# Shared System-Level Drivers of Unprofessional Conduct During Clinical Rotations Among Medical and Dental Students: An Interpretive Description Study

## TL;DR

This study explores how system-level factors in clinical education settings in Pakistan contribute to unprofessional behavior among medical and dental students.

## Contribution

The study identifies shared, system-level drivers of unprofessional conduct in low-resource clinical education settings.

## Key findings

- Unprofessional conduct is influenced by hierarchy, hidden curriculum, and systemic pressures in clinical training.
- Students experience moral distress and withdrawal due to exposure to unprofessional behavior.
- Institutional strategies are needed to promote respectful supervision and safe reporting mechanisms.

## Abstract

Introduction

Unprofessional conduct in clinical education refers to behaviours that deviate from accepted professional norms. These behaviours undermine learner well-being, patient dignity, and the development of professional identity. Findings from previous literature suggest that unprofessional conduct is common in Pakistani clinical training and may be reinforced within clinical environments, potentially through the influence of negative elements of the hidden curriculum. While individual incidents are often reported, less is known about how institutional and system-level factors interact to normalise or hinder mistreatment in low-resource clinical education settings. Therefore, this study aimed to explore final-year medical and dental students' perceptions of shared, system-level drivers of unprofessional conduct during clinical rotations, with the goal of producing practice-oriented recommendations for clinical education.

Methodology

This interpretive description study was conducted at a private medical and dental college in Multan, Pakistan. Participants were recruited with purposive sampling that included final-year Bachelor of Medicine, Bachelor of Surgery (MBBS) and Bachelor of Dental Surgery (BDS) students who had completed clinical rotations and consented to audio-recording. Data collection continued until interpretive sufficiency was reached. Semi-structured, in-depth interviews were conducted face-to-face using a pilot-tested, expert-validated guide. Recordings were transcribed manually, and data were analysed using iterative immersion, open coding, constant comparison, development of analytic categories, and construction of higher-order themes consistent with interpretive description.

Results

Interviews revealed five interrelated thematic patterns: (1) hierarchy and power, including unchecked senior authority, social bias, and unfair treatment with paramedical staff; (2) hidden curriculum and norms, including silence and obedience, compensatory acts by clinicians, haphazard training, and informal practices that contradicted formal professionalism teaching; (3) systemic pressures and drivers, including excessive patient loads, resource scarcity and dual-practice incentives which shifted faculty priorities away from clinical teaching and promoted expedient, and instrumental behaviours; (4) challenges to patient-centred practice, where patients were often objectified during teaching, with inadequate communication, privacy breaches, and gendered biases; and (5) student impact and coping, where exposure to unprofessional conduct produced shame, moral distress, and withdrawal, while some students expressed a strong desire for institutional change. Together, these themes indicate that unprofessional behaviour is systemically embedded and socially learned rather than solely individual failings.

Conclusions

Unprofessional conduct during clinical rotations reflects the combined influence of unregulated power, negative role-modelling in hidden curricula, and system-level constraints rather than isolated individual failings. Addressing these issues requires institutional strategies that protect teaching time, promote respectful supervision, and provide safe, confidential reporting mechanisms. Such approaches can strengthen learner well-being, uphold patient dignity, and reinforce professionalism in clinical education.