, some participants questioned whether values like empathy, honesty, and respect can be fully taught. Key influences on student PIF included domain-specific self-efficacy, role modelling, peer interaction, the learning environment, and iv reflection. Students recommended embedding professionalism more fully across the curriculum, improving assessment, and promoting professional culture among faculty. For practitioners, PIF was shaped by work experience, personality and upbringing, education, and the title of “doctor.” However, findings suggested a potential disconnect between professional identity and ethical conduct, suggesting that experience alone, without deliberate reflection, may not ensure ethical behaviour. Dentists also noted gaps in ethics and interprofessional education, recommending enhanced professionalism training, stronger institutional oversight, and supportive work environments. Conclusion: While professionalism is highly valued, cultivating core values such as empathy, honesty, and respect may require a more comprehensive approach beyond traditional instruction, which often emphasizes knowledge acquisition and technical skills over the deeper, reflective aspects of professional identity. Integrating professionalism education throughout the curriculum and positioning PIF as a central goal could support ethical and humanistic development. v Lay summary Professionalism is essential in preparing students to become licensed dentists. This study explores how dental students and practicing dentists develop professional identity and how professionalism might be better addressed in education. Surveys and interviews were conducted with dental students and dentists to understand factors influencing their professional identity. The results suggest that while professionalism is valued, core attributes like empathy, honesty, and respect may not be fully teachable in classrooms; real-life experiences were seen as essential, though not always sufficient without intentional reflection. Key influences on students’ professional identity included role models, self-efficacy, peer interactions, and reflection. Students recommended integrating professionalism across the curriculum and improving assessments and faculty support. For practicing dentists, work experience, personality, education, and the title of “doctor” were identified as shaping their identity. Overall, the findings highlight the need to embed professionalism intentionally throughout dental education to support the development of ethical, well-rounded professionals. vi Preface This dissertation is an original and independent work by Jennifer Kwon. As the lead author, I was responsible for developing the research proposal, securing ethics approval, designing the study, collecting data, and conducting the data analyses for the studies presented in this dissertation, employing thematic analysis, template analysis, descriptive statistics, and axiological analysis. The data for this study were collected through online surveys and semi-structured interviews with dental students and practitioners in British Columbia, Canada. Additionally, secondary interview data from the UBC Progress Survey Testing Program (2015-2019), developed by my supervisor, Dr. von Bergmann, were analyzed to identify key factors contributing to dental students’ professional identity formation. All studies in this dissertation were approved by the Behavioural Research Ethics Board at the University of British Columbia (UBC), with Ethics ID numbers H16-00957, H20-03728, and H21-03350. Two studies utilized different portions of data from the same data collection (H20-03728), though they focused on different aspects of professionalism. This dissertation comprises eight chapters: Chapter 1 provides an overview of the study, including the background, literature review, and motivation for pursuing this research. By incorporating my motivation at the outset, I aim to highlight the significance and relevance of this topic while conveying its meaning and importance to me as a researcher. vii Chapter 2 outlines the identified knowledge gaps, study rationale, objectives, sub-objectives, and research questions. It describes the conceptual framework of the dissertation and provides a brief overview of the methods used in the studies. Chapter 3 presents Study 1, which explores the key contributors influencing dental students’ professional identity formation, using secondary data from the Progress Survey Testing Program (UBC 2015-2019) developed by my supervisor, Dr. von Bergmann. The study addresses what influences dental students’ professional identity formation and the challenges they encounter in adopting their new professional identity. I prepared the manuscript, which was reviewed and edited by collaborators. A version of this paper is published in the Journal of Dental Education as: Kwon JH, Shuler CF, von Bergmann H. Professional identity formation: The key contributors and dental students’ concerns. J Dent Educ. 2022;86(3):288-297. This study received the Top Cited Article Award 2022-2023 as one of the most cited papers between January 1st, 2022 and December 2023 in the Journal of Dental Education. Chapter 4 presents Study 2, which examines students’ perspectives on professionalism through a two-part online survey. The first part consists of twelve slider questions designed to examine students’ perspectives on the integration of professionalism into their education. The second part includes four open-ended questions focusing on students’ definitions of professionalism, motivation for entering the program, key qualities they associate with being a dentist, and recommendations for enhancing professionalism education. The results from the slider questions are analyzed quantitatively using mean and standard deviation, while the results from the four open-ended questions are analyzed qualitatively using thematic analysis. viii Chapter 5 presents Study 3, which builds on the findings from Studies 1 and 2 but shifts the focus to practicing dentists. Investigating the perspectives of practicing dentists is critical, as their lived experiences in professional practice provide insights into how professionalism and professional identity evolve beyond the educational setting. This study examines the participating dentists’ perceptions of professionalism, the barriers they face in their workplaces, key influences on their professional identity formation, and their recommendations for improving professionalism education. Template analysis was used to analyze the data. Chapter 6 presents a synthesis of the findings of Studies 1, 2, and 3. While some overlap exists with the previous chapters, this chapter clarifies how each study’s findings contribute to the broader discussion of professional identity formation in dental education. Chapter 7 introduces a pedagogical tool aimed at fostering professional identity formation within dental ethics classrooms. Informed by the findings from earlier studies, this study explores the use of ethical dilemmas and axiological analysis to examine the underlying value conflicts in students’ clinical decision-making. Through a survey, students responded to two short-answer questions, and their responses were analyzed using axiological analysis to identify and examine value conflicts. Chapter 8 concludes the dissertation with a comprehensive discussion, conclusions, and directions for future research. It highlights the implications of the findings for dental education. ix Since the four studies were conducted independently, some overlap may exist in the introduction and literature review sections of each study. While efforts were made to minimize redundancy, some repetition remains where necessary to maintain clarity and coherence across the studies. Following the submission of this dissertation, revised versions of Studies 2, 3, and 4 will be submitted for journal publications. Generative AI (Open AI) was used solely for grammar and spelling checks in the preparation of this dissertation. All ideas, content, study design, analysis, and manuscript writing are the original work of the author. x Table of Contents Abstract........................................................................................................................................ iii Lay Summary................................................................................................................................ v Preface.......................................................................................................................................... vi Table of Contents.......................................................................................................................... x List of Tables.............................................................................................................................. xvi List of Figures........................................................................................................................... xvii List of Abbreviations................................................................................................................. xix Acknowledgements..................................................................................................................... xx Dedication................................................................................................................................... xxi Chapter 1: Introduction............................................................................................................... 1 1.1 Dentistry as a Profession and Social Contract.......................................................................... 1 1.2 Motivation for the Study........................................................................................................... 2 1.3 Defining Professionalism, Its Concept and Evolution.............................................................. 4 1.3.1 Historical Development and Professionalization of Dentistry................................... 8 1.3.2 Contemporary Challenges in Dental Professionalism in North America................ 10 1.4 Understanding Professionalism: Shared Themes and Models................................................ 11 1.5 Exploring the Three Dominant Frameworks of Professionalism........................................... 13 1.5.1 Dominant Framework I: Virtue-Ethics (Person-based)........................................... 13 1.5.1.1 Virtue Ethics in Professional Roles.......................................................... 15 1.5.1.2 Criticism for Virtue Ethics........................................................................ 16 1.5.2 Dominant Framework II: Principlism (Behaviour-based)....................................... 16 1.5.2.1 Principlism and Dental Ethics Education in North America................................ 18 xi 1.5.2.2 Criticism for Principlism........................................................................... 20 1.5.3 Dominant Framework III: Professional Identity Formation (Process-based).......... 20 1.5.3.1 Defining Professional Identity Formation................................................ 20 1.5.3.2 Limitations of the Current Professionalism Education and the Emergence of Professional Identity in Healthcare Education................................................. 21 1.5.3.3 Amending Miller’s Pyramid to Include Professional Identity Formation..24 1.5.3.4 Framework to Understand Professional Identity Formation in Adults: Robert Kegan’s Stages/Orders of Mind.................................................... 25 1.6 Next Chapter........................................................................................................................... 28 Chapter 2: Research Rationale, Objectives, and Methodological Framework..................... 29 2.1 Knowledge Gap and Study Rationale..................................................................................... 29 2.2 Research Objectives................................................................................................................ 30 2.2.1 Overarching Objectives........................................................................................... 30 2.2.2 Sub-Objectives and Research Questions................................................................. 30 2.3 Methodological Framework.................................................................................................... 34 2.4 Next Chapter........................................................................................................................... 36 Chapter 3: Cumulative Findings from Studies Dental Students’ Professional Identity Formation: The Key Contributors and Their Influences....................................................... 37 3.1 Summary................................................................................................................................. 37 3.2 Introduction............................................................................................................................. 39 3.3 Methods................................................................................................................................... 40 3.3.1 Context of the Previous Study................................................................................. 41 3.3.2 Data Analysis........................................................................................................... 42 xii 3.4 Results and Discussion........................................................................................................... 43 3.5 Conclusion.............................................................................................................................. 57 3.6 Next Chapter........................................................................................................................... 58 Chapter 4: Navigating Professional Identity Formation: Insights and Challenges in Dental Student Professionalism............................................................................................................. 59 4.1 Summary..................................................................................................................................59 4.2 Introduction..............................................................................................................................61 4.3 Methods................................................................................................................................... 63 4.3.1 Survey Development................................................................................................ 64 4.3.2 Sampling and Administration of the Survey............................................................ 65 4.4 Results and Discussion........................................................................................................... 66 4.4.1 Part 1: Slider Questions........................................................................................... 66 4.4.2 Part 2: Short Answer Questions............................................................................... 68 4.5 Conclusion.............................................................................................................................. 82 4.6 Next Chapter........................................................................................................................... 82 Chapter 5: Professionalism and Professional Identity Formation Among Practicing Dentists: A Template Analysis Study........................................................................................ 83 5.1 Summary................................................................................................................................. 83 5.2 Introduction............................................................................................................................. 85 5.3 Method.................................................................................................................................... 86 5.3.1 Study Design and Participants................................................................................. 86 5.3.2 Data Collection and Consent................................................................................... 88 5.3.3 Data Analysis: Template Analysis........................................................................... 88 xiii 5.4 Results..................................................................................................................................... 90 5.4.1 Domain One: Dentists’ Perspectives on Professionalism........................................ 91 5.4.1.1 Comparison Between Students’ and Dentists’ Definitions of Professionalism..................................................................................................... 92 5.4.2 Domain Two: Barriers and Challenges at Workplaces............................................ 94 5.4.3 Domain Three: Dentists’ Recommendations for Enhancing Professionalism......... 95 5.5 Discussion............................................................................................................................. 106 5.6 Conclusion............................................................................................................................ 112 5.7 Next Chapter......................................................................................................................... 113 Chapter 6: Cumulative Findings from Studies One, Two, and Three................................. 114 6.1 Introduction........................................................................................................................... 114 6.2 Threats to Professional Identity Formation: Dental Students’ Perspectives......................... 114 6.3 Professionalism Challenges: Workplace Barriers and Challenges Experienced by Interviewed Dentists....................................................................................................................................... 116 6.4 Students’ Suggestions for Enhancing Professionalism Education........................................ 117 6.5 Dentists’ Suggestions for Enhancing Professionalism Education........................................ 119 6.6 Common Suggestions from Students and Dentists for Enhancing Professionalism Education.................................................................................................................................... 120 6.7 Lessons Learned from Studies One, Two, and Three........................................................... 121 6.8 Next Chapter......................................................................................................................... 124 Chapter 7: A Pedagogical Strategy to Promote Professional Identity Formation in Ethics Classrooms..................................................................................................................................126 7.1 Summary............................................................................................................................... 126 xiv 7.2 Introduction........................................................................................................................... 128 7.3 Methods................................................................................................................................. 132 7.3.1 Scenario Development, Participants, and Data Collection.................................... 132 7.3.2 Data Analysis......................................................................................................... 134 7.4 Results................................................................................................................................... 135 7.4.1 Analysis Findings from Scenario One................................................................... 135 7.4.2 Analysis Findings from Scenario Two.................................................................. 140 7.5 Discussion............................................................................................................................. 143 7.5.1 Suggestions for Educators...................................................................................... 146 7.5.2 Limitations and Future Considerations.................................................................. 147 7.6 Conclusion............................................................................................................................ 148 7.7 Next Chapter......................................................................................................................... 149 Chapter 8: Discussion, Conclusions, and Future Directions................................................ 150 8.1 Introduction........................................................................................................................... 150 8.2 Key Lessons and Recommendations.................................................................................... 151 8.3 Conclusions.......................................................................................................................... 154 8.4 Study Limitations................................................................................................................. 155 8.5 Future Directions.................................................................................................................. 156 Bibliography.............................................................................................................................. 157 Appendices................................................................................................................................. 174 Appendix A: Study 2 Student Consent Form............................................................................. 174 Appendix B: Study 3 Dental Professionalism Interview Guide................................................. 177 Appendix C: Study 3 Dental Professionalism Interview Study Email....................................... 178 xv Appendix D: Study 3 Consent Form........................................................................................... 179 xvi List of Tables Table 1-1: Kegan’s Stages/Orders of Mind.................................................................................. 27 Table 2-1: Summary of the Dissertation Research Objectives and Questions............................. 31 Table 2-2: A Brief Overview of Methods Employed in Each of the Four Studies....................... 35 Table 3-1 Themes and Concepts Identified from Open Coding................................................... 44 Table 3-2 Components of Professional Identity........................................................................... 46 Table 4-1 DMD Students’ Perspectives on Their Professionalism Education............................. 67 Table 4-2 Students’ Recommendations for Enhancing Their Professionalism Education........... 76 Table 5-1 Demographics of the Study Participants...................................................................... 88 Table 5-2 Barriers and Challenges Experienced by the Interviewed Dentists.............................. 95 Table 6-1 Students’ Suggestions for Enhancing Professionalism Education............................. 117 Table 7-1: Axiological Analysis Results from Scenario One..................................................... 138 Table 7-2: Axiological Analysis Results from Scenario Two.................................................... 141 xvii List of Figures Figure 1-1: The Evolution of Professionalism from Ancient Roots to Modern Standards............ 6 Figure 1-2: Three Dominant Frameworks in Professionalism...................................................... 12 Figure 1-3: Miller’s Pyramid Expanded to Include Professional Identity Formation.................. 25 Figure 2-1: Progression of Studies Informing Professional Identity Formation and Professionalism Education in Dentistry........................................................................................ 33 Figure 3-1: Process of Coding Applied to Eighteen Participants’ Transcripts............................. 42 Figure 3-2: Domain-Specific Self-Efficacy as a Factor for Professional Identity Formation...... 49 Figure 3-3: Five Contributors to Dental Students’ Professional Identity Formation................... 55 Figure 4-1 Dental Students’ Definitions of Professionalism in Dentistry.................................... 69 Figure 4-2 Most Important Qualities of a Dentist According to Dental Students........................ 70 Figure 4-3 Students’ Motivation for Entering the DMD Program............................................... 72 Figure 4-4 Self-Determination Theory’s Taxonomy of Motivation............................................. 74 Figure 4-5 Key Influences on the Development of Students’ Professional Identity in Dentistry........................................................................................................................................ 79 Figure 5-1 Data Coding Process in Template Analysis................................................................ 90 Figure 5-2 Interviewed Dentists’ Definitions of Professionalism................................................ 92 Figure 5-3 Students’ and Dentists’ Definitions of Professionalism.............................................. 93 Figure 5-4 Influencers of Dentists’ Professional Identity Formation......................................... 102 Figure 7-1: The Process of Axiological Analysis....................................................................... 135 Figure 7-2: The Main Value Conflicts and Resolution Strategies from Scenario One.............. 138 Figure 7-3: The Main Value Conflicts and Resolution Strategies from Scenario Two.............. 141 Figure 7-4: The Dynamic Process of Professional Identity Formation...................................... 144 xviii Figure 7-5: Balancing Personal and Professional Identity in Development............................... 145 xix List of Abbreviations ABIM American Board of Internal Medicine ACD American College of Dentists ADA American Dental Association ADEA American Dental Education Association BCCOHP British Columbia College of Oral Health Professionals CDA Canadian Dental Association DMD Doctor of Dental Medicine FOD Faculty of Dentistry NBDE National Board of Dental Examinations PIF Professional Identity Formation RCDSO Royal College of Dental Surgeons of Ontario UBC University of British Columbia USA United States of America xx Acknowledgements First and foremost, I am profoundly thankful to God Almighty for His blessings and guidance throughout my doctoral journey. I would like to express my deepest gratitude to my supervisor, Dr. HsingChi von Bergmann, for her unwavering support, encouragement, and expertise. Her insightful feedback and dedicated mentorship have been instrumental in shaping my research and enhancing my academic skills. I am truly grateful for the countless hours she devoted to reviewing my work, providing constructive critiques, and guiding me toward achieving a high standard of scholarship. Her guidance has not only shaped this dissertation but has also profoundly influenced my growth as a researcher and educator. Thank you, Dr. von Bergmann, for your invaluable belief in my potential. Your confidence in me, even during moments when I doubted myself and when others had not given me a chance, has been truly transformative. It has been an honour to work under your supervision. I would also like to extend my heartfelt thanks to my committee members, Dr. Charles Shuler and Dr. Judith Walker, for their invaluable support, insightful feedback, and thoughtful advice. Your commitment and dedication have been integral to the success of this work, and I am deeply appreciative of your guidance throughout this journey. Finally, I am immensely grateful to my family for their unwavering support and encouragement. Your love and belief in me have been my source of strength, and I could not have accomplished this without you. xxi Dedication To all those in the dental field—students, educators, and practitioners—who strive daily to uphold the values of professionalism and ethics while shaping the future of dentistry. May this work inspire and contribute to the ongoing pursuit of excellence in our profession. 1 Chapter 1: Introduction 1.1 Dentistry as a Profession and Social Contract A profession is often defined by its high level of skill and knowledge applied in practice.1 Dentistry exemplifies this by integrating theoretical expertise with practical skills, providing significant benefits to those seeking care.1 In recognition of this expertise, dentistry holds a unique place in healthcare and society, granting dentists privileges such as elevated status, extensive autonomy, public trust, and financial rewards.1 However, these privileges come with obligations, including prioritizing patient wellbeing, maintaining ethical conduct, ensuring competence, and addressing broader social responsibilities.1,2 A key distinction between professions and other occupations is the autonomy granted by society, with the expectation of exceptional competence and trustworthiness.1,3,4,5 This autonomy is accompanied by significant responsibilities that reinforce the ethical and societal commitments of professionalism.1 These responsibilities form the basis of a social contract between the public and the profession, in which dentistry pledges to serve the public good.6,7 Both the Canadian Dental Association and the American Dental Association emphasize that “the dental profession holds a special position of trust within society.”8(p3),9 In return for this trust, society grants the profession certain privileges not extended to the general public. Consequently, “the profession makes a commitment to society” by upholding its responsibilities.7,8(p3) To fulfill these responsibilities, dental education aims to prepare skilled clinicians who embody professionalism. Accreditation bodies for dental programs in Canada and the United States require the integration of professionalism into dental curricula.5 Since dentistry operates within a social contract framework, professionalism is widely considered fundamental to ensuring that practitioners provide optimal oral healthcare to the public while adhering to the 2 highest ethical and behavioural standards.6,10 Upholding professionalism is crucial for dentistry to maintain its status as a respected profession.8,10,11 In exchange, society grants dentists various benefits, such as above-average income, professional recognition, and protection of their specialized dental skills.7,8 Given dentistry’s relationship with public trust and responsibilities placed on practitioners, expectations for professionalism remain high. However, despite its strong emphasis in dental education, challenges and evolving expectations continue to shape its professional practice. 1.2 Motivation for the Study Professionalism and ethics are foundational aspects of dental education, yet questions remain about how professional values are learned and maintained throughout a dentist’s career. While professionalism is emphasized in dental curricula, concerns occasionally arise regarding professional behaviour and ethical decision-making in practice. Public discussions surrounding professionalism have been prompted by instances of student and practitioner misconduct, underscoring the challenges of fostering and sustaining professional values. However, these examples are not meant to serve as justification for this study, but rather to provide context for broader discussions about professionalism and the complexities of professional identity formation in dentistry. One such example is the 2014 “Dalhousie Dental School Scandal” at the Faculty of Dentistry at the Dalhousie University in Halifax, Nova Scotia, in which a private Facebook group, “Class of DDS 2015 Gentlemen,” created by male dentistry students, contained misogynistic, sexist, and violent comments about their female classmates. The university’s 3 response involved suspending the students from clinical practice and initiating a restorative justice process, which included facilitated discussions, educational workshops, and public apologies aimed at reconciliation and addressing the harm caused. However, this approach received mixed reactions.12 Some supported it for promoting long-term cultural change while others criticized it as too lenient. This incident led to policy reviews and increased scrutiny of the university’s professional programs, reflecting broader discussions about how professionalism is taught and reinforced in dental education.12 Beyond dental school settings, concerns about professionalism occasionally emerge in clinical practice, prompting regulatory bodies to uphold professional standards through public accountability measures. In British Columbia, Canada, the British Columbia College of Oral Health Professionals (BCCOHP) publicly lists cases in which dental professionals have been disciplined for breaches of professional conduct.13 Similar practices exist across Canadian provinces. While these cases represent a small proportion of the profession, they serve as reminders of the expectations placed on healthcare professionals and the challenges of maintaining professionalism over time. As a registered dental hygienist since 2009, I have encountered various professionalism-related challenges in clinical practice, ranging from ethical dilemmas to variations in professional behavior and communication. These experiences sparked my interest in studying how professionalism is understood, taught, and reinforced in dental education. Rather than focusing solely on cases of misconduct, this study seeks to explore the paths that have been explored in the literature to teach professionalism and how dental students and practitioners navigate professionalism. Furthermore, given the contemporary medical education literature linking professionalism to professional identity development, this study explores the factors that 4 shape dental students’ and dentists’ professional identity. Building on these insights, this doctoral study then investigates the role of education in supporting dental student’s ethical development. Dental professionals face ethical dilemmas frequently. These challenges have grown increasingly complex due to commercial pressures, variations in professional behaviours, legal and regulatory concerns, lack of accountability, and professional burnout.1,14,15,11 This context underscores the importance of examining how professionalism education prepares future dental professionals to navigate ethical challenges and maintain public trust. 1.3 Defining Professionalism in Healthcare: Concept, Evolution, and Ethical Connections In both medical education and dental education literature, there is no universally agreed-upon definition of professionalism.16–18 This may be due to its multifaceted and evolving nature, influenced by cultural, social, and historical contexts.19 Webster’s Dictionary offers a very broad and general definition, describing professionalism as “the conduct, aims, or qualities that characterize or mark a profession or a professional person.”20 However, the practical meaning of professionalism varies across different contexts, shaped by the perspectives of professionals, patients, third-party payers, and other stakeholders.21 This variability highlights the challenge of formulating a definition that is both concise and comprehensive. The Royal College of Physicians of London defines professionalism as “a set of values, behaviours, and relationships that underpins the trust the public has in doctors.”22 Another definition of professionalism in healthcare is “a set of standards of competence and ethics which is communicated within the medical profession and towards the general public in order to determine what individuals (patients) can and should expect from physicians and other medical 5 professionals.”23(61) This view emphasizes professionalism’s role in safeguarding the public trust and establishing clear expectations for healthcare providers.23 Stern provides a more focused definition tailored for assessment in medical education, describing professionalism as “a foundation of clinical competence, communication skills, and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”24(p.19) While Webster’s definition serves as a starting point, Stern’s perspective articulates specific values and competencies essential to healthcare professionals, providing a clearer framework for evaluation and development. These values hold particular relevance in dentistry, where patients place great trust in their practitioners to perform technically complex and often invasive and irreversible procedures. Over the last 25 years, professionalism has received increasing attention, reinforcing its role as an essential component of medical and dental practice.25 The concept of professionalism is extensively explored across three primary academic fields: sociology, medicine, and education.26 Sociology has the longest history of examining professionalism, with theoretical and analytical writings dating back to the late 1800s.24,27 Medical literature also contributed a rich history of discussions on professions and professionalism, often intertwining terms like profession, professional, and professionalism with ideals of ‘good doctoring’ and ‘exemplary practice.’26 While the term ‘medical professionalism’ has been widely used only in the past century, the principles underlying professional conduct in healthcare, its concepts and ethical foundations have roots that extend back to ancient times.28 6 Foundational concepts of professional conduct and ethical responsibility in healthcare can be traced back to the Hippocratic Oath from around 400 BC, which established core values such as patient welfare, confidentiality, and ethical practice.28 These early ethical guidelines laid the groundwork for the modern understanding of professionalism, emphasizing the duty of healthcare practitioners to prioritize patient care, maintain trust, and uphold moral integrity.29 Over time, professionalism in healthcare has evolved to encompass not only ethical principles but also accountability, competence, empathy, and effective communication.24 In this evolution, ethics serves as the moral foundation for professionalism, guiding decision-making and behaviour. Professionalism in healthcare, in turn, integrates these ethical principles with standards of conduct, social responsibility, and commitment to continuous learning.30 This integration ensures that ethical principles are upheld in clinical practice, reinforcing professional conduct.30,31 This is particularly crucial in healthcare, where trust, integrity, and patient-centred care are essential for effective and compassionate treatment.32 Figure 1-1 illustrates the historical progression and development of healthcare professionalism in relation to ethics over time. Figure 1-1 The Evolution of Professionalism from Ancient Roots to Modern Standards33,34 7 In ancient Greece and Rome, the Hippocratic Oath established early standards for ethical conduct in medicine, while the Roman legal system laid the foundation for professional expertise and integrity.33 During the Middle Ages, guilds emerged as associations of skilled craftsmen and tradespeople, regulating training, apprenticeships, and work quality. These guilds introduced early forms of professional standards, emphasizing the importance of skill and quality in various trades.34 During the Renaissance, formal codes of conduct and ethical guidelines began to emerge in fields such as medicine, law, and the clergy.33 These emerging regulations aimed to govern professional behaviour and ensure adherence to high ethical standards.33 With the Industrial Revolution in the 18th and 19th centuries, new professions such as engineering, architecture, and accounting emerged, necessitating the establishment of formal educational institutions and associations to train and certify practitioners. By the 19th and 20th centuries, professional associations and societies—such as medical and bar associations—were founded to standardize practices, define ethical codes, and foster a sense of community among professionals. These organizations played a critical role in shaping modern professionalism by regulating practices and promoting professional integrity.34 In the late 1970s, during the formative years of bioethics, there was a growing interest in adapting teaching models to foster professionalism and meet the demands of a rapidly globalized society.32 By 1983, the American Board of Internal Medicine (ABIM) had identified respect, compassion, and integrity as the fundamental aspects of humanistic medicine.32 In the 1990s, the ABIM formally introduced the term ‘professionalism,’ defining it through core values such as altruism, duty, service, responsibility, and excellence as its constituents.35 8 By 2000, many medical colleges had already developed or were in the process of creating tools to assess students’ professionalism.32 In 2002, ABIM, in partnership with the European Federation of Internal Medicine, published Medical Professionalism in the New Millennium: A Physicians’ Charter in Annals of Internal Medicine, defining professionalism as the cornerstone of physicians’ contract with society.36,37 Following the examples set by medical education, dental schools began to adopt professionalism frameworks similar to those introduced in medicine in the 1990s. In 1997 and 2008, American Dental Education Association (ADEA) published Competencies for the New General Dentist, explicitly identifying professionalism as one of the core competencies essential to dental practice.38 Professionalism gained further prominence with its inclusion in Article 18 of the Universal Declaration on Bioethics and Human Rights.39 Since then, numerous publications, conferences, and initiatives have highlighted the growing importance of professionalism in medicine, dentistry, and bioethics. However, despite this widespread recognition, integrating professionalism into medical and dental curricula remains a persistent challenge due to factors such as resource limitations, inconsistent faculty training, and competing curricular demands.32 1.3.1 Historical Development and Professionalization of Dentistry In dentistry, the evolution of professionalism has largely followed a trajectory similar to that of medicine, although it has encountered its unique challenges and milestones. Dentistry is one of the oldest medical practices, tracing its origin back to 7000 BC within the Indus Valley 9 Civilization.40,41,42 Despite its ancient roots, dentistry was traditionally regarded more as a trade than a profession.40 Practitioners acquired their skills through apprenticeships instead of formal educational pathways.42 This perception began to shift in the 18th century when Pierre Fauchard, widely recognized as the ‘Father of Modern Dentistry,’ published The Surgeon Dentist, a Treatise on Teeth in 1723.43,44 This seminal work laid the foundation for systematic dental care and introduced concepts such as dental fillings and prosthetics.44 Fauchard’s contributions were pivotal in establishing dentistry as a specialized field of knowledge. Dentistry’s professional status advanced significantly during the 19th century with the founding of the first dental schools, including the Baltimore College of Dental Surgery in 1840, along with the implementation of the first Dental Practice Act in Alabama in 1841.42 The establishment of professional organizations, such as the American Dental Association (ADA) in 1859, together with the formation of university-affiliated dental programs like the Harvard University Dental School in 1867, further reinforced the perception of dentistry as a legitimate profession.42 In Canada, the Royal College of Dental Surgeons of Ontario (RCDSO) was established in 1868 as the first self-regulatory body.45 Its creation was driven by the need to standardize dental education, improve the quality of care, and protect the public. Before the RCDSO, dentistry in Ontario and much of Canada was largely unregulated, with dental services often provided by barbers and blacksmiths with limited training.45 These institutions and organizations were instrumental in establishing ethical standards and reinforcing the idea that dentists have responsibilities not only to their patients but also to society as a whole—defining characteristics of professionalism.7,42 10 1.3.2 Contemporary Challenges in Dental Professionalism in North America Despite its long history and the central role in healthcare, professionalism in dentistry continues to face challenges, particularly in the modern context.46,47 In North America, a recurring theme in discussions of dental professionalism is the tension between viewing dentistry as a profession versus treating it as a commercial enterprise.1,11 Aggressive marketing, an emphasis on cosmetic procedures over essential care, and a perceived prioritization of profit over patient needs threaten to erode public trust and challenge dentistry’s claim to professional status.25,46 The current model of dental care in North America may be seen as a breach of public responsibility, as it favours those with greater access—typically the wealthy and those with private insurance.11 The commercialization and oversaturation of dental practices, particularly in cities like Vancouver and Toronto, have created ethical dilemmas. Many practices struggle to balance patient-centered care with financial pressures,1,47 undermining the altruistic nature of professionalism15 and potentially shifting patient perceptions of dental care from a professional healthcare service to a transactional relationship.1,48 In response to concerns about access to care, the Canadian government launched the $13 billion Canadian Dental Care Program (CDCP) in 2024. However, opinions on its effectiveness remain divided, with dental professionals expressing concerns about administrative complexities, inadequate coverage, and potential financial strain on practices.49 These challenges reflect the broader challenge within dentistry: the struggle to maintain professionalism—rooted in a social 11 contract that prioritizes patient wellbeing and ethical standards—amid commercial pressure and systemic barriers.11,47,50 1.4 Understanding Professionalism: Shared Themes and Models Numerous efforts have been made to describe and define professionalism in medicine and dentistry.25,51,52 Both fields recognize it as a core competency that healthcare providers must cultivate and exhibit.25,51,53 Despite the importance placed on professionalism, recent systematic reviews of medical and dental education literature from regions including Australia, America, and Europe indicate that there is no universally agreed-upon definition of professionalism.18,25,54,55 In the absence of consensus, educators and scholars have sought to identify recurring themes that shape how professionalism is conceptualized and applied. Shared themes commonly emerge, conceptualizing professionalism through personal attributes, interpersonal communication, approach to practice, and commitment to lifelong learning.56 To capture these dimensions, various models have been developed to define and assess professionalism. These models range from trait theory—which emphasizes attributes like empathy, integrity, and responsibility—to competency-based frameworks that focus on the demonstration of professional behaviours in specific contexts.20, 54 Building on this, professionalism can also be examined from multiple perspectives, including interpersonal, public, and intrapersonal perspectives,57 or categorized into professional parameters, behaviours, and responsibilities.58,59 12 Expanding on these theoretical models, empirical studies further highlight the essential components of professionalism valued by society. A factor analysis of a public survey on the most valued professional traits in doctors highlighted three key areas: interaction with patients (“clinicianship”), interaction with colleagues (“workmanship”) and interaction with society (“citizenship”).60 Moreover, aspects of professionalism can include elements like professional-client relationships, ethical decision-making, and critical reflection.25,61,62,63 These overlapping elements reflect the multifaceted nature of professionalism, reinforcing the need for comprehensive frameworks that address its diverse manifestations. Despite ongoing variations in curriculum design, pedagogy, and assessment—stemming from differing interpretations of professionalism—three dominant frameworks have shaped the discourse on professionalism within medical and dental education. As illustrated in Figure 1-2, these frameworks—Virtue Ethics (person-based), Principlism (behaviour-based), and Professional Identity Formation (process-based)—are the most widely discussed and applied approaches, each offering a distinct lens for understanding and fostering professionalism in the context of healthcare professional education.28,64–67 Figure 1-2 Three Dominant Frameworks in Medical Professionalism 13 1.5 Exploring the Three Dominant Frameworks of Medical Professionalism Professionalism in healthcare is inherently intertwined with ethical principles, as both domains strive to foster behaviours and attitudes that prioritize patient welfare and integrity. The incorporation of virtue ethics and Principlism within professionalism frameworks underscores that ethical considerations—whether through cultivating moral character or adhering to established ethical principles—are indispensable to the practice of professionalism.68 This convergence demonstrates that professionalism is not merely about observable behaviours but also about an underlying ethical commitment, emphasizing that the development of professional identity is rooted in moral values. Recognizing this interdependence clarifies that ethical practice and professional conduct are mutually reinforcing, ultimately enriching the quality of patient care.69 Among the three dominant frameworks, two key perspectives in health professions education that are closely intertwined with ethics are virtue ethics and Principlism.69,70 1.5.1 Dominant Framework I: Virtue-Ethics (Person-based) Virtue ethics is a person-based approach that focuses on the moral character rather than specific actions themselves.70 Unlike Deontology, which emphasizes duties, rules, or principles, and Consequentialism, which considers the outcomes of actions, virtue ethics does not function as a decision-making or problem-solving tool.71 Rather, it emphasizes cultivating virtues—such as empathy, integrity, compassion, and responsibility—which form the foundation of professional behaviour.71,72 14 A virtue represents a disposition to notice, appreciate, feel, desire, select, act, and respond in morally characteristic ways.73 Virtues serve as “regulative ideals”—internalized concepts of excellence or correctness that guide our actions and motivate us to uphold certain standards.69 Virtue exists on a spectrum rather than as an absolute state,73 and achieving perfect virtue is rare.74 According to virtue ethics, a virtuous person refines their motivations and perceptions to the point where these regulative ideals become central to their behaviour. Historically, philosophers from ancient Greece, such as Aristotle and Plato, highlighted the importance of cultivating moral virtues.70 Aristotle, in particular, believed that the ultimate aim of life is to achieve eudaimonia, often translated as ‘happiness’ or ‘flourishing.’ For Aristotle, genuine happiness is attained through cultivating virtues like courage, honesty, and wisdom, which equip individuals to face life’s challenges.18 Other core concepts of the virtue ethics approach include arête and phronesis.71 Arête refers to ‘the embodiment of a morally desirable character, involving a conscious choice to develop traits’ such as honesty, compassion, or courage.71 However, excessive application of virtues can become problematic. This is where phronesis—'moral and practical wisdom,’ comes into play.51 Since relying solely on virtues may lead to misguided actions, phronesis enables individuals to discern what is most important in a given situation, shaping rational decision-making.71 In addition to Eudaimonist virtue ethics, contemporary variations include agent-based and exemplarist virtue ethics, target-centered virtue ethics, and Platonic virtue ethics.73 While these schools of thought differ slightly, they share the fundamental belief that living without virtues contradicts human nature.69 This study, however, specifically examines professional 15 identity formation within the broader context of professionalism. While the influence of virtue ethics as a dominant framework in health professions education is acknowledged, a detailed discussion of its various forms falls beyond the scope of this research. 1.5.1.1 Virtue Ethics in Professional Roles In health professions education, professionalism extends beyond adherence to codes of conduct or regulations—it requires embodying the virtues that underpin ethical and compassionate care.72 Virtue ethics recognizes that professional roles often necessitate specific virtues and may demand actions that would be considered inappropriate in other contexts.69 For example, a journalist may choose to withhold sensitive information to protect a source’s identity—an action that might be seen as deceptive outside journalism. This illustrates how virtue ethics acknowledges that moral behaviour can be context-dependent, allowing for morally necessary actions within professional roles.75 However, virtue ethics does not claim that professional obligations override all moral values.69 Even within a professional role, individuals remain bound by broader ethical considerations. Moral philosophers have revisited virtue ethics to address these contingencies and promote habitual behaviours that remain consistent across diverse situations.75 According to virtue ethics, professional roles are justified insofar as they promote some important human good, such as health or justice.69 When a professional obligation requires actions that severely violate broader moral values, individuals may be morally obligated to act against their professional duties.69 16 1.5.1.2 Criticism for Virtue Ethics While virtue ethics offers a valuable framework for understanding professionalism, it is not without critique. One major criticism is its lack of clarity and specificity.69 Critics argue that the theory is too vague to provide concrete ethical guidance, as defining essential virtues and predicting how a virtuous agent would act in various situations can be difficult.69 Additionally, virtue ethics has been described as ‘circular.’76 Some question how we define a virtuous agent without first determining what actions are right. If ‘right actions’ are those performed by virtuous individuals, and virtuous individuals are defined by their right actions, the theory risks becoming self-referential.76 Furthermore, even individuals with virtuous characters may still act wrongly.77 For example, a benevolent doctor might withhold a terminal diagnosis from a patient out of compassion, but this could be morally questionable despite good intentions.69 Another concern is virtue ethics’ reliance on character alone to determine ethical correctness.69 Critics argue that the actions of a virtuous agent may not always justify ethical decisions, as there is no guarantee that virtuous individuals will always act correctly.69 Finally, virtue ethics can struggle to reconcile professional roles with broader moral values.69 For instance, a lawyer may be obligated to defend a client they believe to be guilty, which may seem dishonest outside the legal profession. This raises challenges in determining how virtue ethics should address conflicts between professional duties and overarching moral obligations. 1.5.2 Dominant Framework II: Principlism (Behaviour-based) The second key framework in healthcare education and practice, as depicted in Figure 1-2, is Principlism, an ethical decision-making approach guided by a set of moral principles.70 17 Introduced by Beauchamp and Childress in Principles of Biomedical Ethics (1979), Principlism has become one of the most influential frameworks addressing ethical dilemmas in healthcare education.20 Its appeal lies in its straightforward and culturally neutral approach, making it widely applicable across diverse clinical settings.25 This framework is based on four prima facie principles: autonomy, beneficence, non-maleficence, and justice.21 The term ‘prima facie’ implies that these principles are binding unless they conflict with another moral principle, in which case a choice must be made between them.20 Autonomy emphasizes respect for patients’ rights to make independent healthcare decisions.20 This principle is fundamental to informed consent, shared decision-making, and the commitment to honour patients’ values and preferences, even when they may diverge from the healthcare provider’s own judgment or societal norms.70 Beneficence involves acting in the patient’s best interest and includes both positive beneficence (acting in the patient’s best interest) and utility (prioritizing society’s interests over individual interests and rights).21,70 Non-maleficence centers on avoiding harm to the patient, while justice relates to fairness, respect for individual’s rights, and the equitable distribution of limited healthcare resources.70,19 Beauchamp and Childress developed Principlism to bridge the gap between ethical theory and clinical practice, arguing that these four principles can guide decision-making to yield ‘normatively justified conclusions’ relevant to real-world cases.78 Building on its widespread application in healthcare, Principlism has also become a cornerstone of dental ethics education in North America, shaping how ethical principles are taught and applied in clinical and academic settings. 18 1.5.2.1 Principlism and Dental Ethics Education in North America Over the past thirty years, dental ethics education in dental schools in the United States (US) and Canada has expanded beyond jurisprudence and malpractice avoidance to include bioethics, professionalism, and humanistic approaches to patient care.79 In 1989, a committee of ethicists, psychologists, and practitioners from the American Association of Dental Schools (now ADEA), the ADA’s Council on Dental Education (CDE), and the American College of Dentists (ACD) developed ethics curriculum guidelines for dental schools.79 Drawing Bok’s ethical teaching goals80 and the early work of the Hastings Center,81 the committee developed a framework on Rest’s Four Component Model of Morality (FCM).82 This model outlines four essential elements of moral behaviour: moral sensitivity, moral reasoning, moral motivation, and moral implementation.83,84 From this foundation, the committee recommended integrating ethics and professionalism instruction throughout dental education across all years of dental education to foster a comprehensive ethical foundation.79 In the U.S., this evolution has led to expanded content and teaching methodologies, though the total instructional time dedicated to ethics has remained relatively stable at 26.5 clock hours—accounting for approximately 0.5% of the total curriculum.79 In Canada, dental schools show greater variability. A survey of Canadian dental schools revealed that 10% of the schools offer formal ethics education in only one year, 40% in two years, 30% in three years, and 20% throughout four years of the program.85 Despite differences in instructional time, both countries have broadened the scope, teaching strategies, and assessment methods in ethics education to better address the increasingly complex ethical landscape faced by dental professionals.79,85 This shift reflects the growing recognition of ethics and professionalism as 19 core components of dental education, essential for preparing students to navigate moral and professional challenges in clinical practice. Ethics education in North American dental schools centers on Principlism and veracity (truthfulness), as outlined in the American Dental Association (ADA)’s Principles of Ethics and Code of Professional Conduct.8 The National Board of Dental Examinations (NBDE) reinforces Principlism by requiring students to answer ethics-related questions specifically evaluated within its framework.86 A 2011 study by Lantz et al. found that all surveyed dental schools in the U.S. (100%) incorporated the Principles of Ethics and Code of Professional Conduct into their curriculum, highlighting Principlism’s central role in shaping ethical decision-making and professional conduct in dental education.79 Similarly, the four principles of Principlism (autonomy, beneficence, non-maleficence, and justice) are embedded in dental curricula and in the professional standards and ethical guidelines governing dental practice across Canada. For instance, the College of Dental Surgeons of Alberta (CDSA) highlights these principles in their Code of Ethics, emphasizing “respect patient autonomy,”(autonomy), “do no harm” (non-maleficence), “do good” (beneficence) and “be honest and fair, be respectful and inclusive” (justice).87 British Columbia College of Oral Health Professionals also incorporates autonomy and beneficence into its Code of Ethics,88 while the Manitoba Dental Association’s Code of Ethics includes all four principles of Principlism along with an additional emphasis on veracity.89 While Principlism serves as a foundational framework for dental ethics education and professional practice in North America, it is not without its limitations and critique. 20 1.5.2.2 Criticism for Principlism A key criticism of Principlism is its lack of a unified moral theory.90 Since its four core principles originate from different moral philosophies, it is often unclear how they relate to each other or which should take precedence in conflicts.25,90 This lack of hierarchy and coherence makes Principlism vulnerable to "freestyle reasoning," where the principles function more as labels for arguments instead of serving as a structured framework for ethical decision-making.90 Consequently, Principlism is often criticized for failing to provide clear action guidance, as the principles may highlight ethical issues but rarely offer concrete methods for resolving conflicts.90 Additionally, while Beauchamp and Childress argue that no principle is inherently superior, critics observe that autonomy often overshadows beneficence or justice in practice.78 The absence of a clear method for balancing principles further complicates ethical decision-making. Despite these limitations, Principlism has provided a valuable framework and common language in bioethics, advancing ethical discourse in healthcare and dental education. Recognizing the challenges of a behaviour-based framework, there is growing interest in process-based approaches, such as Professional Identity Formation (PIF), which emphasize the continuous development of ethical and professional values throughout a practitioner’s career. 1.5.3 Dominant Framework III: Professional Identity Formation (Process-based) 1.5.3.1 Defining Professional Identity Formation Professional identity formation (PIF) is a relatively new term and a process-based perspective on professionalism.91 Cruess et al. define professional identity as “a representation of 21 self, achieved in stages over time during which the characteristics, values, and norms of the profession are internalized, resulting in an individual thinking, acting, and feeling like a physician.”67(1447) Paterson et al. describe professional identity as "the sense of being a professional" and emphasize that technical skills and interpersonal skills alone are insufficient for its development.92(6) They argue that individuals must employ professional judgment and reasoning, engage in critical self-evaluation, and pursue self-directed learning to truly cultivate a professional identity.92 PIF involves a shift from focusing on the “doing” of professionalism to the “being” of a professional.93 1.5.3.2 Limitations of the Current Professionalism Education and the Emergence of Professional Identity Formation in Healthcare Education The concept of professional identity emerged in response to concerns about traditional approaches to professionalism education. Professionalism gained prominence in the 1980s and 1990s during the healthcare ethics movement, driven by perceived threats to medicine’s integrity.3 By the early 2000s, dentistry followed this trend, and accreditation bodies in North America began mandating the integration of professionalism into curricula. Historically, professionalism was imparted primarily through role modelling by respected practitioners.66 However, this method alone has proven insufficient to address contemporary challenges in professionalism education. Despite widespread recognition of its importance, professionalism education faces persistent challenges, particularly the lack of a universally agreed-upon definition of professionalism within dental education literature.25 This lack of consensus creates conflicting expectations for educators and students, complicating efforts to teach, assess, and enforce 22 professionalism. While technical skills are relatively straightforward to measure, assessing qualities such as ethical conduct, empathy, and reflective capacity remains subjective and prone to bias. As a result, many assessments focus on observable behaviours rather than fostering the internalization of professional values, which may contribute to students perceiving professionalism education as overly focused on errors and negative behaviours.94–96 This critique has led to a shift toward professional identity formation (PIF), as educators recognize that merely knowing what is right is not enough.97,98 Values must be deeply internalized to foster appropriate behaviours.10,67,99 Studies have shown that professed beliefs in adhering to professional values do not always translate into ethical behaviour unless these values are deeply ingrained in one’s identity.23 Research on military leadership and exemplary dental professionals suggest that those with strong professional identities possess a clear understanding of their professional growth and articulate their expectations for professional conduct.24,15 This underscores PIF’s relevance beyond healthcare, highlighting its role in leadership and ethical decision-making across various professions. PIF is a developmental process unique to each learner. Just as individuals shape their personal identity throughout life, dental professionals develop their professional identity throughout education and practice. However, not all students naturally align their personal values with professional expectations.93 That is why proponents of PIF argue that professionalism education should not simply ensure that students understand medical professionalism and demonstrate expected behaviours but should actively guide and support them in identity formation.67,99 23 Through the lens of PIF, learning is viewed as a journey towards an evolving professional identity. Initially, students may adhere rigidly to rules, but as their professional identity develops, they gain a more sophisticated understanding of professionalism and realize that those rules serve as guidance rather than rigid absolutes.19 Medical and dental schools provide an ideal environment for this transformation, where experienced professionals share knowledge, judgment, and values to newcomers.100 While competency-based education focuses on discrete skills, its structure may not fully support holistic development PIF offers.99 Instead, PIF emphasizes reflection, relationships, and resilience, helping students internalize values and develop the tenacity to navigate challenges.101 Emphasizing PIF in dental education does not diminish the importance of teaching professionalism’s foundational aspects. Instead, it shifts the focus from an abstract and often unclear understanding of professionalism to helping students develop their own professional identities.102 While this may seem similar to existing methods, teaching students professional values to inspire their aspirations is far more constructive than teaching these values solely to ensure correct behaviour.93 Proponents argue that PIF aligns with the profession’s broader goal of maintaining its social contract with society. By fostering an enduring professional identity, PIF aims to ensure that future practitioners are not only clinically competent but also committed to professionalism despite the complexities of the modern healthcare landscape.67,103 As professionalism education has evolved into PIF, educators have recognized the need to adapt existing models to better reflect the integration of professional identity. One such example has been the amendment to Miller’s Pyramid, a widely used framework in clinical assessment that is elaborated below.104 24 1.5.3.3 Amending Miller’s Pyramid to Include Professional Identity Formation Introduced in 1990, Miller’s Pyramid provides a framework for assessing clinical skills, competence, and performance in medical education.104 Structured as a four-level pyramid, it outlines a progression of mastery, beginning with “Knows” at the base, which assesses foundational knowledge, followed by “Knows How,” which evaluates the ability to apply this knowledge in clinical contexts.104 The next level, “Shows How,” requires learners to demonstrate skills in a supervised environment, while the apex, “Does,” reflects the ability to perform independently in clinical settings—an aspect that has proven challenging to assess reliably.104,105 The model has been widely adopted in competency-based education as a roadmap for tracking learner progression from knowledge acquisition to autonomous clinical action.105 As professional identity formation gained more attention in medical education, scholars proposed an amendment to Miller’s Pyramid by introducing a fifth level: “Is”.105 This new apex represents the integration of professional values, attitudes, and beliefs into the learner’s identity.105 It shifts the focus from simply “doing” the right things to “being” a medical professional. This addition does not diminish the value of the original four levels but instead highlights an essential aspect of professional development: the transformation of an individual into a medical professional who consistently embodies the profession’s values.67 The amended pyramid, with “Is” at the apex, promotes a more holistic understanding of professionalism. While competence and performance remain crucial, they are most effectively grounded in a strong professional identity.105 25 Proponents of PIF argue that this newly formed identity, shaped through socialization and experience within the community of practice, provides a stable foundation for ethical decision-making, consistent professional behaviour, and commitment to patient care.105 See Figure 1-3 for an illustration of the amended pyramid. Figure 1-3 Miller’s Pyramid Expanded to Include Professional Identity Formation105* (*Adapted from Cruess et al. 2016) The adaptation of existing models like Miller’s Pyramid illustrates the growing emphasis on identity formation within healthcare education. As a result, it is essential to examine the developmental frameworks that support this process. 1.5.3.4 Framework to Understand Professional Identity Formation in Adults: Robert Kegan’s Stages/Orders of Mind 26 There are several theories that explore psychological development within specific domains, such as intellectual understanding, moral and ethical reasoning, identity, and ego development.106,107,108,109,110 Among these, Robert Kegan’s theory of meaning-making stands out for its comprehensive approach, examining shifts across multiple areas of development, including motivation, interpersonal relations, self-concept, idealism, metacognition, perceptions of fairness, and the ability to avoid adolescent impulsivity.111 While both Kohlberg and Kegan proposed stage theories that concentrate on individuals’ growth and development of moral reasoning over time, Kohlberg’s model primarily focuses on moral reasoning from childhood to adulthood, whereas Kegan’s framework centers on the ongoing development of adults.25 To gain insight into professional identity formation, this study adopts Kegan’s framework because it specifically addresses identity development in adults. According to Kegan, identity development is a lifelong process encompassing cognitive, social, and emotional aspects, through which individuals develop increasingly complex ways of understanding themselves and the world around them.111,112 In healthcare, identity is generally examined through two theoretical perspectives: one emphasizing cognitive and developmental processes, and the other focusing on social and interactional phenomena.27 Medical education often adopts cognitive perspective, viewing identity development as an internal process shaped by personal experiences.28 As individuals progress through different stages, their cognitive frameworks evolve, leading to greater independence and social maturity.29 Table 1-1 provides an overview of the developmental processes at each stage of Kegan’s model. According to Cruess et al., Stages 2 to 4 are particularly relevant for professional identity development.113,114 27 Stage 1, characteristics of childhood, is excluded from the adapted version of Kegan’s framework for professional identity development, as it reflects impulsive, pre-reflective behaviour lacking self-awareness, autonomy, and relational capacity essential for engaging in professional roles.114,115 Table 1-1 Kegan’s Stages/Orders of Mind115,116* *(Adapted from Brown et al., 2022; Kalet et al., 2017) Levels of mental complexity relevant for professional education Description of stage Stage 2: “The self-sovereign mind/the Instrumental mind” Emphasize their own needs, interests, and agendas as their primary goal. To self-sovereign minds, relationships are transactional—a means to an end of having their own needs and desires met—and rules or philosophies are adhered to because of eternal reward or punishment, not due to true belief or moral integrity. Limited perspective-taking ability, and an emphasis on the mastery of technical skills. This stage is characteristic of adolescence and early adulthood. Transition (Stage 2/3) Increased ability to have perspective, to learn organizational norms from others, and to emphasize mastery beyond technical skills Stage 3: “The socialized mind” Most adults exist within stage 3. External sources shape one’s sense of self and understanding of the world. In this stage, focus has shifted so priority is placed on the ideas, norms, and beliefs of other people and the systems around us, as opposed to one’s own needs. External validation such as grades or feedback is sought to develop one’s identity, as individuals don’t have a strong, independent sense of self. Follows the norms and status quo within the organization without question. Transition (Stage 3/4) Greater understanding of one’s self in the professional role and greater awareness of choices in dealing with influences that work against a professional’s integrity. Stage 4: “The self-authoring mind” Other adults progress their identity to stage 4. Within this stage, one’s sense of self is more independent, and individuals can define who they are without relation to other people, their relationships, or their environment. An internal sense of direction is established, where individuals become the ‘author’ of their own life course. Greater fidelity to one’s sense of self within the professional role. One can discern negative social influences that can erode one’s professional 28 identity and integrity. Effectiveness within high-level professional or leadership roles requires stage 4 capacities. Transition (Stage 4/5) One can understand and reconcile multiple contradictory ways of thinking and being. Stage 5: “The self-transforming mind” The final stage of Kegan’s model. This is beyond what Cruess et al. deem relevant to medical students. One’s sense of self is constantly created and recreated through exploration of roles and beliefs with others. Ability to examine one’s self-authored personal authority, recognize the limits of any one system of constructing meaning, and seek out novel or alternative systems. A recognition of the interdependencies of different systems or ways of being, and an ability to reconcile contradictory or seemingly paradoxical ways of constructing meaning is a hallmark of the emergence. 1.6 Next Chapter Chapter 1 explores the concept of professionalism as presented in the literature, tracing its historical evolution and outlining its three dominant educational frameworks—virtue ethics, Principlism, and professional identity formation (PIF). Special focus is given to PIF as a developmental process, guided by Kegan’s model of adult development, highlighting how professional identity evolves through experience, reflection, and socialization. This foundation serves as a basis for investigating professionalism and professional identity formation among dental students and professionals. The following chapter addresses the knowledge gaps identified in the literature, outlines the rationale for this study, and presents the research objectives and methodological framework underpinning this dissertation. 29 Chapter 2: Research Rationale, Objectives, and Methodological Framework 2.1 Knowledge Gap and Study Rationale The central question that guided the inception of this thesis was, “What educational practices are required to prepare future dental professionals to embody and maintain strong professional values?” Through the literature review, I found several areas requiring further investigation. Much of the research on professionalism in dental education has focused on ethical decision-making and behaviour-based applications rooted in Principlism.79,83,117,118 It also became clear that while some research on professional identity formation (PIF)—one of the dominant and most recent frameworks for understanding professionalism—had been explored in medical education, PIF remained a relatively new and under-researched area in dental education when I began this doctoral journey in the fall of 2020. Additionally, longitudinal data capturing dental students’ experiences across various domains of professionalism was scarce. Most existing studies were cross-sectional, focusing on single points in time rather than examining how professionalism and professional identity evolve throughout dental education and into clinical practice. Furthermore, there was a limited insight into the barriers that dentists face in practice, which may hinder their ability to uphold professional standards and shape their evolving professional identity.15,119,120 These real-world challenges are not always explicitly addressed in dental education curricula, yet understanding them is crucial in preparing dental students to navigate complex ethical and professional situations throughout their careers. Since professionalism has traditionally been examined through a behavior-based framework, and its limitations have already been discussed in Section 1.5.3.2, exploring professional identity formation (PIF) offers an alternative perspective. PIF provides a 30 more holistic framework for investigating how individuals integrate personal and professional values, beliefs, and experiences to develop a coherent professional self-concept.121,122 Shifting from a behaviour-based professionalism framework (Principlism, as outlined in Chapter 1) to a process-based professionalism framework (PIF) allows for an expanded focus—not only on what students know and how they behave, but also how they perceive themselves as professionals. 2.2 Research Objectives 2.2.1 Overarching Objectives The overall objective of this research is: • To identify key factors influencing the development of professional identity and its relationship to professionalism among dental students and practicing dentists, and • To generate insights for enhancing professionalism education through the lens of professional identity formation. 2.2.2 Sub-Objectives and Research Questions Table 2-1 below outlines each study's specific objectives and corresponding research questions, demonstrating how these align with the overarching inquiry question of this dissertation. 31 Table 2-1 Summary of the Dissertation Research Objectives and Questions Overarching Inquiry Question What educational practices are required to prepare future dental professionals to embody and maintain strong professional values? Overarching Research Objectives à To identify key factors influencing the development of professional identity and its relationship to professionalism among dental students and practicing dentists, and à To generate insights for enhancing professionalism education through the lens of professional identity formation. Specific Objectives of Each Study Study 1 Study 2 Study 3 Study 4 • To investigate key contributors to dental students’ professional identity formation (PIF) • To explore perceived obstacles and challenges to their PIF • To explore dental students’ views on professionalism and its integration into their education • To examine their definitions of professionalism, motivations, and the most important qualities they attribute to a dentist. • To derive insights from their overall perspectives on professionalism to inform and enhance the dental curriculum • To explore dentists’ definitions of professionalism • To explore workplace barriers and challenges that impact their PI and conduct • To identify key factors shaping their professional identity • To gather their recommendations for enhancing professionalism education • To demonstrate how ethical scenarios and axiological analysis can create structured opportunities for self-reflection, fostering professional identity formation Research Questions Guiding Each Study Study 1 Study 2 Study 3 Study 4 1. What are the key contributors to the development of professional identity in dental students and in what ways do they influence this identity? 1. How do dental students perceive the role of professionalism in their education program, and how is it addressed within the curriculum? 1. How do dentists define professionalism in the context of their practice? 2. What workplace barriers and challenges do they encounter that 1. How can ethical scenarios and axiological analysis be used to create structured opportunities for self-reflection that foster professional 32 2. What concerns do students have regarding their professional identity development? 2. How do dental students define professionalism, what motivates them to pursue dentistry, and what qualities do they consider most essential for a dentist? 3. What insights can be drawn from dental students’ perceptions of the current emphasis on professionalism, and what recommendations do they have for improvement? influence their professional identity and behaviour? 3. What factors have the greatest influence on their PIF? 4. What recommendations do dentists have for improving professionalism education in dental training programs? identity formation in dental education? Additionally, the accompanying figure below (Fig. 2-1) visually represents how this dissertation is structured, showing how insights from the first three studies informed the development of the fourth. This structured presentation highlights the progression of the research, culminating in actionable recommendations to enhance professionalism education through the lens of PIF. 33 Figure 2-1 Progression of Studies Informing Professional Identity Formation and Professionalism Education in Dentistry Study 1 aimed to provide a foundational understanding of professional identity formation among dental students, identifying key factors and challenges that influence this development. Building on these findings, Study 2 broadened the scope by exploring students' perceptions of professionalism, focusing on how they define professionalism, their motivations for entering the profession, and their recommendations for strengthening professionalism education. Study 3 extended the investigation to practicing dentists, integrating elements of Studies 1 and 2 to compare students’ and practitioners’ perspectives. This study examined the factors shaping practicing dentists’ professional identity while addressing workplace challenges that impact their professionalism and conduct. 34 While the ideal approach to studying the development of professional identity would have been a longitudinal design—tracking dental students from the start of their training through their years in practice—this was not feasible within the time constraints of a PhD program. Instead, I conducted two cross-sectional studies: one focusing on dental students and the other on practitioners. Although the two participant groups were distinct, my goal was to explore the perspectives of both students and practitioners, seeking to identify any similarities and differences, and to connect these findings with existing literature. This pseudo-longitudinal (cross-sectional sequential design) approach aimed to offer insights into the potential progression of professional identity, despite the limitations of a cross-sectional design. Finally, key findings from Studies 1, 2, and 3 were synthesized to inform the development of an educational strategy, presented in Study 4, aimed at supporting professional identity formation in dental education. 2.3 Methodological Framework This research is grounded in a constructivist philosophical paradigm, which emphasizes the active role of individuals in shaping their understanding of the world through personal experiences and social interactions.123 Professional identity formation (PIF) is inherently subjective, shaped by complex, socially embedded processes, while professionalism develops through socialization, mentorship, and practice.124 The constructivist perspective is appropriate for exploring how students and practitioners interpret and internalize professionalism in dentistry, recognizing that knowledge and identity are co-constructed through social interactions and institutional frameworks. 35 This dissertation primarily employed a qualitative methodological approach, supplemented by descriptive statistical analysis for select quantitative survey components (specifically, 12 slider questions from Study 2). The qualitative approach is well-suited for exploring nuanced, context-dependent phenomena such as professionalism and PIF. Through qualitative methods, including semi-structured interviews and open-ended survey questions, the research aimed to capture the depth and richness of participants’ subjective experiences and perspectives. Additionally, the inclusion of axiological analysis in Study 4 further supported the exploration of value-based conflicts and reflective processes, both of which are integral to understanding professional identity development. Table 2-2 briefly summarizes the methods and data analysis for each of the studies. Table 2-2 A Brief Overview of Methods Employed in Each of the Four Studies Research Design Participants Analysis Approach Study 1: Key Contributors to Dental Students’ Professional Identity Formation In-depth Semi-structured interviews (Secondary Data) Graduating dental students (Progress testing program study) (N=18/46) Thematic analysis informed by grounded theory analysis techniques Study 2: Students’ Perspectives on Professionalism Online Survey (Part 1: Close-ended questions, Part 2: Open-ended questions) Dental students (N=83/225) Descriptive statistical analysis (Part 1) and qualitative analysis (Part 2) Study 3: Dentists’ Perspectives on Professionalism and Key Contributors to Their PIF In-depth Semi-structured Interviews Practicing dental professionals (N=10) Template Analysis Study 4: Educational Strategy to Promote PIF in Students Online Survey (Data from Part 3 of the Study: Two open-ended questions) Dental Students (N=33 out of 83 in Study 2) Axiological analysis 36 2.4 Next Chapters The next three chapters present Studies 1, 2, and 3 in publication format. Chapter 3 introduces the first study, which uses secondary interview data to examine key contributors to professional identity formation (PIF) in dental students. By analyzing these early influences, the findings from Study 1 establishes the foundation for the subsequent studies, which explore the perspectives of dental students (Study 2) and practitioners (Study 3) on professionalism, the challenges they encounter, and how these experiences shape their evolving professional identity. This structured approach provides a comprehensive exploration of PIF and its relationship to professionalism within dental education and clinical practice. To further contextualize these findings, Chapter 6 synthesizes the results from Studies 1, 2, and 3, offering a cumulative perspective on their interconnected contributions to the dissertation's overarching inquiry: What educational practices are required to prepare future dental professionals to embody and maintain strong professional values? 37 Chapter 3 Professional Identity Formation in Dental Students: The Key Contributors and Students’ Concerns1 3.1 Summary Purpose: This study aimed to explore the components of professional identity formation and understand dental students’ concerns towards their professional identity development so that research-informed recommendations can be made to improve dental professional programs. Methods: This is a qualitative study. A total of eighteen students out of the whole graduating class (Class size: 46) were interviewed about their progress through a newly designed curriculum specific for the dental students at a large public research university in Canada. The audio files were recorded, transcribed, and corrected by a research assistant. Using QSR International's NVivo (Version 12), the researchers of this study conducted a thematic analysis to generate overarching themes and extract the relevant components of professional identity formation. Results: Five themes emerged from the study as follows: (i) domain-specific self-efficacy, (ii) role modeling and mentoring, (iii) professional socialization with peers, (iv) learning environment, and (v) reflection. We considered these to be the five key contributors to dental students' professional identity formation. Conclusions: Understanding the main concerns for students and improving the learning environment are critical in helping students form their professional identity. The findings of this qualitative study identified some important aspects of the dental curricula for educators to 38 consider. These results can be used by future research studies to explore models for professional identity assessment tools that can aid in guiding students' professional identity development. Keywords: dental education, professionalism, professional identity formation, self-efficacy, learning environment 1A version of this chapter has been published as Kwon JH, Shuler CF, von Bergmann H. Professional identity formation: The key contributors and dental students’ concerns. J Dent Educ. 2022;86(3):288-297. https://doi.org/10.1002/jdd.12810 39 3.2 Introduction Professionalism is defined as “the conduct, aims, or qualities that mark a profession or a professional person.” 20 In health care, some describe it as ‘medical morality’ 125 and it captures the essential features of a profession including clinical competence, ability to communicate clearly, ethical and legal understanding, commitment to excellence, humanism, accountability, and altruism. 24 A healthcare professional will consider and respond to patients’ needs and be aware of social determinants of health and her social and professional responsibilities.67 In dental education, educators' ultimate aim is to prepare students to become competent clinicians who exhibit professionalism. Hence, professionalism has become an integral part of the dental program. The accreditation bodies in Canada and the United States also recognize its importance and the need to include it in dental curricula. Medical education has the same commitment to the development of professionalism by students. However, those studying professionalism in medical education criticized the way it is taught, if ever, is often superficial, with a list of desirable values and behaviours that can be generated by students with an inadequate depth of thought and commitment.126 Furthermore, considering the market forces and the generational shifts of incoming applicants, who are increasingly more ‘self-centered’ than ‘others-centered’ than previously observed, the past teaching approach may be inadequate. 3,122,127 Education researchers thus argued that something more that is “grounded in what one IS rather than what one DOES” needs to be done 100(p.54). According to Jarvis-Selinger and colleagues, the implicit purpose of teaching professionalism is to help students take on their professional identity. Thus, the educational objective should expand and focus on professional identity formation.99,128 40 Professional identity can be understood as “the concept which describes how we perceive ourselves within our occupational context and how we communicate this to others.”129(p.14) It is “a person’s perception of themselves within a profession or the collective identity of the profession.” 130(p.90) Professional identity formation (PIF) can be described as “a mental process where learners assign meaning to themselves, achieved in stages over time, while internalizing the profession's norms, attributes, and values, resulting in thinking, acting, and feeling like members of the profession.”24(p.8) Professional identity (PI) develops superimposed on the existing identities that began at birth, and it can be influenced by gender, race, religion, nationality, and class.67 At times of transition, individuals gradually go through a series of transformations to form a PI as they socialize into a community of practice, influenced by clinical and non-clinical experiences.93,131 Professional programs play a significant role in students' PIF by helping them acculturate into their chosen profession. However, the development of PI does not end when students complete their program. PIF is a fluid, dynamic, ongoing process.132 If developing a PI is critical to achieving professionalism, understanding the factors contributing to dental students’ PIF during their preparation years will be necessary. Our objectives for this study were to: 1. Investigate and analyze the relevant components of professional identity in dental students, and 2. Explore students' concerns towards their professional identity formation. 3.3. Methods 41 This is a qualitative study that involved interview data. The data used in this paper was a part of a bigger study that received approval from the ethics board of the University of British Columbia (# H16-00957). 3.3.1 Context of the Previous Study Doctor of Dental Medicine (DMD) students used to take a joint biomedical curriculum with Doctor of Medicine (MD) students at the University of British Columbia (UBC). This curriculum, however, was mainly geared towards MD students. Over the years, the DMD faculty and students increasingly highlighted the specific learning needs of the dental profession. Starting in 2010, the faculty began extensive re-evaluation and revised the DMD program. From the beginning of the 2015 fall semester, curricular changes based on the students' feedback and experiences were implemented one year at a time, allowing a smoother transition to the newly revised DMD curriculum. Some of the modifications included interactive style learning, case-based learning relevant to dentistry, and the Progress Testing Program, through which students could monitor their acquisition of dental knowledge with 200-item online multiple-choice exams given to all UBC dental students twice a year. By 2019, the DMD students who have experienced the full four years of the newly revised curriculum were invited to participate in this study to reflect on their progress through the program and review the implemented curriculum. Each interview participant received a $30 e-giftcard as a token of appreciation. Out of the forty-six graduating DMD students who were invited, eighteen volunteered to participate in an hour-long individual semi-structured interview. Interviews were recorded, and later transcribed and corrected by a research assistant to ensure transcription accuracy. 42 3.3.2 Data Analysis The secondary interview data from the Progress Testing Program study was imported into QSR International’s NVivo (Version 12), and Strauss and Corbin’s approach to data analysis was applied.133,134 First, categorization and thematic coding were used to identify six overarching themes, twenty-three sub-themes, and thirty-five main concepts. After open coding was used to categorize data until no more sub-themes and concepts emerged, axial coding was conducted to link the themes and concepts relative to influencers of PIF. After the results were compared across all participants’ interview transcripts, selective coding was used to extract and integrate relevant sub-themes and concepts to possible components involved in professional identity formation. Figure 3-1 illustrates the process of data analysis. Figure 3-1 Process of Coding Applied to Eighteen Participants’ Transcripts It is important to acknowledge that the use of secondary data in this study limited the ability to conduct a full grounded theory study; therefore, a thematic analysis guided by 43 grounded theory methods was conducted instead. Grounded theory typically involves simultaneous data collection and analysis, enabling iterative exploration and theory development.133 It also depends on theoretical sampling—where participants and data sources are selected based on emerging concepts—and constant comparison to ensure that the developing theory is deeply grounded in the data.134 These key methodological components were not possible with secondary data. However, to maintain systematic rigour and structure, Strauss and Corbin’s grounded theory analysis method was applied. This approach facilitated a thorough and organized examination of the data, ensuring that the findings remained robust and meaningful despite the limitations of using secondary data. 3.4 Results and Discussion Table 3-1 presents the themes and concepts identified through open coding, highlighting the key patterns and categories that emerged from the data. From open coding, I analyzed and categorized the data into six main themes: 1) Comments about courses, 2) Desirable qualities of a dentist, 3) Motivation for applying for dentistry, 4) Learning experience, 5) Reflection on their progress from year one to four, and 6) Student expectation. From the general themes, sub-themes and main concepts were identified. 44 Table 3-1 Themes and Concepts Identified from Open Coding General Themes Sub-theme Main concept No. of references 1. Comments about courses 1-1 Ethics course 1-1-1 Content not useful 1-1-2 Redundant 1-1-3 “Ethics cannot be taught” 1-1-4 Common sense 20 1-2 Introduction to Dental Practice 1-2-1 Content not explained properly 1-2-2 “It’s about infection control” 17 2. Desirable qualities of a dentist 2-1 Humanistic 2-1-1 Compassionate and empathetic towards patients 2-1-2 Build rapport with patients and make them feel comfortable 2-1-3 Ethical practice 2-1-4 Be kind towards patients and earn respect from them 2-1-5 Patient focused 5 2-2 Clinical 2-2-1 Familiar with new materials 2-2-2 Good patient management 2-2-3 Be proficient 2-2-4 Solve problems 5 3. Motivation for applying for dentistry 3-1 Aspirations to become a dentist from early on 2 3-2 Being my own boss 1 3-3 Curiosity and interest 10 3-4 Desire to help others 1 3-5 Inspired by other dentists 1 3-6 Just take whatever comes 3-6-1 Too hard to get into medicine, so applied to dentistry 3-6-2 Lack of knowledge about profession before getting in 4 3-7 Like working with hands 2 3-8 work-life balance 2 4. Learning experience 4-1 Positive learning experience 4-1-1 Applicable to the real world 4-1-2 Good communication with clinical instructors 4-1-3 Instructors make time for students 4-1-4 Networking with peers 6 4-2 Negative learning experience 4-2-1 Bad role model 4-2-2 Don't agree with the clinical instructor on patient treatment 4-2-3 Learning environment uneasy, intimidating, and uncomfortable 4-2-4 Stressed that they aren't going to be good enough 17 5. Reflection 5-1 Reflection on their progress from year 1 to 23 45 year 4 through Progress surveys 6. Student expectation 6-1 Change the curriculum for efficient learning 18 6-2 Make contents more relevant 7 6-3 Provide a checklist of things to be done 6-3-1 Understand that students want to do well. Without a checklist of what is expected, they are lost 1 6-4 Have more time for clinic 6-4-1 Students want to be proficient 11 6-5 Better student to instructor ratio 6-5-1 Students want to do well but not enough instructors to guide them 6 6-6 UBC teaching contents a little different from what is expected from the National Board exam 1 6-7 Reorganize courses for efficiency and relevance 6-7-1 Want to focus on more practice relevant information rather than spending time on ethics 6-7-2 Reorganize practice management because the same content is taught again in later years 6 6-8 Problem-based learning 6-8-1 PBL was geared towards medicine in the beginning 6-8-2 Students should be taught formal lectures first before having PBL discussions 6-8-3 Some students like PBL 4 From the identified general themes and concepts, the researchers used axial and selective coding to extract five key components influencing professional identity formation: 1) Domain-specific self-efficacy, 2) Role modelling and mentoring, 3) Professional socialization with peers, 4) Learning environment, and 5) Reflection. The results and the corresponding quotes are in Table 3-2. 46 Table 3-2 Components of Professional Identity Components Sub-component Example comments 1. Domain-specific self-efficacy Desire to become competent “…like you have to keep on top of everything. If you want to be a good dentist, you have to know the new materials, new technique...” “I would like to be proficient. How to do the dental procedures, how to manage patients, becoming familiar with all the dental materials and all the knowledge…” “I want to be a dentist who is very proficient at what they are doing, someone who feels comfortable with their skill set...” “I guess just a competent one that is able to problem solve and be kind to patients and have them like respect me…” 2. Role modeling and mentoring Positive “she made it a learning experience. Again, like a positive learning experience. She always made herself available. Really like typing out detailed emails that are just completely transparent…” “We have a clinical advisor that we can go and talk to…” Negative “She just berated students in front of their patients… she was hovering over him the entire time and it was just like breathing down your neck, like measuring every freckle on the face…” “…it doesn’t make sense sometimes and just having some incidents where she failed people professionalism for all stupid reasons…” 3. Professional socialization with peers Networking with peers “…learning the communication skills and kind of building like social networking was really big here…”. "I really enjoy the camaraderie that I've had with my classmates…" “We’re in a pretty small community of dentists in BC, so it’s nice to feel like I have these connections with people that I can kind of rely on and stuff going forward…” 4. Learning environment Organizational changes (eg. Clinic, student-teacher ratio, classroom, curriculum) “…that’s why I joined gold club because we have like a two to one instructor ratio… they don’t do any of it for you, which is great because they actually have the time to teach you. But in clinic, my instructor did the entire thing because we were behind in time because he had too many students….” “I don’t really understand why we’re not like in a better relationship with the hygiene department and why we don’t delegate to that hygiene department. …we don’t have time to see all of our perio patients. And I think like it’s actually not fair to our perio patients…” “Sorry, I feel like we had some things that were fillers, like for instance, geriatrics…” “principle ethic, it was good but I didn’t find that it contributed much to my dental knowledge or passion in anyway. It was kind of like something we already knew that we almost felt it was a waste of time…” "I think practice management could be reorganized into a much more useful course." “….I know we put a lot of emphasis on PBL, but I really think the lecture should come first. We shouldn’t be learning this stuff on our own. We shouldn’t be teaching ourselves and then coming back on Friday, be enlightened about a certain topic… It just doesn’t make sense to be the other way around…” 5. Reflection Reflection on their progress from year 1 to year 4 through “I definitely notice in most of the progress surveys, there's always one subject that I always kind of feel like I'm lacking on…” 47 the Progress surveys “..it made me realize where my faults are, like what subjects I was a little bit withdrawn from… I'm going to go back and read more of the dental facts about it or answer our questions or even just go back to like old notes…” "…if you were deficient compared to the class, those might be areas that you would want to personally spend some more time on…" “I feel like that's just for me personally. I think it's a useful adjunct because it's interesting to see your progression. Um, but for me and knowing my personality, I probably would have still gone through the same method of looking at the question bank and as well as the dental decks.” Dental education goes beyond teaching and demonstrating mastery in clinical knowledge and competence. The ultimate goal is to prepare a dental professional who can exhibit the values set by the profession. As described in health sciences education literature, professional identity formation should be the central focus of dental education because professionalism and professional identity are tightly coupled. By recommending PIF as the program goal, it can potentially help students understand the concept of professional identity, teach them about how it connects to professionalism, potentially help them be engaged in their progress and become active participants of their own professional identity development. The movement to emphasize the PIF in medical schools partly derives from psychologists who studied moral development of individuals. They examined the difference between “knowing and doing,” noting that strong beliefs in acting according to the values set by profession may not be enough to generate behaviours if they are not deeply rooted in their identity.97 If we accept PIF as the fundamental goal of dental education, then we must first understand what contributes to its process. This study sheds light on its five relevant contributors: domain-specific self-efficacy, role modeling and mentoring, professional socialization with peers, learning environment, and reflection. In this discussion, we describe the findings situated in both of our professional experiences in dentistry and literature in the areas of professional identity formation. 48 Contributor One: Domain-specific self-efficacy When the participants were interviewed, they were asked to reflect on “what kind of dentist you had envisioned becoming when you first entered the program?” and “how much of their learning experience helped them reach their goal by graduation?” Based on the students' answers, organized in the second category in Table 3-1, "Desirable qualities of a dentist," the DMD students equally value both soft skills and hard skills. They perceive good dentists to be competent in what they do while caring towards patients. Contrary to this view, what is presented in the last category in Table 3-1, "Student expectation," shows that the DMD students' main focus for learning is becoming clinically competent at dental procedures rather than being more compassionate towards patients. Simply put, from students' perspective, being a dentist weighs more on performing dental procedures proficiently. Student 1: “I would like to be proficient. How to do the dental procedures, how to manage patients, becoming familiar with all the dental materials and all the knowledge…” Again, students’ point of view is revealed through their comments under the general theme, category 4 “Learning experience,” concept 4-2-4 “stress that they aren’t going to be good enough.” Student 9: “for restorative, no matter how much you study or how much you practice at the time, you can’t really control the outcome. I think it was a lot of like stress and pressure on me…because you’re always worried, ‘oh, if I can’t do it now, I’ll never be able to do it in the future.’” 49 From students’ concerns about their performance and their suggestions on what they would like to improve about their learning environment, it appears that achieving a certain level of dental-related self-efficacy is a vital element of PIF for dental students. Figure 3-2 Domain-Specific Self-Efficacy as a Factor for Professional Identity Formation Contributor Two: Role modeling and mentoring Role modeling and mentoring are closely related to professional socialization. We divided up role modeling and socialization with peers into separate categories because, based on the content and the frequency of students’ comments, it shows that educators play a crucial role and may have a more significant impact on students’ PIF. Having a good role model is extremely important for bringing up the next generation of good role models, even influencing career choices.135 In medical education literature, it is often reported that students choose a particular specialty in medicine because they like the role model (the person) rather than having a genuine interest in the specialty itself.93 In this study, some of 50 the students’ comments indicated that what motivated them to apply to the program was based on the positive perception of their regular dentist. Student 6: “…when I shadowed my dentist, he’s like, ‘Oh, you could do anything you want. Why don’t you be a dentist?’ Yes. Okay. I liked how nice and clean and smooth the office was, and how everyone seemed to be happy to see him… So I was like, I could see myself doing this…” Students had a favorable view of the instructors who were approachable and made themselves available or taught them the dental knowledge they felt was highly applicable to the real-world practice. Student 7: “We have like a clinical advisor that we can go and talk to...” Student 12: “…she kind of made it into a positive learning experience. She didn’t punish you for anything. She always made herself available…” Student 10: “it’s very applicable to the real world. It’s like getting an introduction on how the real-world dentistry actually works.” While educators can positively influence students’ motivation, productivity, competency, satisfaction, and professional growth, they can also have an opposite impact on students. If role models or mentors are not supportive and if students’ experiences with them are not interpreted as positive, they can profoundly impact professional behaviors and possibly inhibit PIF.105,136 Student 3: “She was brutal… She berated students in front of their patients…She just totally missed the point of what this module was supposed to be.” Contributor Three: Professional socialization with peers 51 Building relationships with peers can act as an essential contributor in PIF as it provides a sense of belonging to a professional community of practice. Small group learning as a pedagogical approach has been one of the core emphases in the UBC Dentistry. Such an approach intentionally builds collaboration habits and fosters the establishment of a community. Student 12: “I really enjoy the camaraderie that I’ve had with my classmates. It was really good to experience these four years of dentistry with each other.” Student 4: “…learning the communication skills and building social networks was really big here…We’re in a pretty small community of dentists here, so it’s nice to feel like I have these connections with people that I can kind of rely on going forward.” Contributor Four: Learning environment The learning environment (LE) is defined as the “social interactions, organizational cultures and structures, and physical and virtual spaces that surround and shape the learners’ experiences, perceptions, and learning.”137(p.969) This definition also includes the clinical environment, ranging from the student-instructor ratio, instructors’ attitude or behavior towards students. All these contribute to the creation of a certain learning atmosphere. An intimidating and hostile clinical environment and frustration with the curriculum could bring unnecessary stress on students and may negatively impact their PIF. Student 13: “…I remember just feeling awful, and for this one course, if I didn’t know anything, they were like ‘go read your books and come back.’ Great. I hear that...So it was a really hostile environment...I didn’t trust the instructors to be kind and friendlier or more helpful on the spot…” 52 Student 11: “….I know we put a lot of emphasis on problem-based learning (PBL), but I really think the lecture should come first. We shouldn’t be learning this stuff on our own. We shouldn’t be teaching ourselves and then coming back on Friday, be enlightened about a certain topic… It just doesn’t make sense to be the other way around…” Student 14: “…Intro to dental practice, we learn to wipe down all the operatories, infection control... I felt that it was overdone…a waste of equipment...” Contributor Five: Reflection Reflection plays a vital role in identity formation. Dewey argued that reflective thinking could be used to solve problems.138 Schön agreed with Dewey and further expanded our understanding by introducing the ideas of “reflection-in-action” and “reflection-on-action.”63 When reflection is done "in action," there is a continuous internal dialogue as individuals face a problem. When reflection is done "on action," they reflect on their prior experiences as they construct and revise meaning and explanations.63 This continuing reinterpretation of relevant experiences is analogous to professional identity formation, which develops from understanding one’s professional self in terms of values and beliefs through continuing narratives of relevant experiences.139 The Progress testing program was designed to help the students critically reflect on their learning with the regular benchmarking reports. By comparing their scores year after year and measuring themselves against the class median, students can derive further learning needs (reflective learning).140 Ultimately, educators expect students to link between classroom learning and clinical practice (reflective practice). Improvement in clinical performance brings positive changes in self-appraisal and confidence. 53 Student 3: “If there were areas we were deficient in, maybe compare to the class, those might be the areas that you would want to personally spend some more time in.” Student 5: “I think in the beginning, I didn't really find it (the Progress tests) that useful… that was actually a way to test my knowledge in the field to see what I know and what I don't know. So it was helpful for me. I felt that the most effective Progress survey was the very last one you gave us.” Student 12: “It (the Progress surveys) made me realize where I lacked in, like what subjects I was a little bit withdrawn. Especially this year, as we come close to the board exam, it helped with that aspect. This is a nice kind of run-through before the board. These are the areas I’m going to go back and read more on or answer more questions, or even just to go back to my old notes…” To conclude the results and discussions above, one critical finding from our study that needs to be highlighted is domain-specific self-efficacy, in our case, dental self-efficacy. This factor has not been widely discussed before or explicitly identified as a contributor to PIF in dental education. Previously in the medical education and dental education literature, role models and mentors, clinical/non-clinical experiences, formal teaching and assessment, peers, and reflection received much attention as elements influencing PIF.121 The notion that dental self-efficacy contributes to PIF is closely linked to the students’ perspective of what it means to be a dental professional. In reviewing dental education curricular studies, clinic time has often been brought up. Similarly, anxiety associated with lack of clinic time was the common complaint from everyone 54 who was interviewed. From the dental students’ perspective, the desire to enhance their clinical skills is only natural if their professional identity strongly centered on achieving clinical competence. The acquisition of psychomotor skills is significant for successful dental professionals, as their typical daily routines include a wide range of procedures requiring varied levels of psychomotor skills. Developing these skills needs an ample amount of time and practice. The students' remark regarding needing more clinic time evidenced their perspective of what becoming a dentist means to them. Professional self-efficacy is defined as the perception of self being able to perform professional tasks. For the dental students, performance in the clinic helps them to evaluate their dental self-efficacy. Repeatedly meeting or exceeding the clinical standard fosters a positive sense of dental self-efficacy, while frequent negative feedbacks or substandard performance lowers it. Timely and constructive feedback is critical in the development of students’ sense of self-efficacy. When students’ dental self-efficacy is increased, in other words, when they can do the procedures to their satisfaction, they may feel more like a dentist. Implication for educators One of the objectives of this study is to provide suggestions for dental educators. Figure 3-3 is my attempt to describe, based on the qualitative data of dental students, the five contributors to dental students' professional identity formation. 55 Figure 3-3 Five Contributors to Dental Students’ Professional Identity Formation Dental students are becoming oral professionals who will serve the public. How they form their professional identity and other identities has important implications for their present wellbeing and the future relationships they form with colleagues and patients.141 As identified through this study, educators can be role models or mentors and play a vital role in students’ PIF. Identities are created during all sorts of interactions, both in formal and informal settings.142 Educators can positively influence students by demonstrating appropriate behaviours fitting to the profession in an organized setting.143 Students adopt behaviours and traits that appear successful to them.141 There is also a danger that students can be negatively influenced if the environment is hostile and exclusionary or if there are many individuals who model unprofessional behaviours. These factors should be addressed so that the learning environment 56 can support students’ PIF. Therefore, institutions must reflect on the norms and conventions that could influence students’ behaviours.144 Educators' attitudes and feedback also have a significant impact on students. Our study participants noted that they were troubled by a possible "you are not going to be a good dentist" stigma caused by poor performance in some clinic sessions and what they believed their instructors thought of them. Although educators understand that there is a learning curve in developing psychomotor skills and sufficiently implementing dental knowledge, the way feedback is given to students may not reflect this understanding. How students perceive and interpret feedback is critical to the effectiveness of the formative assessment and involves both emotional state and personal tendencies.145 As several recent studies suggest, today’s applicants to the medical and dental programs tend to have greater expectations, higher levels of narcissism and entitlement, and more anxiety and mental problems.146 Therefore, providing feedback while considering these generational changes is essential. It is important to note that students naturally focus on what is assessed, which are primarily procedural skills and not human skills. Dental students figure out very quickly the aspects of the program that yield them positive rewards. Nevertheless, educators have an important yet challenging mission to guide students to develop PI and moral reasoning so that they could become effective and altruistic dental professionals despite these huge impediments. Limitations A bigger sample size could add a richer view to the data. We could have had more participants if we used an online survey, but we chose individual interviews because we wanted 57 to hear their honest and open reflections of the revised program and their journey of becoming a dentist. 3.5 Conclusion Professional identity formation is influenced by personal, social, and environmental aspects, as identified in this study. Under the three main aspects, domain-specific self-efficacy, role modeling and mentoring, professional socialization with peers, learning environment, and reflection were found to contribute to students' professional identity formation. Based on listening to the students and reading through the transcripts, we found that each aspect carries a different weight of importance for the students' PIF, depending on their disposition and background. The hidden curriculum could provide both opportunities and threats to students’ PIF. Understanding the contributors of PIF could greatly help educators devise a plan that can foster professionalism in professional programs. In addition, improving the learning environment in both clinic and classroom was found to be critical in helping students form their professional identity and lead to professionalism. Funding This study was financially supported by the UBC Teaching and Learning Enhancement Funds (TLEF) (2014-2017: 14G32326). 58 3.6 Next Chapter The findings from Study 1 provided valuable insights into the key factors influencing the professional identity formation (PIF) of dental students. Building on this foundation, the next chapter uses a survey to further explore students' perspectives on professionalism—how they define and interpret professionalism within the context of their dental education—and how these perspectives may contribute to the development of their professional identities. 59 Chapter 4 Navigating Professional Identity Formation: Insights and Challenges in Dental Student Professionalism 4.1 Summary Purpose: Professional identity formation (PIF) is a process-based framework for understanding professionalism. It focuses on how individuals integrate professional values and roles into their broader sense of self. However, limited research exists on how dental students perceive professionalism and how these perceptions shape their developing professional identities. Understanding these perspectives may provide insight into their PIF journey and help inform the design of educational strategies to address their need. This study aimed to examine dental students’ perspectives and gather their recommendations for enhancing professionalism education. Method: An online survey was emailed to undergraduate students in the Faculty of Dentistry at one Canadian university. Descriptive statistics and thematic analysis were performed using JASP version 0.16.1(https://jasp-stats.org) and QST International’s Nvivo (Version 12) software, respectively. Results: The participants reported that they felt they had a good understanding of professionalism and expressed confidence in identifying unethical behaviours within clinical settings. While students noted that professionalism is an important element of dental education, some believed that values such as empathy, honesty, and respect could not be fully taught through a professional program. Students provided several recommendations to enhance 60 professionalism education: 1) the role of dental school role models in teaching professionalism should be taken more seriously, 2) explicit discussions on professionalism issues should be integrated throughout the entire program, and 3) effective methods should be designed and employed to measure students’ professionalism development. Conclusion: Based on students’ perspectives reflected in the survey, our findings suggest that the adoption of professional values by students should not be assumed but must be purposefully and explicitly discussed throughout the program. Professional identity formation is a developmental process for every learner, and understanding their views on professionalism—along with identifying ways to enhance education in this area—can provide valuable insight into how their professional identity is shaped. Key Words: professional identity, professionalism, dental education, perception, survey 61 4.2 Introduction Professionalism remains crucial to dental education, encompassing the values, traits, and skills essential for good oral health practice.121 The increasing focus on professionalism in dental education highlights the importance of understanding how students and practitioners conceptualize this crucial aspect of their professional identity and professional growth.147,148 Analyzing how they perceive and internalize professionalism at different stages of their education and career allows educators to evaluate developmental milestones, identify strengths and areas for growth, and generate actionable recommendations to improve educational strategies.149 This understanding enables the creation of tailored curricula, effective role modelling, appropriate assessment methods, and initiatives that support student wellbeing.149 In dentistry, professionalism is especially critical as it influences patient-provider relationships, ensures high standards of care, and fosters public confidence in dental practitioners.51,121 While no single definition of professionalism has been universally adopted as discussed in Chapter 1, dental and medical educators commonly emphasize key attributes such as competence, integrity, respect, and accountability.32,148 The American Dental Education Association (ADEA) codified these principles in its 2009 Statement on Professionalism, identifying six fundamental values—competence, fairness, integrity, responsibility, respect, and service-mindedness—that guide dental professionals in their commitment to patient-centered care.150 Dental education programs aim to uphold these values, preparing students with both the essential clinical and ethical competencies required for professional practice. Challenges in Teaching and Assessing Professionalism 62 Teaching professionalism in dental education presents significant challenges, largely due to the complexities involved in assessing this multifaceted concept. According to Stern, as mentioned in Section 1.3, the foundation of medical professionalism rests on three core elements: clinical competence, communication skills, and ethical and legal understanding.24 Building on this foundation are aspirational principles—excellence, humanism, accountability, and altruism—that, while essential to professional development, are difficult to measure as observable behaviors.24 Unlike clinical skills, professionalism encompasses these broader values and ethical decision-making, which are often challenging to assess objectively.151 Assessment innovations are further constrained by the loosely structured nature of many evaluation methods, necessitating a range of tools and techniques, a process known as triangulation, to capture students' growth in this area effectively.152 Traditional assessment models struggle to keep pace with the abstract and diverse definitions of professionalism, making it challenging for educators to accurately gauge students' progress.153 While peer feedback, self-reports, and faculty evaluations can offer valuable insights, they often fall short of capturing the full scope of a student’s professional development.154 Advancements in Professional Identity Formation Research To address these challenges, recent research has turned toward professional identity formation (PIF) as a framework for understanding and promoting professionalism within healthcare education.99 PIF emphasizes the journey students undergo as they internalize the values, attitudes, and behaviours of their chosen profession.121 My earlier study (Study 1) in Chapter 3 identified key contributors to dental students’ PIF as role modelling, domain-specific self-efficacy, peer socialization, the learning environment, and reflection, all of which contribute 63 to a student’s evolving professional identity.155 Results from Study 1 provide educators with key areas to consider when designing curricula and learning environments that support dental students’ PIF, offering insights into how targeted strategies can strengthen this identity formation. By emphasizing the integration of professional values rather than solely focusing on behaviours, PIF research offers a potential approach to curriculum design that aligns with the complex and gradual nature of professional growth. It is important to understand this within the context of dental education. The Aim of the Study The increasing emphasis on professionalism in dental education underscores the need to better understand the values, behaviours, and identities that contribute to professional development. While professionalism is widely regarded as a core element in dental education, there is ongoing discussion about how to best teach, assess, and support its development. Gaps remain in how dental students and practitioners conceptualize professionalism, which may have implications for how professionalism education is structured. Without this insight, efforts to teach and assess professionalism may miss key components that resonate with those in the field. This study aims to explore these gaps by using a literature-informed survey to investigate dental students’ perceptions of professionalism and gather insights that may inform future curriculum development. 4.3 Methods This study received approval from the ethics board at the University of British Columbia (# H20-03728). Informed consent was obtained from all individual participants. 64 4.3.1 Survey Development For the survey development process, I used Stern’s definition for assessing professionalism, the American Dental Education Association (ADEA)’s professionalism domains, and my prior research on factors influencing dental students’ professional identity development (Study 1).24,150,155 I identified overlaps among these sources in terms of values and key components. From this, I extracted elements such as "clinical competence," "ethical and legal comprehension," "communication proficiency," "excellence/competency," "humanism," "accountability/responsibility," "altruism," "role modelling," and "learning environment" to inform my item design. The questions were designed to capture students’ perspectives rather than directly assess their level of professionalism. Furthermore, I included a question to assess the degree of acceptance of professional values taught in the program and another to explore their motivation for pursuing dentistry. These two questions aim to understand students’ professional identity and their initial motivation to enter the profession. The survey consisted of twelve slider questions and four open-ended questions. Slider questions were designed to investigate students’ perspectives of dental professionalism, professional values, role modelling, and the learning environment. The scale for these slider questions ranged from zero to 100, with zero indicating “not at all” and 100 indicating “extremely.” For instance, in question seven (Q7), “I think professionalism is a critical component of oral health education,” zero signifies “not at all” and 100 signifies “extremely.” Slider questions are a distinct feature of web surveys, presenting a horizontal or vertical line with a movable bar. Participants indicate their responses by clicking and dragging the bar to the desired position on the line.156 65 The four open-ended questions aimed to inquire about students’ motivations for entering the profession, their understanding of professionalism in the oral healthcare context, their definition of exemplary professionalism, and their recommendations for fostering students’ professionalism. I pilot-tested this survey with a small group of graduate students (N=10), all of whom were recent graduates from dental preparation programs and early-career dentists, as well as members of the faculty’s education research lab, in December 2020. Subsequently, I had discussions with these pilot participants to evaluate their understanding of the survey questions, measure the average time taken to complete the survey and collect possible suggestions for improvement. In response to feedback from the pilot participants, the questions were reworded to solve ambiguities and improve clarity. Afterwards, the survey underwent review and modification with input from the research team prior to its submission for ethical approval. 4.3.2 Sampling and Administration of the Survey This study employed a cross-sectional survey method, integrating both quantitative and qualitative sections. Purposive sampling was utilized to select participants. The target population was full-time undergraduate Doctor of Dental Medicine (DMD) students at the University of British Columbia (UBC) Vancouver Campus. Qualtrics was used as the survey delivery platform, as it is the standard survey tool provided by UBC to faculty and students. After obtaining the ethics approval, participants received an email containing a survey link and a letter of consent. It was explicitly stated that participants consented to participate in the study by clicking the provided link, with the option to 66 withdraw at any time by refraining from submitting their responses. To incentivize participation, one participant from each program year was randomly selected to receive a $40 coffee gift card. Data was collected from January 1st, 2021, to February 28th, 2021. Three reminder emails were sent following the initial survey dissemination to encourage further participation. Descriptive statistics and thematic analysis were performed using JASP version 0.16.1(https://jasp-stats.org) and QST International’s Nvivo (Version 12) software, respectively. 4.4 Results and Discussion Of the 225 DMD students, 83 participated in the survey (participation rate: 37%), with 98.6% completing the slider questions and 74.5% completing the short-answer questions. The difference in response rates is likely due to the relative ease of interacting with slider questions, which require simple clicking and dragging, compared to the effort needed to type out responses for short-answer questions. 4.4.1 Part 1: Slider Questions Table 4-1 below presents the results from the slider questions, sorted by values from high to low. To encourage participants to engage thoughtfully with the survey, short-answer questions were interspersed among the slider items, resulting in the 12 items not being sequentially numbered. Question 13 was designed as a reverse-scored item to assess perceptions of altruism. Due to its negative wording, a lower mean score reflects a more favourable outcome. The items that are highlighted in red indicate mean scores below 70. For Q13, even when the item is 67 reversed, a mean score below 70 continues to reflect a less favourable perception of altruism compared to items with higher scores. Table 4-1 DMD Students’ Perspectives on Their Professionalism Education Note: For the slider scale, 0 represents “not at all,” 10 represents “extremely” Statements DMD (N=83) Q12 I respect a patient’s opinion and decision even if it differs from my professional judgment 86.35±13.07 Q7 I think medical/dental professionalism is a critical component of oral health education 86.33±12.71 Q17 Values such as empathy, honesty, respect, etc. are equally important aspects of oral health profession as clinical skills and knowledge 86.01±13.51 Q9 My professional program explicitly teaches about ethical principles regarding patient management 84.35±14.81 Q11 I can identify unprofessional behavior and practice 83.90±15.40 Q5 I understand about professionalism in oral healthcare settings 83.31±15.17 Q8 My professional program explicitly teaches about professionalism 78.12±20.84 Q14 When I give or suggest treatments, I often take into account my patients’ ability to pay 73.73±21.15 Q16 My values as an oral health professional have increased since entering this program 69.69±23.96 Q10 Most of my current or past instructors are my oral health professional role models 67.87±24.72 Q15 I believe values such as empathy, honesty, respect, etc., can be taught in a professional program 57.54±27.00 Q13 In general, I often think about my needs first before others’ needs 44.83±26.37 68 This table provides a snapshot of students' perspectives on professionalism, shedding light on their ethical understanding, values, and education experiences within their dental program. The highest scores were in the values of empathy, respect and accepting patients’ opinions and decisions, as well as the importance of professionalism (Q12, Q17, Q7). Students also feel that they have a good understanding of professionalism (Q5), and reported that they could identify unprofessional behavior (Q11). However, they may not fully agree that values like empathy and honesty can be effectively taught through formal education (Q15). Role modelling is viewed as moderately impactful (Q10), though variability in responses indicates inconsistency in students’ experiences with role models. Students place high value on ethical care and respect for patients (Q12, Q14), but show a moderate score in prioritizing others' needs over their own (Q13). 4.4.2 Part 2: Short Answer Questions The short-answer section of the survey explored four key aspects, including 1) students’ definitions of professionalism, 2) the qualities students consider most important for a dentist, 3) 3) motivations for entering the program, and 4) their recommendations for improving professionalism education. The responses were analyzed using thematic analysis with NVivo software. 1) Students’ Definitions of Professionalism Figure 4-1 illustrates the qualitative thematic analysis of students’ definitions of professionalism in dentistry. Although the data was analyzed qualitatively, frequencies were included to highlight which themes students emphasized most. The most frequently mentioned theme was patient- 69 centered care (20 times), which encompasses sub-themes of having the patient’s best interest at heart, caring, and patient autonomy. The second most frequent theme students used to define professionalism was respect (15 times), underscoring the importance students place on maintaining respectful interactions within their professional roles. Respect was followed by upholding the standards of the profession and demonstrating honesty and ethical behavior, highlighting their recognition of integrity and adherence to professional norms as central to professionalism. Figure 4-1 Dental Students’ Definitions of Professionalism in Dentistry Students also identified appropriate outfit and presentation as an important component, suggesting that students in their early stages of developing into dentists, they may focus on more tangible, superficial aspects of professionalism. While less frequently mentioned, good interpersonal relationships with colleagues and patients was also noted several times, suggesting an awareness of the relational and patient-centered dimensions of professionalism. 70 2) Most Important Qualities of a Dentist According to Students Figure 4-2 illustrates key attributes identified by students as the most important qualities of a dentist. Similarly, frequencies were used to highlight which attributes students emphasized most. Figure 4-2 Most Important Qualities of a Dentist According to Dental Students According to students, clinical skills and knowledge was identified as the most important qualities for a dentist. This aligns with findings from Study 1 on key contributors to students’ professional identity formation in dentistry. In Study 1, students highlighted domain-specific self-efficacy, or dental self-efficacy in this case, as a key contributor to their professional 71 identity.155 At this stage of their PIF, students view clinical proficiency as the most essential aspect of the dental profession, emphasizing their commitment to mastering clinical skills. Honesty and integrity were closely tied to the ethical dimension of professionalism. Attributes such as effective communication skills and collaboration, compassion and empathy, and respect towards colleagues and patients underscore a strong emphasis on interpersonal and relational aspects of professionalism. These findings are consistent with students’ earlier definitions of professionalism, where respect and communication were recurring themes. Patient autonomy also emerged as a valued attribute, reflecting students’ awareness of the importance of respecting patients' rights and decisions. This is closely related to the patient-centered approach noted in their definitions of professionalism. In contrast, appropriate appearance was mentioned far less frequently, indicating that while students acknowledge the significance of professional demeanor, they prioritize other attributes such as clinical skills, ethics, and interpersonal qualities. This observation also aligns with students’ definitions of professionalism, where appearance was considered less critical compared to other aspects. 3) Motivations for Entering the Program Thematic analysis of students’ motivations for entering dental programs revealed five key themes: lifestyle choices (32%), joy of working with people (24%), curiosity and interest (22%), monetary reward (17%), and family business (5%). Figure 3 illustrates the analysis result. 72 Motivation Relevance to Professional Identity Implications for PIF in Dental Education Lifestyle Choices (32%) Students may focus on work-life balance, financial stability and flexibility; might take a more transactional approach to PI Emphasize balance between lifestyle benefits and professional responsibilities. (study 4 implications) Joy of Working with People (24%) Students value interpersonal relationships; aligns with empathy, communication, and patient-centered care; fosters relational PI. Focus on interpersonal and communication skill development. Curiosity and Interest (22%) Likely to develop PI tied to lifelong learning, innovation, and advancing skills; supports intrinsic professional identity. Reinforce this intrinsic motivation by encouraging reflective practices, continuous learning, and critical thinking. Monetary Reward (17%) Students may focus on external rewards; over time, they need to integrate ethics and patient-centered values into their PI. Highlight professionalism, ethics, and patient-centered care to balance financial motivations. Family Business (5%) Students are influenced by familial expectations; may experience external pressures to prioritize their family reputations Support individual professional identity formation while respecting familial influences. Figure 4-3 Students’ Motivation for Entering the DMD Program As shown in the figure, 32% of the surveyed students (83 out of 225 respondents) cited lifestyle choices as their primary motivation. This was followed by joy of working with people (24%), curiosity and interest (22%), monetary reward (17%), and family business (5%). To better understand how these motivations relate to professional identity formation (PIF) and professionalism, Self-Determination Theory (SDT) was used as a framework for analysis to classify each motivation as intrinsic or extrinsic.157–159 SDT provides a useful lens for understanding how dental students internalize professional values and expectations, influencing their PIF. According to SDT, individuals are more likely to internalize and integrate the values and expectations of their profession when they experience a sense of competence, autonomy, and 73 connection to others or relatedness within their professional environment.157,158 In the context of dental education, these three psychological needs play a critical role as students navigate academic demands, clinical responsibilities, and professional interactions, all of which shape their evolving professional identity. Study 1 in Chapter 3 identified key contributors to dental students’ PIF—role modeling, domain-specific self-efficacy, peer socialization, the learning environment, and reflection—many of which align with SDT’s psychological needs. The learning environment, and self-efficacy contribute to competence, while role modelling and peer interactions foster connection to others. Similarly, opportunities for reflection and independent decision-making in clinical and educational settings allow students to develop autonomy, as they learn to take responsibility for their professional choices. While other motivational frameworks, such as Maslow’s Hierarchy of Needs160 and Expectancy Theory161 provide valuable perspectives on motivation, SDT was selected for its emphasis on these three psychological needs. These elements are particularly relevant to dental students as they navigate academic demands, clinical responsibilities, and social integration within professional environments. The process of internalization and integration is essential for cultivating a professional identity that is not only competent but also authentic and personally meaningful.157 In the context of extrinsic motivation—where actions are influenced by external factors—SDT identifies four different types of regulation along the continuum of autonomy, starting with external regulation, introjected regulation, identified regulation, and integrated regulation, as illustrated in Figure 4-4. As individuals move from external to integrated regulation, the greater the internalization of motivation.158 74 Figure 4-4 Self-Determination Theory’s Taxonomy of Motivation*158 (*Adapted from Ryan and Deci, 2020) The SDT emphasizes that individuals motivated by intrinsic factors and well-internalized extrinsic motivations (such as identified or integrated regulation) are more likely to develop a stronger sense of ownership and volition in their professional activities, ultimately fostering a more authentic professional identity.158 Using this SDT lens, we can now unpack students’ stated motivation for becoming dentists and connect them to appropriate educational focus in professional identity formation, as described in Figure 4-3. Lifestyle choices, the most frequently mentioned, was categorized as an extrinsic motivation. It suggests a focus on work-life balance and financial stability, which may lead to a more transactional approach to their professional identity unless balanced with ethical and patient-centered values. Joy of working with people, an intrinsic motivation, aligns strongly with 75 empathy, communication, and patient-centered care, fostering a relational dimension of professional identity. Curiosity and interest indicate an intrinsic motivation tied to lifelong learning and advancing skills, which supports the development of a deeply rooted professional identity. Conversely, monetary reward reflects an extrinsic motivation, requiring an emphasis on ethics and professionalism to integrate patient-centered values. Finally, family business influences, though less common, highlight external pressures and extrinsic motivation, necessitating support for individual professional identity development while respecting familial expectations. These findings illustrate the interplay of intrinsic and extrinsic motivations in shaping professional identity. This analysis underscores the importance of aligning educational strategies with students’ motivations to strengthen their professional identity formation. 4) Dental Students’ Recommendations for Enhancing Professionalism Education In Table 4-2, I present an overview of the thematic analysis of student recommendations for enhancing their professionalism education. Five overarching themes and 12 sub-themes were identified, including 1) Curricular changes, 2) Instructors, 3) Discipline and reward, 4) Selecting better students at entry, and 5) Miscellaneous considerations. Each main theme contained up to five sub-themes. The majority of responses focused on Theme 1, particularly on sub-themes such as (a) integrating more dynamic professionalism scenarios and (c) enhancing clinic monitoring and providing detailed feedback. Under Theme 2, "Instructors," students frequently emphasized the need for more proficient instructors who embody professionalism, with ten comments specifically addressing sub-theme (a). 76 Table 4-2 Students’ Recommendations for Enhancing Their Professionalism Education Themes Sub-theme Some example comments from the students No. of comments 1. Curricular changes a. Integrate more dynamic professionalism scenarios “Have more exposure to different professionalism situations and give opportunities to ask questions to clinical instructors.” “I personally learn best through experiences and scenarios. Incorporating scenarios of unethical or unprofessional practice and identifying methods to avoid/correct these scenarios would be beneficial.” “Have simulated patients and other ethics-related scenarios with role-playing actors.” “Give more real-world examples, instead of just describing what you should do in different situations.” 21 b. Arrange visits to observe role models in real-life settings “Have more time volunteering or watching professional (high quality) dentists so that students can observe how these dentists interact with their surroundings.” 3 c. Enhance clinic monitoring and provide detailed feedback “Receiving frequent feedback should help with improving our professionalism.” “Having more monitoring of student interaction and performance with patients is important. I do agree that “professional” behaviors can be taught even if it wasn’t in someone’s nature to begin with. But with practice, it turns into a good habit of that person.” “Give more explicit feedback to students.” 7 d. Give clearer guidelines and expectations “Tell students explicitly what professionalism types of actions the instructors are looking for and what to avoid.” “Clearly lay out expectations for students.” 5 e. Emphasize professionalism in all aspects of teaching “It would be important to have professionalism lectures and seminars…” 3 2. Instructors matter a. Employ instructors who demonstrate a high level of competence and professionalism “I would ensure the instructors are calibrated to act more professionally. It is hard to be professional at all times when we are belittled, yelled at, made to feel inferior, as well as witness instructors act unprofessionally in front of patients with no consequences.” “Better role models are needed. Instructors should be professional at all times in front of patients and students.” “Instructors should teach as if we are colleagues to cultivate a better learning environment.” 10 77 “Have module coordinators and clinical advisors who value professionalism more than just clinical progress.” “I would encourage instructors, teachers, and all employees to act professionally. At school, I sometimes see instructors act unprofessionally or in a way that a student would be disciplined for and it comes across as a big double standard that doesn’t inspire students to act professionally.” b. Improve the student-to-instructor ratio “Spend quality time teaching students instead of rushing through. Decrease teacher-student ratio to increase active participation.” 3 3. Discipline and reward a. Implement stricter penalties for unprofessional behavior and reward exemplary conduct “When students act unprofessionally, I would provide more examples of consequences.” “Be stricter with people who are unprofessional instead of letting things slide.” “Reward students for professional conduct.” 5 b. Ensure that students maintain professionalism in their interactions with fellow students “I think observing whether students are professional to each other is important.” 2 4. Selection of better students at entry a. Improve the selection process to choose the most suitable candidates at entry “Quality of character should be (or at least try to be) assessed during the interview and admissions stage…” “Conduct more thorough student selection process in the beginning…” “I believe the interview process is so very important in choosing people with the right attitude.” 4 5. Miscellaneous considerations a. Less focus on appearance (eg. Tattoos and piercings) “I would focus less on appearance. I don’t think visible tattoos or piercings affect professionalism. Allowing self-expression is important to support the whole person, not just as a clinician but as a person.” 2 b. Professionalism is observed and experienced “I don’t believe in the act of “teaching” professionalism. It is observed and imitated in the way the role models carry themselves.” 2 Based on themes mentioned five or more times in the Table 4-2, the most significant recommendations are summarized below. 78 1. Curricular Changes The students suggested integrating more dynamic and realistic professionalism scenarios into the curriculum to encourage ethical reasoning and self-reflection. They also emphasized the need for improved clinic supervision, accompanied by detailed feedback, to help them identify areas for improvement and further develop their professional behaviours. Additionally, students highlighted the importance of clearer guidelines and expectations to better understand professionalism standards and work effectively toward meeting them. 2. Role Modeling Students emphasized the importance of having instructors who consistently demonstrate high levels of competence and professionalism. They proposed that hiring faculty who serve as strong role models could provide clear, tangible examples of professional behaviour to emulate. Observing these role models would help reinforce essential professional values, behaviours, and attitudes, making role modelling a crucial component in fostering professionalism within dental education. 3. Institutional Responsibilities Students recommended that institutions should play a proactive role in promoting a professional culture. Some suggested implementing stricter consequences for unprofessional behaviour could reinforce accountability, while others emphasized the value of recognizing and rewarding exemplary conduct to encourage professionalism. They believe a balanced approach would emphasize the importance of professionalism and motivate students to consistently uphold high ethical and professional standards. 79 Implication for Educators Along with what we have found in Chapter 3, from the perspective of professional identity formation (PIF), students’ motivations for entering the dental program, their definitions of professionalism, and the qualities they associate with being a dentist serve as a foundational blueprint for their professional identity, as illustrated in Figure 4-5. As students make progress through the program, this professional identity blueprint evolves through experiences such as clinical practice, interactions with role models, the learning environment, socialization with peers, and opportunities for reflection, as illustrated by studies of practicing dentists (Chapter 5) and existing literature. 155 PIF is understood as a dynamic process in which initial perceptions integrate with lived experiences, ultimately shaping a cohesive sense of self as a dental professional.121 This survey study offers insights into students' starting points and identifies ways to provide targeted opportunities for reflection, growth, and alignment between personal and professional identities. 80 Figure 4-5 Key Influences on the Development of Students’ Professional Identity in Dentistry The key contributors to students’ PIF shown in Figure 4-5 are drawn from the findings of this study and the findings from Study 1 presented in Chapter 3. While the graph assumes PIF begins at the start of dental education, it is important to note that some students may already have a nascent professional identity due to prior experiences, such as shadowing dentists, working as dental hygienists or assistants, exposure to family members in dental practice, or engaging in community service. These pre-existing identities may influence how students engage with and respond to the key contributors to PIF throughout their educational journey. Additionally, the trajectory of PIF is likely to be unique for each individual, as personal experiences, challenges, and learning moments vary in timing and impact from person to person. This dynamic interplay highlights the individualized nature of PIF and underscores the importance of understanding students' backgrounds and perspectives when designing educational approaches. Furthermore, professional identity continues to develop beyond graduation, shaped by ongoing work experiences and challenges, a topic that will be explored further in the next chapter. As identified in both Chapter 3 (Study 1) and this study, role modelling is a key contributor in influencing dental students’ professional identity formation, with educators playing a vital role in promoting professionalism. In this study, some students expressed frustration about instructors who behaved unprofessionally without facing consequences, while students themselves were held to higher standards. One student said, “I would ensure the instructors are calibrated to act more professionally…” Such perceptions may create a disconnect between students’ expectations and the behaviours they observe, which could 81 influence how they internalize professionalism. To address this, clearly defining professionalism and setting explicit expectations may help mitigate these concerns. As discussed in Section 1.5.3 and in Chapter 3 (Study 1), professionalism is not only taught through formal instruction but also developed through socialization and lived experiences. When students notice inconsistencies between the expected and actual professional behaviours, it can cause confusion and challenge their ability to internalize professional values and solidify their professional identity. These perceptions can have an impact on their PIF. To support students’ development, within an education program, educators should define professionalism clearly, set clearer expectation, and consistently model professional behaviours. It is important to recognize that role modelling does not only happen during specific curriculum sessions.162 Professional behaviours are learned through observing and imitating peers and faculty in everyday settings, such as hallways, cafeterias, and elevators.163 Therefore, faculty should demonstrate and reinforce professionalism consistently in real-life clinical and educational settings.162 Limitations and Future Research The response rate for this study was 37%, but given the study's primary focus was to explore students’ perspectives not to generate scores on students’ level of understanding professionalism, 83 DMD students’ input sufficiently provide us rich information. However, as this was data collected from only one institution, the findings should be interpreted with caution, as they represent the perspectives of a specific group of students. 82 A notable limitation is the absence of baseline values for the slider questions, as this survey was conducted for the first time. The scale ranged from 0, representing "not at all," to 100, signifying "extremely." While students reported an average mean score above 70% for 10 of the 12 questions, it is difficult to conclude definitively that they perceive themselves as having a high level of understanding of dental professionalism without comparative data. As discussed in Chapter 1 Section 1.3, professionalism lacks a universally agreed-upon definition, which may also influence how students interpret and rate their own understanding. 4.5 Conclusion Students’ perspectives on professionalism—how it is integrated into their education, their motivations for entering the program, their definitions of professionalism, and the key qualities they associate with a dentist—provide valuable insights into the early influences on their professional identity development. These factors shape their roles within the profession and influence their professional growth. By understanding the elements that impact students’ professional identity formation (PIF) and addressing gaps in professionalism education, institutions can work toward cultivating dental professionals who identify with professional values and begin to integrate their professional identities with their personal ones. 4.6 Next Chapter Having explored dental students' perspectives on professionalism and how these views influence their professional identity formation, the next chapter shifts focus to practicing dentists' perspectives on professionalism. This chapter examines how experienced dental professionals define and navigate professionalism in clinical practice, the challenges they encounter, and the factors that continue to shape their professional identities over time. 83 Chapter 5 Professionalism and Professional Identity Formation Among Practicing Dentists: A Template Analysis Study 5.1 Summary Purpose: Professionalism is essential in dental education, yet limited research examines the barriers and challenges dentists face and how these affect their professional identity. This study addresses this gap by exploring dentists’ perceptions of professionalism, identifying workplace challenges, analyzing contributors to their professional identity development, and gathering recommendations to enhance professionalism. Methods: Semi-structured interviews with ten practicing dentists in the Metro Vancouver area of Canada. These interviews, held via Zoom, were analyzed using template analysis in NVivo (Version 14) by QSR International. Results: Dentists identified patient-centred care, effective communication, adherence to ethical standards, and maintaining boundaries as key aspects of professionalism. While work experience reinforced professional identity, findings suggest a possible disconnect between professional identity formation and ethical behavior, emphasizing the need for deliberate and guided self-reflection. Participants also reported insufficient training in ethics and interprofessional collaboration, highlighting gaps between their understanding of professionalism and the education they received. They recommended improved professionalism training, stricter institutional oversight, and better workplace dynamics to support ethical decision-making. 84 Conclusions: This study emphasizes the need for a strategic approach to foster professionalism in dental education, including enhanced professionalism training, promoting professional behavior in dental practice, and potentially revising licensing and oversight frameworks. Future research could examine broader contextual impacts, such as regional or cultural influence on professional identity to develop a more holistic understanding of professionalism in dentistry. These insights can inform dental educators in refining curricula to ensure that dentists provide patient care that adheres to the highest ethical and caring standards. Keywords: professionalism, professional identity, template analysis, dental education, ethics 85 5.2 Introduction Dentistry is a profession with health-service obligations to the public.1 The value of dental care extends beyond individual perceptions, as it plays an important role in people’s overall wellbeing. Since oral health directly impacts patients’ ability to maintain both their physical and mental health, dentists must prioritize patients’ oral health over advancing their own interests.164 Thus, professionalism is a cornerstone of dental practice, influencing both the quality of patient care and the profession’s reputation.165,166 Accrediting bodies recognize it as essential and mandate its inclusion in the dental education curricula.167 In North America, the American and Canadian Dental Associations emphasize professionalism through statements outlining core values such as competence, fairness, accountability, integrity, respect, etc., which serve as guidelines for dental practitioners.165,168 While dental educators acknowledge the importance of professionalism, they often struggle to effectively “teach” it. Although professionalism encompasses more than just ethical practice, most of the professionalism education in dental schools has traditionally focused on ethics and ethical reasoning. Nearly two decades ago, Bertolami169 critiqued the dental ethics curricula, arguing that the traditional ethics courses were only teaching about ethics rather than instilling ethics in a way that would foster positive change in behavior.169 He emphasized the need for introspection and personalization in ethics education, suggesting that curricula should help students reflect on their core beliefs and better understand themselves—"who they really are, what they really want, and what they really believe and why.”169(418) When dentists face high overhead costs and intense competition in a saturated market, professionalism can be jeopardized. This highlights the need for more discussions on revitalizing professionalism in dentistry. While some studies explore students’ or the public’s perspectives 86 on professionalism, there is a notable lack of research focused on dentists’ own views.170–173 Moreover, no existing studies examine how real-world barriers and challenges shape dentists’ professional identity. This study addresses this gap by being the first to investigate multiple aspects of professionalism specifically from the practicing dentists’ perspectives. It not only explores their views but also examines the factors shaping their evolving professional identity. By understanding dentists’ real-world experiences, this study provides valuable insights into the obstacles they face when making ethical decisions in their practice. These findings can guide educators in making informed adjustments to dental curricula. Therefore, this study aims to understand dentists’ perspectives on professionalism, explore workplace barriers and challenges that affect their professional identity and conduct, identify factors shaping their evolving professional identity, and gather their recommendations for strengthening dental professionalism. 5.3 Method This study was approved by the University of British Columbia (Ethics Approval #H21-03350). 5.3.1 Study Design, Participants, and Development of Interview Questions This qualitative study used semi-structured interviews for data collection and template analysis for data analysis. Each participant completed a one-hour interview. The questions were developed based on literature and reflections on findings from two prior studies (Study 1 and 2) involving dental students.155 87 The semi-structured interview questions used in Study 3 were informed by the findings and insights gained from Studies 1 and 2, which explored dental students’ professional identity formation (PIF) and their perceptions of professionalism during their dental preparation training. In particular, Study 1 identified key contributors to dental students’ PIF and their concerns and Study 2 highlighted students’ views on professionalism education in their program, their initial motivation to enter the profession, and the most important qualities they attribute to a dentist, and students’ recommendations to enhance the professionalism education within the program. These themes shaped the focus of the Study 3 interview guide by prompting questions that explored how practicing dentists reflect on their own professional development, what factors influence their evolving PIF, and how their workplace challenges or experiences align or diverge from the professional ideals introduced during their education. The guide was intentionally designed to examine whether the contributors and challenges identified by students persist or evolve in clinical practice, and to elicit practitioner recommendations for improving professionalism education. In this way, the interview questions served not only to deepen the exploration of PIF but also to create continuity across the studies by tracing developmental patterns from dental school into professional practice. The inclusion criteria required participants to be fluent in English and to have completed the Doctor of Dental Medicine program in Canada. Purposive sampling was used to target the desired population. Recruitment advertisements were posted on a Facebook group page dedicated to dental professionals in Vancouver, British Columbia, from December 1, 2021 to December 31, 2021. The researcher then selected the participants based on the established inclusion criteria between January 1, 2022, and March 1, 2022, and conducted interviews. Each 88 participant was compensated with a $25 coffee gift card for participation. A total of ten individual interviews were conducted. See Table 5-1. Table 5-1 Demographics of the Study Participants PARTICIPANTS 1 YEARS OF EXPERIENCE M/F DMD1 16 F DMD2 3 F DMD3 7 (practicing), 10 (teaching) M DMD4 27 M DMD5 27 M DMD6 3 (practicing), 15 (teaching) M DMD7 7 M DMD8 7 F DMD9 29 M DMD10 2 F 5.3.2 Data Collection and Consent Before each interview, the researcher explained the process, privacy concerns, and anonymization procedure. Participants signed a written consent form and emailed it back to the researcher before interviews were conducted via Zoom. Only audio was recorded. At the start, the researcher (JK) reiterated the procedure, and participants gave a verbal agreement to proceed. The audio recordings were transcribed with Otter.ai, and the researcher (JK) manually corrected any transcription errors, replacing names with numerical codes to ensure anonymity. Transcriptions were then imported into NVivo (Version 14). Data collection and analysis, conducted from January to March 2022, concluded with 10 transcripts once data saturation was reached. 5.3.3 Data Analysis: Template Analysis 89 To analyze the data, I utilized template analysis (TA) as described by King.174,175 TA is a form of thematic analysis that emphasizes the use of hierarchical coding while allowing for flexibility to meet the specific needs of a study.174 It can be applied to any textual data, such as interview transcripts, diary entries, focus groups, and questionnaire responses.175 The technique involves creating a coding ‘template’ (a priori themes) based on a subset of data, which is then applied to the rest of the data and refined as needed.175 Unlike other thematic approaches, TA does not dictate a predetermined sequence of coding levels. Instead, it encourages the researchers to thoroughly develop themes where the data is the richest, specifically in areas where the research questions are being addressed.176 Philosophical position of this template analysis: One advantage of template analysis (TA) is its flexibility in accommodating diverse philosophical perspectives, ranging from realism to radical constructivism, rather than being bound to a single epistemology. Realism is similar to positivist approaches in quantitative research which seeks to uncover universal truths, while radical constructivism focuses on understanding multiple subjective perspectives and the role of social and cultural contexts in knowledge construction.175 This study adopts the limited realist position, which attempts to navigate between extremes of strict realism and radical constructivism. It commits to a realist ontology combined with a constructivist epistemology.174 This means that there is an external reality that can be understood through empirical investigation, while also acknowledging that researchers are inevitably influenced by their own perspectives and cannot completely detach from their social context.175 90 Creating the initial template and the ‘final’ template: The interview topic guide served as the foundation for the initial template. Four a priori themes were identified: 'Professionalism as defined by the dentists,' 'Barriers and challenges experienced at workplaces,' 'Experience influencing professional identity formation (PIF),' and 'Suggestions for improving professionalism.' This initial template comprehensively covered all the key interview topics. During the analysis, I refined the template while coding the text. The first two interviews were coded and then made adjustments. Afterwards, the final template was developed and applied to the remaining eight interviews. To illustrate the data analysis process using template analysis, an overview figure was created. See Figure 5-1. Figure 5-1 Data Coding Process in Template Analysis 5.4 Results 91 In this study, as described in the ‘Data Analysis: Template Analysis’ section, I focused on four specific domains: 1) understanding how dentists perceive professionalism, 2) identifying barriers and challenges they encounter in their professional environment that may affect dental professionalism, 3) examining the factors influencing their evolving professional identity, and finally, 4) exploring their recommendations for improving dental professionalism. My data analysis results are organized around these four domains, where we uncovered valuable insights to report. 5.4.1 Domain One: Dentists’ Perspectives on Professionalism One objective of this study was to understand participants’ definitions of dental professionalism. Their responses were categorized into four themes: patient-centred approach, communication and interaction, adherence to professional standards and ethics, and personal and professional boundaries. Figure 5-2 illustrates these insights. Participants described a patient-centred approach as ‘educating people so that they can make informed and autonomous decisions. (DMD 1, 2, 8, 9, 10) They emphasized that professionalism involves ‘positive interaction with peers, patients, and staff’ under the theme of ‘communication and interaction.’ Another key theme, adherence to professional standards and ethics, highlighted the importance of following ‘professional etiquette and behaving in a manner expected of their profession. (DMD 3, 4, 7) Finally, participants cited personal and professional boundaries, stressing the need for ‘respect, and setting aside personal matters to focus on patient needs (DMD 5, 6, 9).’ In Figure 5-2, respect is central to the themes, as it was frequently mentioned as a core aspect of professionalism. 92 Figure 5-2 Interviewed Dentists’ Definitions of Professionalism 5.4.1.1 Comparison Between Students’ and Dentists’ Definitions of Professionalism Students were asked to define professionalism through an open-ended survey question in Study 2, while dentists were posed the same question during interviews in Study 3. The dimensions presented in Figure 5-3 were identified through qualitative thematic analysis of their responses, highlighting both similarities and differences in their perspectives on professionalism. 93 Figure 5-3 Students’ and Dentists’ Definitions of Professionalism Both groups emphasize the importance of respect. Students identified it as the second most frequently mentioned theme, and dentists regarded it as a central focus across all aspects of professionalism. Similarly, both groups value adhering to professional standards and ethics. However, notable differences emerged in their views on a patient-centred approach. Students prioritize patient autonomy, keeping the patient’s best interests at heart, and caring while dentists emphasize educating patients to make informed decisions. Both groups value communication and interaction, but students emphasize building good interpersonal relationships, whereas dentists highlight broader interactions with peers, patients, and staff. Additional dimensions reveal more differences. Students note appearance as important for professionalism, while dentists do not. Conversely, dentists highlight the importance of keeping personal and professional boundaries, which students do not address. 94 In the early stages of professional identity formation, as observed in students, there may be a stronger focus on more tangible, superficial aspects of professionalism, such as appropriate outfit and presentation. As professional identity develops with increased practice and experience, dentists tend to shift their focus toward balancing personal and professional needs, as evidenced by the theme of keeping personal and professional boundaries. This shift reflects a more nuanced understanding of professionalism. Overall, this comparison provides insights into how professionalism may be perceived at different stages of professional development, reflecting both commonalities and evolving priorities. 5.4.2 Domain Two: Barriers and Challenges at Workplaces Participants were asked about workplace obstacles impacting their dental professionalism, with findings summarized in Table 5-2. Four themes emerged from the data analysis, reflecting perceived workplace challenges: 1) professional conduct and communication, 2) dental practice environment, 3) patient-related factors, and 4) interprofessional relationships and collaborations. Among the ten interview transcripts, ‘Professional conduct and communication,’ and ‘Dental practice environment,’ contained the most references to professionalism challenges. Under the ‘Professional Conduct and Communication,’ dentists discussed observing both their own and others’ patient care practices. They highlighted several unprofessional behaviours, such as accountability issues, failure to accept responsibility, disregard for punctuality, aggressive treatment, difficulties in reporting misconduct, gossip, favouritism, negative 95 comments about colleagues, condescending behaviour toward peers, lack of mutual respect, and overlooking unsafe practices. Additionally, under the theme of ‘Dental Practice Environment,’ they identified competition and profit-driven pressures, such as production demands, inflated staff wages, oversaturation of dental practices, and insufficient emphasis on dental professionalism, as key challenges to maintaining professional standards. See Table 5-2. Table 5-2 Barriers and Challenges Experienced by the Interviewed Dentists Themes Descriptors Professional Conduct and Communication • Accountability issues, a failure to accept responsibility • Disregard for punctuality • Aggressive treatment • Challenges in reporting misconduct • Gossiping and favoritism • Engaging in negative comments about peers and displaying condescending behaviour • Lack of mutual respect • Practice methods that compromise safety Dental Practice Environment • Competition and profit-driven practices such as pressure to increase production • Staff wages inflated due to competition • Oversaturation of dental practices • Insufficient emphasis on dental professionalism Patient-Related Factors • Varied patient demographics with differing demands • Patients unaware of ethical considerations • Inadequate provision of information to enable patient autonomy in decision-making Interprofessional Relationships and Collaborations • Interviewees (for staff) being late or no show for interviews • Communication issues with support staff members 5.4.3 Domain Three: Dentists’ Recommendations for Enhancing Professionalism 96 The interviewed dentists' suggestions for improving professionalism, representing the most substantial data in the transcripts, were categorized into three themes: professionalism education and training, institutional responsibilities and oversight, and staff and workplace dynamics. Theme 1: Professionalism education and training Building on their definitions of professionalism, the participant dentists strongly advocated for improvements in professionalism education. They emphasized the need for professionalism to be taught explicitly and comprehensively within the dental curricula. Specifically, the interviewees highlighted the importance of incorporating more ethics scenarios, role-playing activities, and small group discussions focused on professionalism. Two specific quotes below highlight this recommendation. “What do you do if you see poor dentistry? Or if your patient talks about the previous dentists recommending stuff that you personally would not recommend? Yeah, they didn't really talk to us about that at school, regarding how to deal with those issues. You kind of have to figure it out on your own when you're working. So I guess there are no real guidelines. I mean, they just tell you not to talk poorly of other dentists.” (DMD 4) “…we did have one ethics course…but I don't remember really talking specifically about what you would do in this situation. When you haven't had a busy month, and you're at the month end. You've got high overheads to pay and the patient comes in. And they're interested in some crowns, but they could clearly do with fillings. What do you do? So I 97 don't remember ever having that discussion, and I don't think there was enough emphasis placed in school on that type of decision-making process or how to handle that when you get out.” (DMD 5) The dentists further argued that interprofessional learning and an emphasis on recognizing individual limitations should be integral parts of the dental curriculum, as these elements are critical to improving patient care. “I think there are multiple things that can be incorporated in dental curriculum. To learn, a lot of real cases needs to be discussed, like complex case that involves multiple disciplines to resolve the issue. And you need to obtain different consultations before you proceed with it. I think it brings interdisciplinary views to the dentist because a lot of people in dentistry think dentistry is one man's job. They are the dentist so they think they can do everything....You have to know your own limitations…I think making people recognize their limitations is an important thing from the time that they're in dental school….Once you recognize your own limitations, you know at what point you need to involve other disciplines of dentistry in your treatment plan, and then bring the best outcome for the patient.” (DMD 2) “Like you know what you are capable of and what you are not, you know,..Because a lot of us come out thinking we’re just supposed to do everything, but then its not necessary.” (DMD 6) 98 For certain clinical procedures, the interviewees believed that more training hours should be required to avoid breaching professionalism. “For example, people doing sinus lifts, or just surgery where they take a weekend course. There is not enough training…standards should be put in place to make sure practitioners get a set number of hours of training. It can't just be like an afternoon session, watching videos, or listening to a lecture to tell you how to do a certain procedure, and then you're good to go. I think you have to have hands-on clinical experience. And I think that would be good at the university, if they have that capability of just having these one-month courses, where you get a…certificate at the end of it, proving that you actually got the training in…providing that treatment.” (DMD 3) Role modeling is crucial to enhance professionalism education. The following quote is one of many examples from our interviewees: “The best way to teach is for the instructors to model that. So role modeling, yeah. There were people there that I respected and I thought were professional, and you want to emulate them some way. There are others that you see that aren't like that, and you don't want to be like them.”(DMD 5) Theme 2: Institutional responsibilities and oversight 99 The interviewed practicing dentists emphasized health authorities’ responsibilities and oversight, even giving ideas such as limiting the number of practitioners per area and enforcing stricter regulatory compliance, which was illustrated in the following quote. “…If there was a way, I think it would be best to, somehow cap the number of dentists practicing in a specific region to benefit everybody in the end.” (DMD 1) They emphasized the need to reassess licensing standards fairly, especially for internationally trained dentists. See the following quotes. “I think it comes down to enforcing the professional standards of the College because we all are regulated by the College. And that's who grants the license. For example, if you graduated from UBC, or if you graduated from some university somewhere else in the world, there shouldn't be two standards saying, Okay, this UBC grad had the training. So they should be treated differently than somebody who graduated elsewhere because they don't know. Just don't give a license to that person. We should be all treated the same.“ (DMD 7) “The College will only respond if there's a complaint. That's the only thing. But when they grant the license, I don't know how rigorous the process is. I do think sometimes it's quite easy to get a license after you pass the examination for dentists nowadays. It doesn't vet the kind of people who are in the profession anymore.”(DMD 9) 100 The participant dentists’ tolerance of misconduct is not high and they believed in tougher screening and harsher punishment for those who don’t abide by the guidelines. There was even a suggestion to have auditors sent out to the offices at random. “…let’s say, a student who plagiarizes. That's like a complete no. So, they should be basically kicking the student out. Like it's part of this is misconduct, not just in dental but in any field. That’s lying. If you cheat in school, you're going to cheat in life.”(DMD 6) “I don’t think they [those who don’t abide by the rules) should be in a healthcare profession, because they will hurt people.” (DMD 8) “Well, there's got to be a real punishment for those that are caught. Yeah. Like a real punishment is not like a few hundred dollar fine. That does absolutely nothing. If they get their license taken away, or, or something like that, then it's more of a real punishment.”(DMD 9) “… just like a secret audit of what's being done in the office… I'm sure it will be legally challenged but at least you put the fear of that into the dentists too, so that they will behave accordingly.”(DMD 5) Theme 3: Staff and workplace dynamics 101 The interviewed dentists also called for promoting better treatment of staff, fostering a team-oriented mindset, and addressing mistreatment issues directly. The two quotes below illustrate this finding. “I don't know if this is helpful or not. But this is speaking from my own experience of owning a dental practice. …I think that if you can set up a practice,…where you treat your staff in a respectable way, and you treat your patients in a respectable way. And you yourself set it up so that you get treated in a respectable way…from the very beginning, you'll be happier, and you'll make better decisions as you go along. And you'll be able to practice longer. I think that one of the biggest stresses when I first had my own practice was letting certain staff members mistreat me, letting patients mistreat me a lot, or taking advantage of me... just abusing my time, abusing my services in terms of not paying or, again, not showing up. Get rid of the patients and the staff that just make your life miserable. And if you can do that as soon as possible, you're going to have a better career, you're going to be happier. And it might be a bit more painful at the beginning because you won't be as busy but it will help you in the long run.” (DMD 9) “… it [workplace] should be more of a team mentality more than anything.” (DMD 1) In conclusion, the interviewed dentists emphasized that creating a respectful, team-oriented work environment, where both staff and patients are treated with dignity, is essential for long-term career satisfaction and success while addressing mistreatment early on can lead to a healthier, more sustainable practice. 102 Domain Four: Dentists’ Professional Identity Formation In examining the progression of dentists’ professional identity development, my focus centred on identifying key contributors to this evolution. For the interviewed dentists, unlike dental students, I explored how their work experiences and challenges encountered in their professional environment shaped their evolving professional identity. These influencers are illustrated in Figure 5-4. Figure 5-4 Influencers of Dentists’ Professional Identity Formation Analysis of the interview transcripts revealed that hands-on work experience was crucial in shaping the dentists' professional identities. This factor is closely tied to domain-specific self-efficacy, a key contributor to dental students’ PIF in Study 1, as well as to the clinical skills identified as essential qualities of a dentist by students in Study 2. For students, developing 103 clinical confidence through repeated practice and successful outcomes is critical, as their professional identity heavily depends on mastering clinical skills. Similarly, for practicing dentists, work experience strengthens and solidifies their professional identity as they navigate real-world patient care and ethical challenges. The confidence they gain from managing complex cases mirrors the way students build self-efficacy through clinical practice. This continuous interaction between experience and growing competence not only enhances clinical skills but also reinforces their identity as confident and capable dental professionals. As they practiced more, their sense of being a dentist strengthened. Some noted that experience led them to adopt more conservative treatment approaches, while others did not experience this shift. Additionally, reducing financial burdens and gaining experience empowered them to make more ethical decisions. The following quotes illustrate these perspectives: “I think your professional identity becomes stronger the more you are exposed to cases as years go by and the more you put your skills into practice. Some challenges that you see at the beginning of your practice that took longer to resolve it, you can resolve it faster as you get more experience. You become more efficient at addressing them.” (DMD 5) “it comes down to those pressures of when you first start practicing and having expenses. A patient comes in and they're like, “Hey, Doc, I just need a checkup. Do you see anything wrong in my mouth?” “Oh, you got some old fillings, but they totally look fine besides they look a little old. Let's just leave them alone and keep an eye on them.” If that patient came 25 years ago, a couple of years into my practice, I probably would have said, “you never 104 know what's happening underneath them. Let’s change them.” And to be honest, it was probably at the end of the day, I thought, ‘Okay, I’ve got to produce something because it was my own practice. And I need to pay the assistants, I need to pay the front desk. I need to pay my rent. I need to pay my mortgage. Yeah, let's do these fillings because they look old. And again, ‘Oh, you got 100% insurance. It's covered. Why don't you do it? Let's get it done.’ So I would have done that. But to be honest, reducing my financial burdens along the way has helped me to be more conservative. But clearly, yeah, the experience along the way has changed my mindset in terms of the decisions I would have made then versus now.” (DMD 9) Another key factor highlighted was the impact of the label or title of ‘doctor,’ which influenced their feelings and behaviour, often fostering a greater sense of responsibility. They reported that this title reinforces a sense of accountability, serving as a constant reminder of their professional roles and expectations. The societal weight attached to the title provides external validation and influences how dentists perceive themselves within the profession. Therefore, within dental education, discussing the weight of the title "doctor" could be valuable for professional identity formation (PIF). The following quotes illustrate this: “It feels good to be called a doctor after graduation… I think that from the beginning, there's just a higher expectation of your behavior in everything that you do. When someone needs help with something, even when it's not dental related, “Oh, I've got this doctor helping me. It's going to be better than someone who's not a doctor.” People have that 105 sort of feeling. Dr. so and so, can you come in to help me fill this form, asking me to help them with some paperwork at the mosque? Oh, Dr. so and so, if you can do this for me versus, you know, Bob down the road there. So, there's more of a responsibility right off the bat.” (DMD 5) “I do feel more responsible. People will look up to me more in terms of, that's not coming again, from a prideful manner. That's just that people expect more of you. When they're calling me doctor, they expect a certain type of behavior and a certain type of decision-making. Or just a certain type of demeanour with them when dealing with them. So, yes, you do feel more responsible when they call you their doctor.” (DMD 10) Some interviewees felt that upbringing and personality play a significant role in shaping their intrinsic values and how dentists practice professionally. As I will discuss later, this factor is closely connected to the dentists' individual identities, which serve as the foundation for their professional identities. Individual identity encompasses a person’s core values, beliefs, traits, and life experiences, all of which are significantly influenced by their upbringing and inherent personality. Further details on this connection will be discussed in Study 4. The following quotes illustrate this: “In my personal opinion, it just depends on how they were brought up and on and, and what their personal views are. I mean, it's like, if you have a person who is not nice, you can tell them what is nice and what is not nice, but they will never be a nice person.” (DMD 7) 106 “I think it's a personality…I think it comes down to the person and their upbringing, like how your family has raised you and what your moral compass is. And I think, if you are that kind of person, you would go in that direction. And if you're not, if you're raised a certain way, if you're a certain kind of person, you wouldn't do that. …Not everybody responds to this kind of pressure.” (DMD 4) The study participants believed that education they received also played an important role in shaping the kind of dentist the participants became, as reflected in the following quote: “I went to UBC. I remember the first day, we had this course called “Doctor, Dentist, Patient, and Society” or something like that. And the first thing we learned was the word “empathy.” And we modelled that and it stayed with me until today. That’s something I learned. And if we were taught, this becomes part of who you are as a dentist, as a doctor. That’s what you’re supposed to do.” (DMD 1) In summary, the dentists highlighted that their professional identity was shaped by a combination of factors, including the responsibility associated with being called "doctor," their upbringing and personal values, the impact of their education, and hands-on experience, with many noting that over time, reduced financial pressures and increased experience allowed them to make more ethical and conservative treatment decisions. 5.5 Discussion 107 The findings of this study aim to understand how practicing dentists interpret professionalism and their perspectives on professional identity. While there are many similarities between the perspectives of dental students and practicing dentists, notable differences also emerge. In the subsequent sections, we will describe in more detail what we learned from interviewing practicing dentists. Professional Identity Formation as the Focal Point Participants identified core values such as patient-centred care, clear and effective communication, adherence to professional standards and ethical guidelines, and maintenance of professional and personal boundaries as essential aspects of professionalism. These values generally aligns with widely accepted definitions of professionalism within medical and dental communities.24,25,165 Interestingly, some senior dentists we have interviewed noted that at the beginning of their practice, the concept of being “called a doctor” emerged as a factor that could enhance their sense of responsibility and contribute to their professional identity. This finding appears to support identity theory177 and social identity theory178, which propose that titles like “doctor” act as markers of group affiliation and individuals’ social identity frequently transition to embody the norms and behaviours linked to that role.179 This behaviour adjustment could bolster the significance of their title as individuals strive to align with the group’s values and standards.178,179 Given that this finding emerged from participants who have practicing for 25 or more years of experience, future research might explore whether the title of ‘doctor’ similarly shapes the professional identity of junior dentists. If the title indeed plays a role, it could be beneficial to 108 incorporate discussions on the expectations associated with the “doctor” title into dental education, in line with social identity theory, where the title is seen as a symbol of social responsibility. Bridging the Gap in Professionalism Education The dentists' responses indicated a gap between their understanding of professionalism and the professionalism education they received. A key concern was the reported lack of training opportunities in crucial areas such as managing ethical dilemmas and fostering interprofessional collaboration. However, it is important to consider the potential influence of reflection bias, where individuals may reinterpret past experiences based on their current perspectives, potentially affecting the accuracy of their recollections. To assess whether professionalism education was indeed insufficient, a review of past dental curricula would be necessary, alongside further research to explore how professionalism training was structured and perceived at the time of instruction. However, as outlined in the literature review of professionalism education in Section 1.5 of this dissertation, the prevalent model of professionalism education—Principlism—along with its reliance on abstract virtue-based principles or behavior checklists, has proven insufficient. Consequently, the findings from practicing dentists in this study provide additional empirical evidence suggesting that Principlism may not be an effective approach to professionalism education. To address this education gap, the dentists recommended more comprehensive professionalism education approaches that are in the form of case-based discussions, role-playing exercises, and group presentations. These activities could help strengthen students’ critical 109 thinking, reflective abilities, and decision-making skills, particularly in navigating ethical challenges or responding to patient requests for non-essential procedures. Future studies could further investigate the impact of these educational strategies on the development of professional identity. Communication and Collaboration The interviewees emphasized the importance of communication skills in facilitating effective professional interaction with patients, colleagues, and staff. As discussed in Section 1.4 of this dissertation, the professionalism literature underscores the significance of interactions with patients, colleagues, and communities.58 Our findings from interviews with dentists further reinforce the need to integrate dedicated and enhanced communication skills within dental curricula. Such integration would better prepare future dentists for complex conversations, enable them to demonstrate empathetic reasoning, and help them build rapport and trust with patients. Additionally, the interviews revealed that fostering interprofessional collaboration through small-group learning activities was strongly recommended by the dentists. This approach, they argue, better prepares students for the collaborative demands of modern healthcare delivery. This recommendation aligns with existing research in dental education, which underscores the benefits of small-group learning in enhancing communication and collaboration skills.180 Workplace Culture and Professionalism 110 An important yet unsurprising finding from the interviews with dentists was the impact of workplace dynamics on professional conduct. As discussed in Section 1.5.3.4, where we explained Kegan’s theory of meaning making pertained to identity formation, three key aspects shape adults’ identity: cognitive, emotional, and social.111,112 The healthcare workplace is where most social interactions occur, whether between clinicians and patients, clinicians and staff, or clinicians and other clinicians. Our participants described that, in some cases, the behaviours of other dentists contributed to professionalism challenges. Moreover, pressure to meet quotas, cover overhead costs, and manage insufficient support staff were identified as threats to professionalism. While dental schools cannot predict the specific workplace environments their students will encounter, they can promote and by establishing mentorship programs focused on ethical decision-making and teamwork. The economic challenges of running a dental clinic could also serve as a real-life scenario in which students can engage and develop their own ethical solutions. The Disconnect Between Professionalism and Professional Identity in Dentistry: Experience vs. Ethics In reviewing the various definitions of professionalism in Section 1.2, Stern’s definition was emphasized for its angle to critical foundations and necessary pillars.181 Clinical competency is one of the three foundations to define professionalism.181 However, in dental schools, exploring values, ethics, and interpersonal skills is equally essential to shaping well-rounded healthcare professionals. Interviews with participants suggested that while clinical practice experiences appeared to strengthen clinicians’ sense of professional identity, these experiences did not always lead to 111 stronger ethical and professional behaviour. External pressures, such as a competitive market environment, may influence clinicians’ professionalism. This suggests that practical wisdom should not be assumed with the accumulation of experience. The dentists’ responses suggest that without deliberate and guided self-reflection, professional identity formation may not consistently get integrated and translate into professional behaviour. The gap became more apparent during the interviews. Only one dentist explicitly acknowledged personal areas for improvement, while many others focused on external factors—such as patients, education, or workplace environment—rather than critically reflecting on their own roles in maintaining professionalism. Further research is needed to explore how guided reflection can be better internalized to support ethical and professional development. Awareness and Empowerment Raising awareness about professionalism issues and empowering dentists to embody professional qualities and behaviours requires a multifaceted effort from educational institutions, regulatory bodies, dental professional associations, and individual practitioners. Comprehensive professionalism education during dental school, along with ongoing continuing education programs such as conferences, webinars, and other educational events focused on professionalism issues in dentistry, may be beneficial. From this study, participants recommended case-based scenarios and small-group discussions as effective tools for enhancing professionalism. They also emphasized stricter penalties for professional misconduct. Some dentists noted that with more experience and reduced financial stress, they felt more ‘empowered in professionalism,’ and could better prioritize patient care. Greater clinical expertise and reduced financial pressures appeared to give them the freedom to focus on patient 112 needs rather than economic demands. However, further research is needed to better understand how these factors influence professional behaviour over time. Limitations and future directions A key limitation of this study is its small and specific demographic. Future research should include a larger and more diverse group of dentists from broader regions, as well as other dental professionals, such as hygienists and certified dental assistants, to gain a more comprehensive understanding of professionalism within dental practice dynamics. Additionally, as the study focuses on practitioners in Vancouver, the findings are influenced by the regional practicing culture. Expanding the investigation to explore how different cultural and professional contexts shape dentists’ professional identity would provide a more nuanced perspective. Such an expansion would allow for a broader examination of the contributors to professionalism identified in this study, offering a more complete understanding of the challenges faced in the dental profession. Furthermore, future research could investigate the effectiveness of various teaching methods in professionalism education and assess the role of regulatory bodies in promoting and enforcing professional standards. These insights could help address the accountability concerns raised by participants and inform improvements in dental education and professional development. 5.6 Conclusion This study suggests that dental education plays a crucial role in shaping professionalism and professional identity, as perceived by practicing dentists in a metropolitan area in Canada. The findings from the dentists offer valuable insights into how professionalism education within 113 the dental curriculum can be enhanced. In summary, these insights emphasize the need for a stronger focus on structured self-reflection, additional support to bridge the gap between theoretical understanding and the practical application of ethics, small-group scenario-based learning to improve communication and collaboration, and fostering a culture of professionalism in both education programs and workplaces by a combination of institutional leadership, mentorship, and continuous professional development, supported by effective licensing and oversight mechanisms from the College. 5.7 Next Chapter Chapter 5 examined practicing dentists' perspectives on professionalism, the challenges they encounter in clinical practice, and the factors that shape their ongoing professional identity formation. To provide a clearer and more cohesive understanding of how the findings from all three studies contribute to the broader theme of professional identity formation (PIF) and its connection to professionalism among dental students and practicing dentists, the next chapter will present a comprehensive synthesis of these results. While there may be some overlap with previously presented information, this integrated discussion is intended to enhance the overall flow and deepen the understanding of how each study collectively informs the overarching research question and main objectives, ultimately laying the foundation for the development of Study 4. 114 Chapter 6: Cumulative Findings from Studies One, Two, and Three 6.1 Introduction This chapter presents some key findings from Studies 1, 2, and 3, highlighting the challenges and barriers to professional identity formation (PIF) reported by both dental students and practicing dentists, along with their suggestions for improving professionalism education. Although these findings were discussed in earlier chapters, consolidating them here provides a comprehensive view of the common challenges and shared recommendations from both dental students and practicing dentists. To ensure a concise discussion, direct quotes have been omitted for findings that overlap with earlier content. This integrated perspective, alongside insights from previous chapters, form the basis for the design and analysis of Study 4 that will be presented in Chapter 7. 6.2 Threats to Professional Identity Formation: Dental Students’ Perspectives The data for the threats to dental students’ professional identity formation (PIF) was drawn from interviews with graduating dental students in Study 1, in which they discussed key contributors to their PIF. These students identified three primary threats to their PIF: 1) Insufficient Clinical Time Students expressed that insufficient clinical time caused significant anxiety, undermining their confidence in developing the clinical skills they closely associate with being competent dental professionals. This concern is linked to domain-specific self-efficacy in Study 1, as identified in the interview study with graduating dental students and aligns with the emphasis on 115 clinical skills highlighted as ‘the most important qualities of a dentist’ in Study 2 with dental students. At this stage, their professional identity is strongly tied to their dental self-efficacy; therefore, limited clinical practice disrupts the progression of their PIF. 2) “You Are Not Going to be a Good Dentist” Stigma This stigma arises from critical feedback about clinic performance as reported in Study 1. While clinical instructors understand that psychomotor skills require time to develop and follow a progressive learning curve, the way feedback is delivered may not always convey this understanding effectively. How students perceive and interpret feedback is critical to the effectiveness of the formative assessment and involves both emotional state and personal tendencies.145 3) Learning Environment (LE) From Study 1, student participants described how the learning environment (LE) plays a crucial role in their professional development. They noted that hostile or exclusionary learning environments as well as those where unprofessional behaviour is frequently modeled may create obstacles to their professional identity formation (PIF). Conversely, positive and inclusive environments were perceived as more conducive to fostering their professional growth. These findings highlight the importance of considering how institutional norms and conventions may shape students’ behaviours within the LE.144 Building on the foundations of students’ PIF discussed earlier, the next section delves into the perspectives of practicing dentists. Here, I explore the key influences that shape their professional identity. This analysis will also connect to the broader framework of professional 116 identity formation among dental graduates, highlighting the transition from education to practice and the various factors that contribute to this development. 6.3 Professionalism Challenges: Workplace Barriers and Challenges Experienced by Interviewed Dentists Study 3, presented in Chapter 5, outlines workplace barriers to professionalism reported by the interviewed dentists. The interview data were categorized into four main themes, as shown in Table 5-2. These barriers include accountability lapses, such as inadequate responses to poorly performed procedures by other practitioners, which can result in compromised safety or difficulties in reporting misconduct. Additional challenges include pressures from profit-driven environments, the oversaturation of dental offices in urban areas driving heightened competition, diverse patient demands paired with limited patient awareness of ethical considerations, and difficulties in interprofessional communication. The table marks barriers emphasized by the interviewed dentists in red. The barriers and challenges discussed by dentists during the interviews significantly impact their professional identity. Many of these obstacles create value conflicts, placing professional ideals such as ethical care and mutual respect in opposition to workplace realities like profit-driven practices and negative behaviours among colleagues. Resolving these conflicts is crucial for maintaining a cohesive professional identity. Persistent exposure to these challenges without adequate support can erode professional values, potentially leading to cynicism, disengagement, or a diminished commitment to professionalism.121,182 When individual and organizational values are misaligned, individuals often struggle to reconcile the work they aspire to do with the work they are required to do, increasing the risk of burnout.182 117 However, dentists who engage in reflective practices and benefit from positive role models are better equipped to navigate these challenges, fostering resilience and preserving a strong professional identity. Having explored the barriers and challenges hindering professionalism, as identified by students in the earlier section and dentists in this section, it is essential to consider strategies for addressing these issues within dental education. The next two sections will present recommendations from students and dentists on how to enhance professionalism. 6.4 Students’ Suggestions for Enhancing Professionalism Education Students offered several suggestions for enhancing professionalism education. Items in bold reflect suggestions mentioned in five or more comments. The number of comments is included in brackets next to each suggestion to reflect the students' emphasis on them. These suggestions were gathered through an open-ended question in the Study 2 survey and analyzed qualitatively. The resulting themes and details were organized and presented in Table 6-1. Table 6-1 is adapted from Table 4-2 in Chapter 4 with the students’ comments removed for conciseness. Table 6-1 Students’ Suggestions for Enhancing Professionalism Education Themes Details (No. of Comments) Curricular Changes à Integrate more dynamic professionalism scenarios (21) à Arrange visits to observe role models in real-life settings (3) à Enhance clinic monitoring and provide detailed feedback (7) à Provide clearer guidelines and expectations (5) 118 à Emphasize professionalism in all aspects of teaching (3) Instructors à Employ instructors who demonstrate a high level of competence and professionalism (10) à Improve the student-to-instructor ratio (3) Discipline and Reward à Implement stricter penalties for unprofessional behavior and reward exemplary conduct (5) à Ensure that students maintain professionalism in their interactions with fellow students (2) Selection of Better Students at Entry à Improve the selection process to choose the most suitable candidates (4) Miscellaneous Considerations à Focus less on appearance (e.g., tattoos and piercings) (2) à Acknowledge that professionalism cannot be taught. Rather, it is observed and experienced (2) These suggestions, particularly those emphasized in bold, reflect a clear demand for systemic changes in dental education to address gaps in professionalism training. The recurring themes, such as the integration of dynamic scenarios, improved mentorship through competent instructors, and a balanced approach to discipline and rewards, underscore the students' recognition of the multifaceted nature of professionalism. Addressing these areas holistically could lead to a more effective framework for fostering professional identity formation and ethical conduct in future dental practitioners. Building on the students’ suggestions, the next section will explore dentists’ recommendations for enhancing professionalism education. 119 6.5 Dentists’ Suggestions for Enhancing Professionalism Education Dentists offered several suggestions for enhancing professionalism education, which have been categorized into three main areas, as outlined in Table 5-2 from Chapter 5. I have included Table 5-2 here again for ease of reference. The suggestions that dentists particularly emphasized are highlighted in red. Table 5-2 Dentists’ Suggestions for Enhancing Professionalism Education from Themes Details Professionalism Education and Training • Explicit and comprehensive teaching of professionalism integrated throughout the dental curricula • Incorporation of more ethics scenarios, role-playing activities, and small group discussions to emphasize professionalism • Interprofessional learning and acknowledging individual limitations as an essential components of the curriculum to enhance patient care • Additional training hours for specific clinical procedures to prevent breaches of professionalism • Role modelling highlighted as a vital element for fostering professionalism education Institutional Responsibilities and Oversight • Dentists emphasized the responsibilities of health authorities, advocating for stronger oversight through: • Limit the number of practitioners in areas with saturated dental practices • Enforce stricter regulatory compliance • Fair reassessment of licensing standards, particularly for internationally trained dentists • Implementation of random office audits to ensure adherence to standards Staff and Workplace Dynamics • Foster better staff treatment, promoting a team-oriented mindset, and addressing mistreatment issues directly within dental practices 120 With studies presented thus far, students and dentists stressed the importance of explicitly teaching professionalism throughout the dental curricula and incorporating more ethics scenarios, role-playing activities, and small group discussions. They also stressed the critical role of instructors and role models in fostering professional identity formation (PIF). While students focused on program-level improvements, such as enhanced clinic monitoring, admissions processes, and stricter penalties and rewards for professionalism, dentists proposed broader systemic measures. These included regulatory oversight, such as enforcing compliance, reassessing licensing standards for internationally trained dentists, and conducting random office audits. Dentists also highlighted workplace dynamics, emphasizing the need for better staff treatment, team-oriented practices, and addressing mistreatment. These suggestions underscore the need for educational enhancements and systemic reforms to strengthen professionalism at individual, institutional, and workplace levels. 6.6 Common Suggestions from Students and Dentists for Enhancing Professionalism Education After reviewing the suggestions from both students and dentists, five key areas of overlap emerged: 1) role modelling, 2) dynamic learning methods, 3) accountability mechanisms, 4) comprehensive integration, and 5) collaboration. Both groups emphasized the importance of observing and learning from exemplary instructors in guiding professionalism education. This aligns with role modelling as a key 121 contributor to students’ professional identity formation (PIF) discussed in Study 1. Dynamic learning methods, including incorporating more ethics scenarios, role-playing activities, and small group discussions, were frequently suggested to create engaging and practical learning experiences. Both groups also advocated stronger accountability mechanisms, such as discipline, rewards, and regulatory oversight, to uphold professionalism. Furthermore, they stressed the importance of integrating professionalism education comprehensively across the entire curriculum to ensure consistency and reinforce its significance at all stages of training. Finally, collaboration, through teamwork and interprofessional learning, was identified as essential for preparing students for real-world professional environments. These shared recommendations reflect a unified desire to make professionalism education more structured, engaging, and impactful. 6.7 Lessons Learned from Studies One, Two, and Three As outlined in the roadmap for this dissertation in Figure 2-1, this section will describe how the findings from these three studies enhance our understanding of professionalism education and professional identity formation (PIF). It serves as a basis for Chapter 7, which presents an actionable strategy to strengthen professionalism education and PIF within dental curricula. 1. Professionalism Education Needs to Be Holistic 122 Building on the common suggestions to improve professionalism education from Studies 1, 2, and 3, both students and dentists emphasized that professionalism should not be taught in isolation or as fragmented components within the ethics classroom. Instead, they noted that an integrated approach throughout the entire curriculum, combined with consistent opportunities for practice, could be more effective. Bridging the gap between theoretical concepts, such as ethical principles, and the practical challenges of real-world situations, such as workplace dynamics, can be valuable. Methods like ethical scenarios, role-playing, and small group discussions—suggested by both students and dentists—may help apply theoretical knowledge to practical contexts, enhancing the overall effectiveness of professionalism education. 2. Role Modeling Is Foundational The findings from Studies 1, 2, and 3 highlight the frequent emphasis placed by both students and dentists on the importance of observing professionalism in action. They noted that educators, including part-time clinical instructors, play a pivotal role in this process, acting as critical role models. However, the findings also suggest that inconsistencies in role modelling can undermine efforts to foster professionalism, with students perceiving such inconsistencies as indicative of hypocrisy. Consequently, it is essential that educators consistently embody professional values and behaviours to reinforce their importance and credibility. 3. Addressing Systemic Challenges Is Crucial 123 From Study 3, dentists highlighted systemic challenges, including regulatory oversight, workplace dynamics, and financial pressures, as significant factors influencing their professionalism. These challenges underscore the importance of preparing students to navigate systemic issues through education that emphasizes interprofessional collaboration and provides insight into the broader context of healthcare systems. Addressing these systemic challenges equips future professionals with the skills needed to maintain their values in complex, real-world environments. 4. Tailored Approaches Are Required The findings in our previous studies reveal that students and dentists focus on different aspects of professionalism. Students tend to prioritize immediate, observable aspects of professionalism, while dentists emphasize long-term, systemic factors. Professionalism education should reflect these developmental stages, starting with foundational values and practical skills during early training and gradually introducing complex, real-world issues as students advance in their education. This tailored approach ensures that professionalism education remains relevant and effective at all stages of professional development. 5. Structured Reflection Is Central to Professional Identity Formation These studies identify structured and deliberate reflection as a cornerstone of PIF. While experience strengthens one’s sense of professional identity, the findings suggest that without 124 guided and intentional self-reflection, professional identity formation may not reliably align with professionalism. This gap was particularly evident in the interview study with dentists, where only one dentist highlighted the critical role of self-reflection and personal responsibility, while others largely attributed professionalism challenges to external factors such as patients, education, or workplace environments. Structured and purposeful reflection should therefore be integrated into dental education programs to encourage students to critically examine their actions, align them with professional values, and refine their identities early on. For dentists, reflective practice should continue throughout their careers within their learning communities, enabling them to adapt and grow as professionals. In summary, these lessons suggest that current approaches to professionalism education may not fully address the evolving needs of students. The findings indicate that professionalism education could benefit from being dynamic, integrated, and adaptable to both individual growth and broader systemic influences. Positioning professional identity formation (PIF) as a central focus of dental education may help address many of the challenges identified in these studies. By incorporating these insights, dental education can more effectively support students in navigating the complexities of their profession and in cultivating a strong and cohesive professional identity. 6.8 Next Chapter The next chapter focuses on an educational strategy designed to foster PIF in students within the context of ethics classrooms. The studies highlighted the crucial role of structured 125 reflection is crucial for PIF. Study 4 demonstrates how value conflicts and axiological analysis can be used to support students’ PIF. 126 Chapter 7: A Pedagogical Strategy to Promote Professional Identity Formation in Ethics Classrooms 7.1 Summary Purpose: One key takeaway from Studies 1, 2, and 3 is that while reflection is essential for PIF, it is most impactful when it is structured and guided to foster deeper critical thinking. Building on this insight, this study introduces a pedagogical tool that uses ethical dilemmas to create structured opportunities for reflection, shifting the focus from solely relying on ethical principles like Principlism to examing how underlying values influence individuals’ decision-making and their professional identity formation. By incorporating axiological analysis, this study extends traditional Principlism-based approaches (see Section 1.5.2) by emphasizing value hierarchies that inform their choices and exploring how these values relate to their multiple identities. This identity-centered framework fosters self-reflection, encouraging students to critically examine the relationship between their values and their evolving professional identity. Methods: Two ethical dilemmas eliciting narrative responses were designed and distributed through an online survey using Qualtrics. The data were analyzed using axiological analysis in Nvivo (Version 14) by QSR International, focusing on identifying, categorizing, and interpreting conflicting values. Results: The findings of this study demonstrate how structured reflection through value conflict scenarios can facilitate deeper engagement with ethical dilemmas by prompting students to examine their value hierarchies in relation to their evolving professional identity. As they navigated tensions between legal obligations, patient care, personal commitments, and effective 127 communication, students engaged in value-based reasoning. The structured exploration of value conflicts demonstrated in this study affirms its pedagogical value, showing its potential to foster self-reflection and support professional identity formation. Conclusion Expanding on traditional case-based learning, ethics courses can provide structured spaces for engaging with value conflicts and fostering deeper self-reflection. This study suggests that ethical scenarios combined with axiological analysis not only enhances students’ understanding of ethical dilemmas but also offers educators valuable insights into how students’ values shape their professional identity formation. Keywords: ethical scenarios, professional identity, axiological analysis, professionalism 128 7.2 Introduction In the medical literature, the proposed shift to prioritize professional identity formation (PIF) as an educational goal aims to move beyond the traditional simplistic approach of teaching professionalism.67,183 Compared to conventional professionalism education, which focuses on pointing out negative professional behaviours, PIF focuses on supporting learners in each transitional phase as they develop a new professional identity in the context of their existing personal identities.93 Experts of PIF in medical education agree that professionalism is “an acquired state, rather than a trait.” 131(59), 67 Study 1 in Chapter 3, which explored key contributors of PIF for dental students, revealed that dental students’ reported learning experiences significantly shape their PIF and their understanding of professionalism.155 Study 3 in Chapter 5, which investigated practicing dentists’ views on professionalism, aligns with the insights gathered from students. Therefore, providing meaningful experiences at each stage of learning—while minimizing unintentional adverse effects from the learning environment—can support learners in developing the professional identity that educators seek to foster.131 In this context, ethics education in dental education is crucial for shaping students’ moral development.184 As part of the curriculum, students need ample opportunities to apply concepts of professionalism specific to their field. This experience enables them to internalize these concepts, shaping their attitudes into behaviours that reflect professionalism.185 When professionalism becomes an authentic part of learners’ roles—rather than a set of rules to follow—they embody the values, attitudes, and behaviours expected in their profession, fostering 129 professional identity and a genuine commitment to the ethical practices that healthcare professionals are expected to uphold.67 However, establishing PIF as the central goal of dental education presents significant challenges for educators, particularly in assessing and understanding students’ progress in their PIF journey. One approach to gaining insight into this process is to examine how individuals handle ethical dilemmas, as this reveals the values that drive their decision-making and highlights the interplay between their professional and personal identities.186 Values Conflict, Shifts in Ethics Education, and the Importance of Self-Reflection When individuals face ethical dilemmas, their decision-making is shaped by their value system and ethical principles.187 Such dilemmas often trigger identity conflicts, forcing individuals to confront the values associated with their multiple identities as they grapple with clashing moral imperatives and challenges of determining ‘the right’ course of action.188 In the clinical context, this decision-making process is often axiologically complex and particularly challenging, as it requires balancing multiple, sometimes competing, values and ethical considerations that go beyond understanding the physical processes within the human body. Clinical decisions frequently impact the bio-psycho-social aspects of a person and touch upon their dignity.189 Core values like altruism, justice, fairness, respect, and excellence serve as the guiding principles that shape our lives and communities.190,191,192 These values transcend specific situations and help us evaluate behaviours and circumstances, allowing us to see actions, things, or situations as positive, desirable, enjoyable, convenient, or useful for reaching goals.192 130 Values are also central to identity construction and can be a major source of conflict when individuals navigate their multiple identities.193,194 They guide attitudes, behaviours, and decision-making, particularly in professional contexts where specific values—such as altruism, fairness, and commitment—are expected.186 When learners perceive a misalignment between the values tied to their professional identity and those linked to their other personal identities, they may experience identity conflict.193,194 In addition to conflicts arising between multiple identities, value conflicts can also emerge even within a single professional identity. Here, different values may be perceived as conflicting or less binding depending on the context, individual beliefs, and emotional responses.194 This suggests that identities are not monolithic entities but rather complex constructs with multiple values that can interact and create internal conflict.194 For instance, a doctor’s value regarding preserving life may clash with their value of alleviating suffering, particularly in end-of-life care situations, and this can lead to inner conflict and moral distress.194 In the last twenty years, there has been a shift in the way ethics is taught in dental schools.195 The traditional didactic approach, often criticized for being dry and ineffective, has largely been replaced by more interactive and practice-oriented methods169,196 Active learning strategies such as workshops, small group discussions, and problem-based learning have become the norm.197,198 Furthermore, ethics instructors now aim to develop both practical and emancipatory knowledge that empowers individuals to question and challenge the status quo, emphasizing critical awareness through innovative approaches like heuristics, reflective practice journals, storytelling, and performance-based assessments.199 To enhance relevance, case-based learning and topic-based learning have been introduced, encouraging students to identify ethical 131 issues they are likely to encounter in clinical practice.200,201 Ethics education is now frequently assessed in clinical settings, allowing students to apply ethical principles in real patient interactions. Despite these improvements, criticisms remain. One concern is the over-reliance on professional regulations as the primary framework for ethical behaviour, which can limit students’ deeper understanding of ethical principles and their ability to navigate complex situations.195 Another issue is the need for a stronger emphasis on self-reflection. While self-reflection is widely recognized as essential for developing professional identity, there is a growing demand for more structured guidance and training in this domain.155 Effective self-reflection involves not just reviewing one’s actions but critically engaging with the ethical principles and underlying values that inform students’ decisions and behaviours.195 The Aim of the Study: Building on discussions in the literature, this study integrates axiological analysis into case-based learning to examine the values shaping students' decision-making. Given the importance of self-reflection in professional identity formation and its need for further development in ethics education, this study demonstrates how ethical dilemmas and axiological analysis can structure reflection. By analyzing how students prioritize and navigate values, it offers insights into professional identity formation in health professions education. 132 7.3 Methods 7.3.1 Scenario Development, Participants, and Data Collection Informed by the literature on value conflicts between multiple identities (as presented in Section 7.2), I prepared two scenarios for this study based on my years of experience in the dental field and the multiple mini-interview cases previously used at the UBC DMD admission process, which none of the students of this research population would have seen. Dr. von Bergmann and I reviewed the scenarios. I then incorporated both scenarios into open-ended questions within an online survey to elicit narrative responses from the participants. These were the scenarios: Scenario 1: A long-time patient of yours needs emergency treatment, but you already have an important family function to attend, which has been booked several months ago. He has dental anxiety and demands that he can only see you and no one else. If you treat the patient now, you will miss the important moments of your family function. What would you do in this situation? Please write briefly explaining your thought process. Scenario 2: A long-time patient of yours is leaving for Costa Rica for four months but urgently needs to get a crown on 36, as her big amalgam filling fell out and there is little tooth structure left. There is no money left on her annual dental insurance to cover the cost. She is adamant; she does not want to spend any money out of her pocket. Her insurance will renew on January 1st the following year, and she is asking whether you could give her the treatment now and postdate the bill. What would you do in this situation? Please write briefly explaining your thought process. 133 This study employed purposive sampling, targeting undergraduate DMD students enrolled in the Faculty of Dentistry (FOD) at UBC. Recruitment was conducted via email through the UBC FOD administrator, inviting students to participate in an online survey created using Qualtrics, an online survey platform utilized by the University of British Columbia. The survey was accessible from January 1st to February 28th, 2021, with three reminder emails were sent to encourage participation following the initial distribution. A total of 33 out of 83 students participated. The survey was anonymized, with only participants’ academic year and sex recorded, ensuring no other identifiable information was collected. Each participant was assigned a random participant number to maintain confidentiality. Given that this study’s purpose was to demonstrate a pedagogical approach grounded in value-conflict case-based learning and axiological analysis, rather than tracking professional identity formation across different years of the DMD program, the results were not linked to specific academic years. Additionally, with only 33 participants, generalizing findings across different academic levels would be challenging. However, future research could explore how students at various stages of the DMD program navigate these dilemmas and whether their values shift over time. A larger-scale longitudinal or cross-sectional study could provide deeper insights into how professional identity evolves throughout dental education. Before accessing the survey, participants received an email with a letter of informed consent. They could proceed only after providing consent and were informed that they could withdraw from the survey at any time. To incentivize participation, one respondent from each 134 academic year was randomly selected to receive a $40 coffee gift card, provided they opted to share their contact information for the prize draw. 7.3.2 Data Analysis Axiological analysis was conducted on the collected data using QSR International's NVivo (Version 14) software. Axiological Analysis Axiology in philosophy stems from two Greek words—axios (meaning “worth” or “value”), and logos (meaning “reason,” “theory,” or “study”).77 It is a study of values, including ethics and aesthetics.202 The axiological analysis is not commonly used in health professions education, and it does not follow a single, uniform approach, nor does it have a formalized methodology. Each study we reviewed employed slightly different approaches, with methodologies varying depending on whether the study was only a qualitative study or a mixed-method study.203,202,204,205 This may be because analyzing values is inherently complex, context-dependent, and subjective, and approaches also vary based on different philosophical foundations. For this study, I adopted a systematic approach to data analysis rooted in thematic analysis but focused on values. The key difference between thematic and axiological analysis is that axiological analysis centers on values and their role in decision-making or conflict 135 resolution, while thematic analysis is broader and encompasses various aspects of human experience. Figure 7-1 illustrates the three-step axiological analysis method we employed. First, I identified all value-based themes from responses and grouped the responses according to the values they emphasized, categorizing them accordingly. Next, I examined how students managed conflicting values, identifying which values were prioritized and under what circumstances. In the final step, we analyze the reasoning students provided for their decisions, determining whether a hierarchy of values existed. I then discussed how these themes and values interact and influence students’ decision-making processes. Figure 7-1 The Process of Axiological Analysis 7.4 Results 7.4.1 Analysis Findings from Scenario One The first scenario of this study presents a dental professional facing a value conflict between attending an important pre-scheduled family event and providing emergency treatment to a long-time patient with dental anxiety. 136 In Step One of the coding process (as depicted in Figure 1), six main themes emerged: (i) evaluating the nature of the event/emergency and providing appropriate treatment, (ii) effective communication with both the patient and family, (iii) maintaining personal and professional boundaries, (iv) prioritizing patient care, (v) balancing personal life and mental health, and (vi) finding solutions to attend both the patient and family commitments. In Step Two of the coding process, I identified the main value conflicts in Scenario One as a clash between Commitment to professional duty and patient needs versus Commitment to family/importance of personal life. Responses emphasizing the prioritization of patient care were grouped under Commitment to professional duty and patient needs. Responses related to Maintaining personal and professional boundaries, Balancing personal life and mental health, and Valuing family importance were categorized under Commitment to family/importance of personal life. The remaining themes were classified under Resolution Strategies. Step Three offers insight into individual students’ choices, revealing how they navigate conflicting values. As an example, I demonstrate here how values associated with an individual participant can be analyzed. The following quote was selected from the Resolution Strategies category. “In order to assess the situation it is important that we consider the severity of our patients health. It is our duty as health care professionals to do what’s best for our patients. If my patient was in an emergency situation I would attend to their needs. This does not necessarily mean my family function had to be canceled. (I may be late or may be rescheduled).” In stating “it is important that we consider the severity of our patient’s health. It is our duty as a healthcare professional to do what’s best for our patient,” the participant 137 acknowledges a professional obligation to prioritize patient care, especially if the patient’s health is at risk. At the same time, their comment, “This does not necessarily mean my family function had to be canceled (I may be late or may be rescheduled),” indicates a strong recognition of family commitment, showing that their personal life holds significant value as well. Based on this quote, it is clear that this participant places high value on the patient’s wellbeing, which guides their decision-making, particularly in cases involving health emergencies. They reflect a commitment to patient-centred care, which is integral to their professional responsibility. This individual also demonstrates flexibility by suggesting the possibility of being “late or rescheduling” rather than outright cancelling the family event. This approach enables them to meet their professional obligations without fully sacrificing their family commitment, showing a willingness to balance and adapt to the demands of both roles rather than choosing one value over the other. The individual's approach reflects an effort to align with professional values in healthcare while also preserving personal commitments through flexibility and compromise. To provide a clearer understanding of the key themes identified in students' responses, the following Figure 7-2 has been included. It illustrates the themes described by students when navigating value conflicts, offering a concise summary of the main ideas and how they interconnect. 138 Figure 7-2 The Main Value Conflicts and Resolution Strategies from Scenario One This visual representation complements the detailed quotes presented in Table 7-1, which focuses on the first scenario. While including a detailed analysis of each student’s decision would make this paper impractically lengthy, the figure and table together provide a comprehensive yet succinct overview of the key findings. Table 7-1 Axiological Analysis Results from Scenario One Main Value Conflict Values References Selected Supporting Responses Value 1: Commitment to professional duties and patient needs 13 Someone who needs emergency treatment and is feeling anxious is deemed more important than a family function and I chose this career to help people; which I understand will mean putting other’s needs before mine sometimes.” “Signing up for a career in health care we are aware that tough decisions like this will need to be made. Our first priority is that of our patients over personal pleasure. Consciously making this decision is an important aspect of professionalism in my opinion.” 139 Value 2: Commitment to family/importance of personal life 17 “It is important that I don’t cancel my family function in opinion because our mental health as dental professionals is important. We can’t always bend over backwards for our patients but we should always give them options.” “It's likely not life or death, so I would keep my commitment to family as that is an important value in my life.” “Family first. No one says they wish they spent more time in the office when they approach the end of life.” Resolution Strategies Evaluating the nature of the event/Emergency and provide appropriate treatment 5 “Need to consider what kind of family function it is. Is it a birthday party that happens every year or is it a once in a lifetime event like a funeral or wedding? Need to consider the emergency treatment. Is it something that can be managed temporarily with pain meds or other at home strategies like heat/pressure/etc?” “In order to assess the situation it is important that we consider the severity of our patients health. It is our duty as health care professionals to do what’s best for our patients. If my patient was in an emergency situation I would attend to their needs. This does not necessarily mean my family function had to be canceled. (I may be late or may be rescheduled).” Effective communication with both the patient and family 18 “I would also thoroughly explain the situation to my family, that way they know that I have not neglected the family function and perhaps ask them to document the event for me to watch at another time.” “Also, letting my family members know about my situation and being honest with them about my duty as a dentist” “Explain the situation to the patient, and see if there is room to compromise by seeing someone else, or book around the schedule of the family function.” Find solutions to attend both the patient and family commitments 6 “I would like to try to find a middle path, perhaps I could book him a few days early or he could see a colleague I can vouch for for triage and then see em for definitive treatment asap.” “I would treat the patient to stabilize his condition (get him out of pain) and then rebook him to complete definitive treatment another day in the near future. Hopefully the family function is still going on when I am done.” “In order to assess the situation it is important that we consider the severity of our patients health. It is our duty as health care professionals to do what’s best for our patients. If my patient was in an emergency situation I would attend to their needs. This does not necessarily mean my family function had to be canceled. (I may be late or may be rescheduled).” 140 The resolution strategies highlight how students attempt to balance professional and personal values. Some strategies lean toward a stronger Commitment to professional duties, emphasizing patient care and ethical responsibilities. Others prioritize Commitment to family, reflecting the significance of personal life and wellbeing. Ultimately, decisions in this scenario are highly individualized, capturing a nuanced integration of professional ethics and personal values. 7.4.2 Analysis Findings from Scenario Two Scenario Two presents a case where a long-term patient requests immediate treatment with delayed billing until her insurance renews, posting an ethical and professional dilemma. Using the approach used to analyze texts in Scenario One, several themes emerged: maintaining professional integrity, providing necessary patient care, maintaining trust with long-term patients, seeking compromise solutions, and effective communication and patient education. In Step Two, we identified the primary value conflict in Scenario Two as a tension between Maintaining professional integrity and Providing necessary patient care. Balancing this conflict requires careful consideration of the legal implications of postdating bills, exploring alternative treatment options, and maintaining transparent communication with the patient regarding her options and any associated risks. The remaining themes were categorized under Resolution Strategies, which included Exploring alternative options and Effective communication and education to the patient. 141 As demonstrated in the Scenario One analysis, each student’s responses can be examined line by line to identify associated values, a process that could serve as a valuable exercise in the ethics classroom. However, analyzing each student’s decision line by line would render this paper excessively lengthy. Therefore, I have provided summarized analyses and the associated quotes in Table 7-2, as well as a visual summary of the key themes in Figure 7-3. Figure 7-3 The Main Value Conflicts and Resolution Strategies from Scenario Two Looking at the students’ responses, this scenario highlights the challenge of upholding ethical billing practices while addressing the patient’s urgent needs, calling for a thoughtful approach to both patient care and professional standards. Table 7-2 Axiological Analysis Results from Scenario Two Main Value Conflict Values References Selected Supporting Responses 142 Value 1: Keeping professional integrity 15 “Don’t treat patient. Post-dating treatment is insurance fraud.” “It is not ethical to postdate the bill, and to risk losing the patient is much better than to risk getting my professionalism doubted by colleagues and and college.” “I would not treat the patient and risk losing her. Post-dating the bill would cause documentation inaccuracies and is also insurance fraud, which I will not commit. I will choose to uphold my integrity in this case.” Value 2: Providing necessary patient care 5 “I trust the patient will pay later since she has been a long-time frequenter of my practice.” “I would take a while to process the bill so it came in early January. 1 year calendar mark for treatment coverage is necessary for logistical purposes but pretty arbitrary. Dental problems don't happen based on a calendar. Make a note in the chart that they have used the claim that year so they don't bill anything for that full upcoming year. This way insurance doesn't take a hit either.” “Treat the patient because seeing that my patient is a long-term patient, I would trust her to keep her word and I also understand her situation and dental treatments are pretty costly and even though she did not disclose any financial difficulties, she may be experiencing some.” Resolution Strategies Exploring alternative options 19 “Assess any other treatments that are lower cost alternatives but insist that she does not prolong her treatment as this is an urgent situation. I would determine whether post-dating bills is something dentists are able to do. If it is not, I would explain to my patient why I cannot do that. If it is allowed I would work out a billing process with her so that she could get the care she needs” “Cannot commit fraud, will not postdate bill. Perhaps can use an ITR (interim therapeutic restoration) treatment that may be less expensive? Would have to look into it. Do not want patient to be without treatment for 4 months.” Effective communication and education to the patient 9 “If I don't feel that postdating is acceptable practice, then I would explain that to the patient and provide other options for treatment. Maybe there is a temporary fix that would be much less expensive, or I would refer her to another clinic (non-for-profit) that could do the work but at a much lower cost.” “I'd have to explain to the patient that it is fraudulent to lie to insurance companies and that it could also affect their ability to get insurance in the future. I would hope that the patient would understand, but if they didn't I would be okay losing a patient who is expecting me to do fraudulent acts on their behalf.” 143 7.5 Discussion This study was structured around two ethical dilemma scenarios presented in a standardized, open-ended survey format. Each participant engaged with the same scenarios and was prompted to select a course of action and justify their reasoning. The structure allowed for consistent data collection across participants while enabling narrative, value-based responses. Axiological analysis was used to systematically examine the underlying value conflicts embedded in participants’ decisions, offering insight into the kinds of tensions that may shape professional identity development. The value conflicts and axiological analysis presented in this study extend the utility of case-based learning—a widely used approach in ethics education within health professions programs—by offering a structured way to surface and examine learners’ internal reasoning. To apply this in an ethics classroom setting, the instructor can facilitate peer discussion or guided reflection by using targeted prompts to encourage deeper critical thinking and value exploration in students. By doing so, this method not only can prepare students to navigate both professional and personal challenges but also foster deeper self-awareness, supporting them in the construction of a cohesive professional identity. In Scenario One, reading through what I classified as students’ resolutions, I recognized students’ efforts to integrate professional integrity with personal commitments, using empathy, problem-solving, and transparent communication to navigate the dilemma. In Scenario Two, students aimed to uphold ethical billing practices, suggesting alternative treatments and educating the patient to resolve the situation within legal and professional boundaries. Overall, the students’ collective resolutions reflect a commitment to professionalism. 144 As discussed in Section 7.1, professional identity develops upon the individual's existing personal identities, which are shaped by supportive influences and challenges from the professional community.103 Through ongoing reflection, education, and self-awareness, individuals internalize the values of their profession, gradually solidifying their professional identity.101,206–208 This underscores the importance of structured reflection in ethics classrooms, which provide a critical foundation for professional identity formation. This dynamic process depicted in Figure 7-4 illustrates my attempt to describe how an individual’s personal identity and core values interact within the professional community. Positive influences contribute to the attainment of professionalism, while external, situational, internal, and interpersonal challenges can lead to an attrition of professionalism.209 Reflection, education, and awareness act as reinforcing forces that promote alignment, integration or negotiation between personal and professional values within a supportive milieu.70,208,210,211 Figure 7-4 The Dynamic Process of Professional Identity Formation70,103,126,208,210,212–214 145 Examining students’ decisions in these scenarios reveals the values they prioritize, offering insights into their value hierarchy and its connection to identity. As individuals adopt a professional identity, their decision-making patterns evolve. Figure 7-5 illustrates this progression, highlighting the continuum from personal to professional identity, where students gradually integrate professional values. This is my attempt to describe the progression, as professional traits become more prominent along the continuum, resulting in a dominant professional focus. Figure 7-5 Balancing Personal and Professional Identity in Development This journey to professional identity, as depicted in Figures 7-5, reflects the interplay between personal and professional identities, guiding students toward a balanced, ethically sound professional identity. However, when only the professional identity remains dominant, our study on conflicting values suggests that this can become overwhelming. I propose that a mature professional identity is achieved when individuals find a meaningful integration of both personal 146 and professional identities (as depicted in the middle part of this Figure), allowing for a more sustainable and fulfilling professional experience. 7.5.1 Suggestions for Educators Reflective exercises within ethical scenarios with conflicting values, as demonstrated in this study, provide students valuable insights into their motivations, self-awareness, and a deeper understanding of the values that shape their professional behaviour. This study revealed that when students encountered value conflicts, they actively engaged in value-based reasoning, weight multiple competing considerations. However, the ways in which they navigated these dilemmas varied, with some students prioritizing professional obligations while others emphasized personal commitments. These findings suggest that structured reflection combined with value conflicts can help students become more aware of the values driving their decisions, allowing them to better understand the complexities of professional identity formation. Study 1 in Chapter 3 identified reflection as one of the key contributors to professional identity formation in dental students, reinforcing its importance in ethics education. As discussed in Section 7.1, values guide individuals’ attitudes, behaviors, and decision-making, particularly in professional contexts. When students encounter a misalignment between values tied to their professional identity and those linked to their personal identities, they may experience identity conflict, which can be challenging to navigate. Educators can enhance this process by incorporating structured reflective prompts that encourage students to examine their underlying values and how these values shape their 147 professional decision-making. Asking students to consider what personal values influence their approach to ethical dilemmas, how a particular scenario makes them feel about their role as a professional, and whether they have encountered similar value conflicts before, can help them recognize the tensions that arise between professional responsibilities and personal, familial, and social expectations. Through structured reflection, students can develop greater self-awareness and refine their ability to integrate their professional identity with their broader sense of self. Given that professional identity formation is a continuous process shaped by both structured learning and real-world experiences, ethics education should provide ongoing opportunities for reflective engagement. Encouraging students to revisit ethical dilemmas at different stages of their education can help them track changes in their reasoning, identify shifts in their value hierarchies, and refine their professional commitments. This iterative process strengthens their adaptability, preparing them to navigate the complexities of ethical challenges in clinical practice. By embedding these reflective strategies into ethics curricula, educators can create a supportive learning environment that fosters deeper self-reflection and strengthens students’ professional identity development. 7.5.2 Limitations and Future Considerations Maximizing participation was not the primary aim of this study, as qualitative studies typically aim for data saturation rather than large sample sizes. The goal was to explore the applicability of ethical dilemmas and axiological analysis in ethics education. The responses from 33 students provided valuable insights, although this limited size may constrain the breadth 148 of the findings. After analyzing responses to the two scenarios, it is possible that additional themes could emerge with a broader participant pool. Another limitation was that the activity was conducted through an online survey format, making it individual and asynchronous. When applied in an ethics classroom setting, however, this tool could be enhanced by incorporating facilitated reflection sessions or follow-up group discussions led by the instructor to further explore the depth of identity development and collaborative reasoning. Future research could also benefit from repeating this study with a larger and more targeted recruitment effort to explore differences based on students’ progression through their program. Comparative studies examining how students navigate ethical dilemmas over time may offer further insights into the development and evolution of their values. Incorporating interviews or focus groups could also provide richer data and enhance understanding of how students’ professional identity shifts over time. 7.6 Conclusion This chapter explored the use of ethical dilemmas and axiological analysis as a possible pedagogical tool for fostering professional identity formation (PIF) in dental education. By incorporating ethical dilemmas and axiological analysis, this approach provides a deeper lens for examining professionalism, revealing the internal and external pressures that shape professional identity. It also offers valuable insights into students’ motivations and the values guiding their decisions, reinforcing the role of structured reflection in professional identity development. Given that case-based learning is already common in ethics education, integrating value conflict 149 scenarios can further enhance self-reflection and deepen engagement with ethical complexities. The insights gained may provide a foundation for future research aimed at enhancing ethics curricula through identity-centered approaches. 7.7 Next Chapter Since the overall objectives, sub-objectives, and research questions have been addressed collectively in all the studies, the next chapter discusses the implications as a whole, thereby concluding my doctoral dissertation. 150 Chapter 8: Discussion, Conclusions, and Future Directions 8.1 Introduction As described in Chapter 1, this research topic stems from my years of experience as a dental hygienist, during which I observed numerous instances of malpractice or professional misconduct among dentists. As one of my supervisory committee members aptly noted, "Dentists are lords and masters of their own practice." This implies a lack of oversight, with regulatory bodies typically intervening only when issues have escalated significantly. These observations underscore the need for a deeper exploration of professionalism and professional identity formation in dentistry to proactively address professionalism-related challenges. While professionalism has long been a core topic in dental education due to its critical importance, research in medical education has introduced professional identity formation (PIF) as a newer, complementary framework aimed at addressing the limitations of traditional professionalism education, as described in Chapter 1. Despite its increasing prominence in medical education, PIF has received relatively little attention in the context of dentistry. This study, therefore, aims to bridge this gap by offering new insights into the factors that shape PIF for both dental students and practicing dentists, as outlined in Studies 1, 2, and 3. Given that identity is inherently personal and subjective, this study was not intended to produce findings generalizable to the entire population but rather to provide in-depth insights into the lived experiences of students and practitioners as they develop their dental professional identity. These insights lay the groundwork for future research, identifying key themes and areas for further exploration through larger-scale, longitudinal studies. 151 8.2 Key Lessons and Recommendations The overarching lesson from the study’s findings suggests the need for professionalism education to go beyond a checklist of procedural knowledge and clinical proficiency. As Stern notes, professionalism encompasses more than the ability to perform the procedures competently24—a perspective that may help dental educators refine how professionalism is defined across institutions. To foster a deeper sense of professionalism, dental education should prioritize the development of core professional values such as humanism, accountability, a commitment to excellence, and altruism.24 The studies in this dissertation demonstrate that both dental student and practicing dentist groups conceptualize professionalism in ways that align with Stern’s framework of professionalism in medical education. Their perspectives suggest that professionalism extends beyond clinical competencies, requiring students and practitioners to internalize and embody these values to fully reflect what it means to be a professional. To instill these values, as highlighted by both dental students and practicing dentists, professionalism education would benefit from a holistic approach. This approach would integrate reflection, value-based education, and real-world applications to foster meaningful professional identity formation (PIF). The challenges to professionalism education identified in this doctoral study, such as insufficient emphasis on role modelling, a lack of teaching on managing value conflicts, and limited opportunities to connect theoretical knowledge of professionalism with practical challenges, underscore the need for greater attention from educators and curriculum designers. 152 Professionalism education should aim to prepare students for the complexities and ethical dilemmas of real-world practice while equipping them with the tools to navigate systemic and interpersonal challenges. This study explored professionalism and professional identity formation from multiple perspectives: graduating students from the DMD program (Study 1), students' in-school experiences (Study 2), the realities encountered by practicing professionals (Study 3), and, as a result, I identified and proposed an educational strategy (Study 4). Together, these components address the overarching inquiry of this dissertation: "What educational practices are required to prepare future dental professionals to embody and maintain strong professional values?” Building on the insights gained throughout this dissertation, I offer the following final thoughts: 1. Professional identity evolves over time, requiring ongoing support from education to practice Comparing the perspectives on professionalism between students (Study 2) and the interviewed dentists (Study 3) reveals a notable shift in focus as individuals progress in their professional identity formation. For students, professionalism is often viewed in terms of mastering clinical competencies and adhering to ethical standards—areas that are emphasized in their education. In contrast, practicing dentists identify the complexities of real-world challenges, such as balancing patient demands, maintaining work-life balance, and navigating competitive market environments, as key factors that shape their professional identity and the application of professionalism. 153 This evolution highlights a crucial gap in dental education. It suggests that while students are well-prepared for foundational expectations, there is insufficient support to bridge the transition to the practical realities of clinical practice. Addressing these shifts in focus could enable dental programs to better prepare students not only for the immediate challenges of clinical work but also for the ongoing adaptive and reflection essential to their professional identity development throughout their careers. 2. Bridging the gap between theoretical education and practical realities to foster professionalism The findings from Studies 2 and 3 reveal that while both dental students and practicing dentists recognize the importance of professionalism, they encounter challenges that impact its development and application. For students, these challenges often arise from a lack of emphasis on real-world scenarios within the curriculum. Practicing dentists, on the other hand, highlight the pressures of real-world clinical practice—such as competitive work environments and patient demands—which can shape, and at times compromise, professionalism, ultimately influencing their professional identity. To address this gap, professionalism education should integrate practical, ethical decision-making. Incorporating case-based learning that simulates real-world challenges—such as ethical dilemmas, value conflicts, and role-playing—can provide students with opportunities to develop and refine their decision-making skills in a structured environment. This approach would help bridge the divide between theoretical knowledge and practical application, ensuring 154 that professionalism education is not only relevant but also effective in preparing students for the complexities of real-world practice. 8.3 Conclusion This dissertation suggests that positioning professional identity formation (PIF) as the central educational goal in dental education may help address current limitations in professionalism education. Unlike the behaviour-based model of ethics education, which focuses on outward actions, PIF emphasizes internalizing professional values, self-reflection, and ethical decision-making. Shifting towards an identity-centered approach could foster a more enduring and personally integrated professional mindset among students. Key findings from this dissertation highlight how a PIF-centered approach could enhance professionalism education. However, adopting this model requires reconsidering curriculum design, faculty development, and assessment strategies to ensure professionalism is cultivated an internalized commitment rather than merely a set of expected behaviours. These findings underscore the need for a critical examination of how educational structures shape students’ professional identity. While PIF presents a promising framework, further research is needed to explore how identity-centered approaches can be effectively integrated into professionalism education and how they influence professional behaviour over time. By building on these insights, professionalism education can evolve to better support dental professionals in developing both clinical expertise and a deeply rooted professional identity. 155 8.4 Study Limitations While this research provides valuable insights into professionalism and professional identity formation (PIF), it is important to acknowledge its inherent limitations. First, this is a qualitative study. It means that the findings reflect the experiences, perspectives, and interpretations of participants within their unique educational and professional contexts. The goal was to explore nuanced perspectives, not to produce universally applicable results. Second, the study’s cross-sectional design captures professional identity at a single point in time, limiting the ability to trace the evolution of PIF. Professional identity is a dynamic, ongoing process, and this study does not account for the longitudinal development that occurs as students transition into practitioners and beyond. Third, the research was conducted within a specific dental education and practice context, shaped by local cultural, institutional, and regulatory influences. As a result, the findings may not fully represent the experiences of dental students or professionals in other regions, cultures, or educational systems, where values, challenges, and professional norms may differ. Finally, the study relied on self-reported data, which carries the potential for some response bias. Participants may have described their experiences to align with social norms or professional expectations, possibly influencing the depth of their reflections. Although efforts were made to foster openness by building rapport and emphasizing that there were no “right” or “wrong” answers, this remains a common consideration in qualitative research, especially when addressing sensitive topics like professionalism that can be value laden. 156 8.5 Future Directions Future research could employ longitudinal designs to track the evolution of professional identity over time. By following students as they transition from dental school into professional practice, researchers could better understand how PIF develops and adapts across different stages of a dental career, providing a more comprehensive view of its dynamic nature. Given the contextual limitations of this study, future research could explore the experiences of dental students and professionals across different regions, cultures, and educational systems. This would help to determine whether the findings are universally applicable or if regional differences in values, norms, and challenges influence professional identity formation. To further explore the integration of professional identity formation (PIF) as a key objective of dental education, additional research could focus on testing and evaluating specific educational interventions designed to support PIF. For example, studies could investigate the effectiveness of incorporating more case-based learning, value-conflict analysis, and structured self-reflection into dental curricula to enhance students' internalization of professional values and address the gaps identified in this study. 157 Bibliography 1. Ozar DT, Sokol DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. 2nd ed. Georgetown University Press; 2002. 2. Welie JVM. Is dentistry a profession? Part 2. The hallmarks of professionalism. J Can Dent Assoc. 2004;70(9):599-602. 3. 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Free Press; 1978. https://ubc.summon.serialssolutions.com/2.0.0/link/0/eLvHCXMwbZ2xbsIwEIZPhS5IHVJaRIAiT6gMqZI4iRN1RCAegD2Kz_aYAbr07Tk7hqbAGCtxlJMv57Pv-w3A0684uvknUJg1ItUoEs3zRmMsDcqqaHKVG4wdxtYv1fm-K9W5Re0e7s5Qap6VAxhwUQ3_znSjkUUxjabZGXdpmT2fqaDB4eV3LtfJP_DeRpddAENLHLzCk27HEHbALPNOd2KfXhl6PYbZFS9hK-bv63Q- 171 ft9g7plbSn1Z0ypmhSCOHbZweofpbnvY7CN6de1XbGr3HekEXhpb5d7-OBpOTYGh1BxVhUJIaVUeS8GR3AhLi5eiMiEEd_2EsOi3XcxWZzR14SKePXhkDqPEKe_alYYFPBvyBP3hzLN0dj0DKSyFuw 178. Turner JC. Rediscovering the Social Group: A Self-Categorization Theory. B. Blackwell; 1987. https://go.exlibris.link/r48GMvsQ 179. Stets JE, Burke PJ. Identity Theory and Social Identity Theory. Soc Psychol Q. 2000;63(3):224-237. doi:10.2307/2695870 180. Lopez EKN, Johnson JH, Cunningham EP, Warshaw J, Baker EW. A unique and effective method of anatomy education: Small‐group learning with prosected plastinated specimens. J Dent Educ. 2022;86(4):425-436. doi:10.1002/jdd.12817 181. Stern DT, CRKN MiL Collection. Measuring Medical Professionalism. 1st ed. Oxford University Press; 2006. doi:10.1093/oso/9780195172263.001.0001 182. Maslach C, Leiter MP. Understanding the burnout experience: recent research and its implications for psychiatry. World Psychiatry. 2016;15(2):103-111. doi:10.1002/wps.20311 183. Jarvis-Selinger S, Pratt DD, Regehr G. Competency is not enough: Integrating identity formation into the medical education discourse. Acad Med. 2012;87(9):1185-1190. doi:10.1097/ACM.0b013e3182604968 184. Eckles RE, Meslin EM, Gaffney M, Helft PR. Medical ethics education: Where are we? Where should we be going? A review. Acad Med. 2005;80(12):1143-1152. doi:10.1097/00001888-200512000-00020 185. Ajzen I, Fishbein M. Attitudes and the Attitude-Behavior Relation: Reasoned and Automatic Processes. Eur Rev Soc Psychol. 2000;11(1):1-33. doi:10.1080/14792779943000116 186. Horton KE, Bayerl PS, Jacobs G. Identity conflicts at work: An integrative framework. J Organ Behav. 2014;35(S1):S6-22. doi:10.1002/job.1893 187. Brosch T, Sander D. Neurocognitive mechanisms underlying value-based decision-making: From core values to economic value. Front Hum Neurosci. 2013;7(Journal Article):398-398. doi:10.3389/fnhum.2013.00398 188. Ramarajan L. Past, Present and Future Research on Multiple Identities: Toward an Intrapersonal Network Approach. Acad Manag Ann. 2014;8(1):589-659. doi:10.1080/19416520.2014.912379 189. Altamirano-Bustamante MM, Altamirano-Bustamante NF, Lifshitz A, et al. Promoting networks between evidence-based medicine and values-based medicine in continuing medical education. BMC Med. 2013;11(1):39-39. doi:10.1186/1741-7015-11-39 172 190. Schwartz SH. Are there universal aspects in the structure and contents of human values? J Soc Issues. 1994;50(4):19-19. doi:10.1111/j.1540-4560.1994.tb01196.x 191. Rohan MJ. A Rose by Any Name? The Values Construct. Personal Soc Psychol Rev. 2000;4(3):255-277. doi:10.1207/S15327957PSPR0403_4 192. Harman G. Explaining Values and Other Essays in Moral Philosophy. Clarendon Press; 2000. https://go.exlibris.link/MxQKpvkG 193. Brown AD. Identity Work and Organizational Identification. Int J Manag Rev IJMR. 2017;19(3):296-317. doi:10.1111/ijmr.12152 194. Carminati L, Héliot YG. Between Multiple Identities and Values: Professionals’ Identity Conflicts in Ethically Charged Situations. Front Psychol. 2022;13. doi:10.3389/fpsyg.2022.813835 195. Patrick AC. A review of teaching ethics in the dental curriculum: challenges and future developments. Eur J Dent Educ. 2017;21(4):e114-e118. doi:10.1111/eje.12230 196. Ardenghi DM. Dentists’ ethical practical knowledge: a critical issue for dental education. Eur J Dent Educ. 2009;13(2):69-72. doi:10.1111/j.1600-0579.2009.00575.x 197. Dibbern DA, Wold E. Workshop-based learning: A model for teaching ethics. JAMA J Am Med Assoc. 1995;274(9):770-771. doi:10.1001/jama.274.9.770 198. FOX E, ARNOLD R, BRODY B. MEDICAL-ETHICS EDUCATION - PAST, PRESENT, AND FUTURE. Acad Med. 1995;70(9):761-769. doi:10.1097/00001888-199509000-00011 199. Whipp JL, Ferguson DJ, Wells LM, Iacopino AM. Rethinking knowledge and pedagogy in dental education. J Dent Educ. 2000;64(12):860-866. doi:10.1002/j.0022-0337.2000.64.12.tb03387.x 200. Berk NW. Teaching Ethics in Dental Schools: Trends, Techniques, and Targets. J Dent Educ. 2001;65(8):744-750. doi:10.1002/j.0022-0337.2001.65.8.tb03420.x 201. Sharp HM, Kuthy RA, Heller KE. Ethical Dilemmas Reported by Fourth‐Year Dental Students. J Dent Educ. 2005;69(10):1116-1122. doi:10.1002/j.0022-0337.2005.69.10.tb04012.x 202. Ellaway RH, Malhi RL, Woloschuk W, de Groot JM, Doig CJ, Myhre D. An Axiological Analysis of One Medical School’s Admissions Process: Exploring Individual Values and Value Systems. Acad Med. 2019;94(8):1229-1236. doi:10.1097/ACM.0000000000002698 203. Ellaway RH, Cooper G, Al-Idrissi T, Dubé T, Graves L. Discourses of student orientation to medical education programs. Med Educ Online. 2014;19. doi:10.3402/meo.v19.23714 173 204. Pezdek K, Dobrowolski R. The Ethical Code of Conduct for Physiotherapists-An Axiological Analysis. Int J Environ Res Public Health. 2023;20(2):1362. doi:10.3390/ijerph20021362 205. Kelly M, Ellaway RH, Reid H, et al. Considering axiological integrity: a methodological analysis of qualitative evidence syntheses, and its implications for health professions education. Adv Health Sci Educ Theory Pract. 2018;23(4):833-851. doi:10.1007/s10459-018-9829-y 206. Goodolf DM, Godfrey N. A think tank in action: Building new knowledge about professional identity in nursing. J Prof Nurs. 2021;37(2):493-499. doi:10.1016/j.profnurs.2020.10.007 207. Wong A, Trollope-Kumar K. Reflections: an inquiry into medical students’ professional identity formation. Med Educ. 2014;48(5):489-501. doi:10.1111/medu.12382 208. Niemi PM. Medical students’ professional identity: self-reflection during the preclinical years. Med Educ. 1997;31(6):408-415. doi:10.1046/j.1365-2923.1997.00697.x 209. Cruess RL, Cruess SR, Steinert Y, Cambridge Core EBA eBooks Complete Collection. Teaching Medical Professionalism: Supporting the Development of a Professional Identity. Second. Cambridge University Press; 2016. doi:10.1017/CBO9781316178485 210. Moyo M, Goodyear-Smith FA, Weller J, Robb G, Shulruf B. Healthcare practitioners’ personal and professional values. Adv Health Sci Educ Theory Pract. 2016;21(2):257-286. doi:10.1007/s10459-015-9626-9 211. Beck-Jones J, Perryman M. Examining Knowledge and Awareness of Professional Identity for Students in Health Management Programs. J Natl Soc Allied Health. 2015;12(1):13-18. 212. Cruess RL, Cruess SR, Steinert Y, Cambridge Core EBA eBooks Complete Collection. Teaching Medical Professionalism: Supporting the Development of a Professional Identity. Second. Cambridge University Press; 2016. doi:10.1017/CBO9781316178485 213. Arnoldi J, Kempland M, Newman K. Assessing student reflections of significant professional identity experiences. Curr Pharm Teach Learn. 2022;14(12):1478-1486. doi:10.1016/j.cptl.2022.10.003 214. Becker M, Dudley-Javoroski S, Shields RK. Professionalism Values in Health Science Education Self- and Peer-Assessment of Faculty, Staff, and Students. J Allied Health. 2017;46(3):178-184. 174 Appendix A: Study 2 Student Consent Form STUDENT CONSENT FORM Principal Investigator: HsingChi von Bergmann, Ph.D. 2199 Wesbrook Mall Vancouver, B.C., Canada V6T 1Z3 Oral Health Professionalism, Survey This is an exploratory study on perception of professionalism. We are inviting all students and instructors in the Faculty of Dentistry at UBC to participate in this study. Please note that: • Your participation is entirely voluntary. • Since the survey is anonymized, once you submit your survey, you will not be able to withdraw. Therefore, please do not submit the survey if you wish to withdraw. • Your input will not influence your academic standing at UBC After you have read the following, please feel free to contact us with any questions you may have. Purpose We are interested in understanding students' and educators' perceptions of professionalism in the UBC's oral health professional programs (DMD). For this research, we plan to use the survey to do the following: a. explore students' perception of professionalism in the DMD program, b. explore students’ definition of professionalism, motivation for entering the program, and most important qualities of a dentist according to students c. gather recommendations from students to improve professionalism education. 175 Study Procedures We are inviting you to fill out an online survey consisting of 19 questions and a few demographic items to help us calibrate the data. These 19 questions include multiple-choice, and short-answer questions. We anticipate the questionnaire will take you 15-20 minutes to complete. In the questionnaire, we will ask you to provide basic information on your views on professionalism education in your program. Potential Benefits By participating in this survey, you are given the opportunity to reflect on your personal view on professionalism. The data may be helpful to inform curriculum design in relation to promote professionalism education. Upon completion of the survey data collection, a random draw of an online $40 gift card winner in each cohort (DMD-Y1, DMD-Y2, DMD-Y3, DMD-Y4) will be announced via email. The last four digits of the number you enter will be used as an identifier. Since the survey is anonymized, both PI and the grad student (Jennifer) will not know who the winners are just by looking at the identifiers. Therefore, an email will be sent out with the winners’ four-digit numbers for the winners to claim an online gift card within a week. If the prize is not claimed within a week a second draw will be conducted for the respective cohort(s). Anyone who participates in the study by submitting the survey will automatically be considered to have consented to the study and will be entered the draw if the complete survey is obtained. Risks & Confidentiality There are no risks associated with participating in this study. This is an anonymized survey, and researchers do not know the details of the student identity or background. Both Dr. von Bergmann (principal researcher) and Jennifer Kwon (graduate student) are not involved in academic promotion in the UBC Faculty of Dentistry. Contact for information about the study If you have any questions or desire further information with respect to this study, please contact Dr. von Bergmann via email. Contact for concerns about the rights of research subjects If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics (Ethics ID for this study: H20-93728) Consent 176 Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without jeopardy to your treatment or activities at UBC. If you wish to withdraw, please do not submit the survey. By completing the questionnaire and submitting the survey, you are consenting to participate in this research. 177 Appendix B: Study 3 Oral Health Professionalism (OHP) Interview These are some sample interview questions. Since this part of the study is semi-structured, the interviewer will try to ask probing questions depending on the interviewee’s answer. Interview questions: 1. Tell me about your experience relating to professionalism in dentistry. (how long have you practiced? Did you own a practice? Are you an associate?) 2. Did you feel that there were potential barriers or challenges to ethical decision-making in your work place? If yes, what was it? 3. Do you think that school curriculum adequately prepared you to deal with those challenges? 4. Tell me about your development as a ‘dental professional.’ What do you think influences your professional identity as a dentist? Do you think your professional identity development as a dentist has any influence on the ethical decision making at work? 5. In your opinion, what kind of changes to the dental curriculum can positively help students develop professionalism? 6. How would you rate the program you’ve gone through now that you have had some years of practice? (added after submission) 7. What is dental professionalism to you? 178 Appendix C: Study 3 Dental Professionalism – Interview Study Dear oral healthcare providers, We are conducting interviews as part of a research study to increase our understanding of how oral health care providers understand dental professionalism and their lived experiences of possible barriers and challenges faced at work. We are very interested in finding out how your experience in the field has impacted you and we are inviting you to join our study! The interview will take approximately 30-60 minutes. Your responses to the questions will be kept confidential. Only Dr. von Bergmann, the principal investigator, and Ms. Kwon, the graduate student and co-investigator, will have access to the data. Identifying information of participants will be assigned a code number, and only demographic information will be used. Transcripts of audio files will include pseudonyms or a code number in place of participant names. The list of names and corresponding code numbers will be stored separately from all other study documents and will be kept in a locked filing cabinet in the UBC Faculty of Dentistry. This list will only be available to the PI. Computer files will be password-protected. Your participation will be a valuable addition to our research and findings could lead to a greater public understanding of professionalism in dentistry. A copy of the consent form is attached for your record. If you have any questions, please do not hesitate to ask. Thank you for considering and responding to our invitation. Sincerely, UBC Principal Investigator: HsingChi von Bergmann, Ph.D. Professor, Director of UBC DER Lab 179 Appendix D: Study 3 Consent Form Oral Health Professionalism, Interview This is an exploratory study on your perception of professionalism in dentistry. We are inviting dental practitioners (dentists) to participate in this study. For this research, we plan to use a semi-structured interview to do the following: a. explore dentists’ experiences and views of professionalism in the dental field b. understand the potential barriers and challenges to ethical decision-making c. understand how their identity as a dentist developed since graduation d. discuss what they can recommend to improve professionalism and how the result of this study can help it CONSENT FOR PARTICIPATION IN INTERVIEW RESEARCH I volunteer to participate in a research project conducted by Dr. von Bergmann from the University of British Columbia, Faculty of Dentistry. I understand the project is designed to gather information about dentists’ and dental hygienists’ views of professionalism in the industry. I will be one of approximately 20 people being interviewed for this research. 1. My participation in this project is voluntary. I understand that I may withdraw and discontinue participation at any time without penalty. If I decline to participate or withdraw from the study, no one will be told. 2. I understand that most interviewees will find the discussion interesting and thought-provoking. If, however, I feel uncomfortable in any way during the interview session, I have the right to decline to answer any question or to end the interview. 3. I understand I will be interviewed by researchers from the UBC Faculty of Dentistry. The interview will last approximately 30-45 minutes. Notes will be taken during the interview and audio recording will be made. If I don’t want to be taped, I will not be able to participate in the study. 4. I understand that in any report on the results of this research, my identity will remain anonymous. 180 All information I provide for this study will be treated confidentially. This will be done by changing my name and disguising any details of the interview, which may reveal my identity or the identity of the people I speak about. 5. The signed consent form and original audio recording will be retained in the computer of the principal investigator and co-investigator until the data is analyzed. Afterwards, the data will be destroyed following the university research guideline. 6. I understand that this research study has been reviewed and approved by the UBC Office of Research Ethics. For problems relating to research or questions regarding subjects, I can contact the Research Participant Complaint Line in the UBC Office of Research Ethics. (Ethics ID for this study: H20-93728) 7. I have read and understand the explanation provided to me. I have had all my questions answered to my satisfaction, and I voluntarily agree to participate in this study. 8. I have been given a copy of this consent form. _________________________________ ___________________________________ My Signature Date _________________________________ ___________________________________ My Printed Name Signature of the Investigator Contact for information about the study If you have any questions or desire further information with respect to this study, please contact Dr. von Bergmann via email. Principal Investigator: HsingChi von Bergmann, Ph.D. 2199 Wesbrook Mall Vancouver, B.C., Canada V6T 1Z3
Thesis/Dissertation
eng
Craniofacial Science
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
von Bergmann, HsingChi
Unveiling the implicit : exploring professionalism and professional identity formation in dentistry
Text