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practice applicationsETHICS IN ACTION
Promoting Professionalism through Ethical Behaviors
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romoting professional behavior isa chief concern across the contin-uum of education, and is applicable
o both students and faculty sharinghe responsibility for the preparation ofuture health care practitioners.
The Commission for Accreditationf Dietetics Education (CADE) com-etencies for entry-level dieteticsractitioners (1) require the ability toerform in accordance with the ADAode of Ethics for the Dietetics Profes-
ion (2). Principles within the Code ofthics reflect the following profes-ional behaviors: honesty/integrityPrinciple #1), responsibility and ac-ountability (Principle #4), self-im-rovement (Principle #4), self aware-ess/knowledge limits (Principle #5),ollaboration (Principle #5), respector others (Principles #8 & #9), andompassion/empathy (Principle #8).n addition, the ADA Standards ofrofessional Practice (3), specificallytandard #6, “Continued competencend professional accountability,” areupportive of professionalism throughelf-assessment and reflection. Focusn professional competence in termsf conduct is evidenced in the CDRrofessional Portfolio Process (4), re-uired for maintenance of the RD andTR credentials. The challenge for di-tetics educators and practitioners iso connect these ethical principles topecific, measurable, achievable, andealistic behaviors. This article pro-ides background for discussion ands significant to students and faculty.
In Defining and Assessing Profes-ional Competence, physician medical
This article was written by AliceFornari, EdD, RD, assistantdirector of education, Departmentof Family and Social Medicine,Albert Einstein College ofMedicine, Bronx, NY.doi: 10.1016/j.jada.2004.01.021
e
2004 by the American Dietetic Associat
ducators Epstein and Hundert pro-ose that “professional competence ishe habitual and judicious use ofommunication, knowledge, technicalkills, clinical reasoning, emotions,alues, and reflection in daily practiceor the benefit of the individual andommunity being served” (5). The Ac-reditation Council for Graduateedical Education (ACGME) defines
ompetency of professionalism as “be-aviors manifesting a commitment toarrying out professional responsibil-ties, adherence to ethical principles,nd sensitivity to a diverse patientopulation (6). Arnold, in a reporteviewing 30 years of medical litera-ure, summarizes professional behav-ors for learners, educational pro-esses, and programs (7). In addition,rnold summarizes steps to identifyound methods for evaluating profes-ional behaviors, with a goal totrengthen professionalism in medi-al education. This review is applica-le to all professionals preparing toork in health care settings.Dietetics educators at Iowa Stateniversity describe a rubric designeds a self-assessment tool for dieteticsnterns to address the issue of profes-ionalism (8). This tool is an effort touantify assessment of professionalevelopment, as related to the ADAore competencies for entry-levelractitioners.A first step in the assessment of the
rofessional behavior process in thecademic setting is to outline the gen-ral responsibilities and expectations ofhe teacher/practitioner and the stu-ent. The Figure serves as a startingoint to benchmark appropriate behav-ors. It can be easily adapted to a spe-ific culture of students and faculty (9).
The following situations identifyossible ethical dilemmas betweentudents and faculty in both campus-nd clinical-based settings. Following
ach situation is a categorical break- oion Journa
own of areas to examine beforeeaching a solution. This breakdownrovides an outline of how to reach anthical decision, as discussed in a pre-ious “Ethics in Action” column (10).t includes application to the princi-les of ethical theory identified byeauchamp and Childress (11). Thisntire process supports professionalehaviors that will ensure that ADAembers, student members, andDR credentialed practitioners aredhering to the Code of Ethics (2) andtandards of Professional Practice (3).
ituation #1: Difference Related to Sexualrientationthical Dilemma: A dietetics stu-ent writes an email containing dis-araging remarks concerning a pre-eptor’s sexual orientation and themail circulates through the programistserv to other students and faculty.
The Ethical Issue: Expressingersonal, offensive thoughts in a pub-ic forum, and creating interpersonalarriers based on difference. Theverarching ethical principle in thisituation would pertain to justice;hat is, fair, equitable, and appropri-te treatment to all individuals.ADA Codes Specific to the Is-
ue: Principle # 8, “The dietetics prac-itioner provides professional servicesith objectivity and with respect for
he unique needs and values of indi-iduals” (2). Principle #9, “The dietet-cs practitioner provides professionalervices in a manner that is sensitiveo cultural differences and does notiscriminate against others based onace, ethnicity, creed, religion, dis-bility, sex, age, sexual orientation orational origin” (2).Factors to Consider: Students
nd faculty must participate in self-eflection to identify personal beliefshat may influence their professionalttitudes and behaviors. The process
f distinguishing personal from pro-l of THE AMERICAN DIETETIC ASSOCIATION 347
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ETHICS IN ACTION
3
essional beliefs is essential to ensurehe Code of Ethics is followed in thecope of dietetics practice.Resolutions: The decision-making
aradigm requires analysis of thearticipants in the dilemma to iden-ify who is causing the dilemma andho is facing the dilemma. In addi-
ion, barriers to resolutions must bedentified, such as personal beliefsnd attitudes toward lifestyle choice.Preventing Future Dilemmas:ase study and role-play activitieshould be part of formal, didactic ed-cation to exemplify lifestyle differ-nces as normative behavior that wille encountered in daily practice.ractice in a simulated environmentill help students and faculty with aovice skill level develop higher-levelhought processes and, therefore,ompetency. Note: In the practice set-ing, adherence by practitioners andtudents to anti-harassment policiess required by law.
ituation #2: Acknowledgment of Studentarticipation in Research Protocolsthical Dilemma: A faculty memberses data collected from a studentroject to prepare a poster session orrticle and does not acknowledge thetudent’s contribution by listing the
Teacher Expectations
● be ethical and in particular to role model● behave with honesty and integrity● commit to excellence● respect professional boundaries and not p
in unethical situations or conflict of interes● respect confidentiality (except where to do
unethical or contrary to law)● not engage in or tolerate any harassment
(including emotional, sexual, physical, etc)● be willing and able to teach, applying wel
methods, including fair and valid evaluatio● be well prepared and knowledgeable in th● participate in professional development ac
maintain pedagogic competence● be open to criticism and adapt to reasona● recognize and appreciate the power differe
teacher and learner● not misuse or abuse the power differentia
gain, intimidation, punishment, etc)● respond to a student’s request for assistan
reasonable period of time
igure. Model for Professionalism. Adapted a
tudent as one of the authors. p
48 March 2004 Volume 104 Number 3
The Ethical Issue: Plagiarism,ollaboration, professional judgment,airness, honesty, and integrity. Theverarching ethical principle in thisituation would pertain to nonmalefi-ience. This principle is more com-only associated with a medical careodel but in this ethical dilemma, inresearch relationship, it can apply
o professional harm that can occur ifhe student is not recognized for hisr her work.ADA Codes Specific to the Is-
ue: Principle #1, “The dietetics prac-itioner conducts himself/herself withonesty, integrity and fairness.” Prin-iple #5, “The dietetics practitionerecognizes and exercises professionaludgment within the limits of his/herualifications and collaborates withthers, seeks counsel, or makes refer-als as appropriate” (2). Practitionersnd student members covered by theDA Code of Ethics are bound to pro-
essional practice that reflects profes-ional judgment and incorporatesonesty, integrity, and fairness.Factors to Consider: The academic
nvironment can foster power strug-les from either a student and/or a fac-lty perspective. The hierarchy of fac-lty over students can be misused.Resolutions: The decision-making
Student Expectations
cal behavior
herself/himself
would be
tudents
cepted
ubject matteries in order to
learner needsal between
, for personal
within a
● be ethical● behave with honesty
education (eg, acadehealth care professio
● commit to the highe● refuse to engage in
respect consent guid● be reliable, timely, a● not engage in misre● respect the educatio
education program● make a conscientiou
of the curriculum● not aim to succeed
peers or teachers● attend all orientation
assignments respect● refrain from disrupti● be available and res● recognize and appre
numbers, can haveinappropriately
eprinted with permission (9).
aradigm requires analysis of the s
articipants in the dilemma to iden-ify who is causing the dilemma andho is facing the dilemma. In addi-
ion, barriers to resolutions must bedentified, such as student fears thatrades or evaluations will be affectedf a faculty member is confronted.
Preventing Future Dilemmas:he faculty should participate in pro-
essional development activities thatupport competencies and demon-trate the importance of recognizinghe work of others. Faculty mentorshould guide students to contract withhe primary researcher for recogni-ion prior to completion of the project.
ituation #3: Memorizing Exam Questionsthical Dilemma: A class makes aact that each student will memorizene or more questions on an examina-ion. The intention is to share theseuestions with students enrolled inuture classes for use in studying forxams.The Ethical Issue: Conduct that
eflects honesty and integrity, androtecting confidential information.he overarching ethical principleould apply to justice; that is, fair,
quitable, and appropriate treatmento all individuals.
ADA Codes Specific to the Is-
d integrity toward all individuals involved inand nonacademic staff, colleagues, other
s, patients and their families)tandards of the professioneducational activity which does notes and/or confidentialitydependableentation, lying, plagiarism, or fraudgoals, standards, and policies of the
ffort to meet and exceed the expectations
xcel to the detriment of the well-being of
d teaching sessions; and complete alldeadlinesehavior and take responsibility for behaviorsivee that students, particularly in terms ofer and that this power can be exercised
ethi
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aningve bponciatpow
ue: Principle #1, “The dietetics prac-
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ETHICS IN ACTION
itioner conducts himself/herself withonesty, integrity and fairness.”Consider the Issues: Studentsay perceive helping peers as a cul-
urally acceptable and normativeehavior. Students in the academicetting may not connect their behav-or to violating ethical principlesnd the ADA Code of Ethics. Shar-ng information among peers is dis-onest and breaks confidentialityules.Resolutions: Students may have
heir own (mistaken) interpretationf the definition of plagiarism andheating.Preventing Future Dilemmas:
aculty mentors must review accept-ble ethical behaviors in all classes,einforce desired behaviors, and dis-uss consequences of professionalisconduct both during their aca-emic tenure and after gradua-ion.
ituation #4: Letter of Referenceonfidentiality is Not Maintainedthical Dilemma: An RD in privateractice prepares a reference letteror a practicum student applying to aietetic internship. The letter wasiven to the student in a sealed andigned envelope (protocol). The stu-ent breaks the seal of the letter,eads it, and confronts the practicumupervisor. The letter was not usedor the student’s dietetic internshippplication.The Ethical Issues: Practitioners
nd students are bound by the Code ofthics to protect confidential informa-
ion. The overarching ethical princi-le here is justice. Justice refers toairness and entitlement. Justice im-lies fair, equitable, and appropriatereatment to all individuals.
ADA Codes Specific to the Is-ue: Principle #1, “The dietetics prac-itioner conducts himself/herself withonesty, integrity and fairness.” Prin-iple #11, “The dietetics practitionerrovides objective evaluations of per-ormance for employees and cowork-rs, candidates for employment, stu-ents, professional memberships,wards, or scholarships. The dieteticsractitioner makes all reasonable ef-ort to avoid bias in any kind of pro-essional evaluation of others” (2).pening a sealed/signed letter is dis-onest and breaks the protocol of con-
dentiality. sIssues to Consider: Student cul-ure does not identify signing aaiver of their right to see a reference
etter as binding. Based on the impor-ance of reference letters to students’uture career choices, requests canoster power struggles, from either atudent and/or a faculty perspective.Resolutions: Students and faculty
nterpret signing a waiver of right toee differently in terms of its bindingerms. Resolution requires clarifyinghe implied responsibility of each per-on involved.Preventing Future Dilemmas:ducation programs are obligated totate in their student policies the con-equences of not following confidenti-lity requirements. Preparing lettersf reference is an expectation stu-ents have of faculty and also a keyesponsibility of faculty. The serious-ess of this professional activity muste appreciated by both the facultyember and the student.In conclusion, Epstein and Hundert
5) identify Dimensions of Profes-ional Competence, which include:ognitive, technical, integrative, con-extual, relationship, affective/moral,nd habits of mind for the medicalrofession. This concept supportsompetence as a developmental be-avior acquired in different stages of
earning and practice.A conversation led by leadership
mong dietetic educators and practi-ioners can result in the dietetics pro-ession agreeing on criteria for bench-
arking and assessing professionalompetence. Stages of professionalraining (entry-level vs. advancedractice) will govern which criteriare applicable and what level of com-etence is appropriate for each crite-ion.As mentioned previously, Iowa
tate University dietetics faculty at-empted designing a rubric, as a self-ssessment tool for dietetics interns,o address the issue of professional-sm by identifying skills correlatedith professional growth and devel-pment. In addition, they anchoredhe skills to levels of competence,rom novice to proficient (8). This ru-ric can serve as guideline for otherrograms beginning the process of de-eloping curriculum specifically sup-ortive of professionalism and theDA Code of Ethics (2). Future cur-
iculum will need to employ innovative
trategies to assess professionalism,Journa
hich includes a strong mentoringystem to provide direction, feedback,nd, when necessary, remediation.
eferences1. American Dietetic Association.
CADE Accreditation Handbook.American Dietetic Association. 2002.Available at: http://www.eatright.org/Public/Files/accreditation_handbook.pdf. Accessed Decem-ber 22, 2003.
2. American Dietetic Association.Code of ethics for the profession ofdietetics. Available at: http://www.eatright.org/Member/index_8915.cfm. Accessed December 22, 2003.
3. American Dietetic Association.Standards of Professional Prac-tice for Dietetic professionals.J Am Diet Assoc. 1998;98:83-87.
4. Commission on Dietetic Registra-tion. The professional develop-ment 2001 portfolio. Available at:www.cdrnet.org/pdrcenter/pdpin-dix.htm. Accessed December 22,2003.
5. Epstein R, Hundert E. Definingand assessing professional com-petence. JAMA. 2002;287:226-235.
6. ACGME Outcome Project. Ac-creditation Council for GraduateMedical Education Web site.Available at: http://www.acgme.org/outcome/comp/compMin.asp.Accessed December 22, 2003.
7. Arnold L. Assessing professionalbehavior: Yesterday, today, andtomorrow. Acad Med. 2002;77:502-514.
8. Anderson JA, Litchfield RE,Kruzich, LA, Johnson JS, Oak-land MJ. Using a rubric as a self-assessment tool for the intern toevaluate professional develop-ment. DEP-Line (a publication ofthe American Dietetic Associa-tion, DPG #50); Summer 2003:12-15.
9. McGill University, School of Medi-cine/Undergraduate Program, Codeof Conduct Web site. Availableat: http://www.medicine.mcgill.ca/ugme/standardsbehaviour2.htm.Accessed December 22, 2003.
0. Fornari AJ. Approaches to ethicaldecision making. J Am Diet As-soc. 2001;102:865-866.
1. Beauchamp TL, Childress JF.Principles of Biomedical Ethics.4th ed. New York, NY: Basic
Books; 1994.l of THE AMERICAN DIETETIC ASSOCIATION 349
