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Original Article 

Volume 13     Number 12     September 2020 
Copyright © 2020 Tehran University of Medical Sciences. 
This work is licensed under a Creative Commons Attribution-NonCommercial 
4.0 International license (https://creativecommons.org/licenses/by-nc/4.0/).  
Non-commercial uses of the work are permitted, provided the original work is 
properly cited. 

Turning unprofessional behaviors around using Holmes' reflection 

approach: a randomized controlled study 

*Corresponding Author 
  
Sara Mortaz Hejri 

Third Floor, No. 57, Hojatdoust St., 

Keshavarz Blvd., Tehran, Iran. 

Postal Code: 141669591 

Tel: (+98) 21 88 95 57 12 

Email: smortaz@tums.ac.ir 

 

Received: 1 Jan 2020 

Accepted: 31 May 2020 

Published: 16 Sep 2020 

 

Citation to this article:  

Naeimi L, Asghari F, Nedjat S, 

Mirzazadeh A, Abbaszadeh M, Sima AR, 

Mortaz Hejri S. Turning unprofessional 
behaviors around using Holmes' 

reflection approach: a randomized 

controlled study. J Med Ethics Hist Med. 
2020; 13: 12. 

Leila Naeimi1, Fariba Asghari 2, Saharnaz Nedjat3, Azim Mirzazadeh4, Mahsa Abbaszadeh5, Ali Reza 
Sima6, Sara Mortaz Hejri7* 
 

1.Researcher, Department of Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, 
Iran; Medical Education Development Center, Zanjan University of Medical Sciences, Zanjan, Iran. 
2.Associate Professor, Medical Ethics and History of Medicine Research Center, Tehran University of Medical 
Sciences, Tehran, Iran. 
3.Professor, Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical 
Sciences, Tehran, Iran. 
4.Associate Professor, Department of Medical Education, Health Professions Education Research Center, Tehran 
University of Medical Sciences, Tehran, Iran. 
5.Assistant Professor, Department of Internal Medicine, Imam Khomeini Hospital Complex, Tehran University of 
Medical Sciences, Tehran, Iran. 
6.Assistant Professor, Digestive Disease Research Center, Digestive Disease Research Institute, Shariati Hospital, 
Tehran University of Medical Sciences, Tehran, Iran. 
7.Assistant Professor, Department of Medical Education, Educational Development Center, Tehran University of 
Medical Sciences, Tehran, Iran. 
 

Abstract  

Many medical schools around the world have included 

professionalism training in their formal curriculum. However, 

these efforts may not be adequate; given the exposure of 

students to unprofessional behaviors in the clinical settings. In 

the present study, we aimed to design, implement, and 

evaluate a longitudinal program to improve professionalism 

among medical students upon their transition to clinical 

settings. A total of 75 medical students were enrolled in the 

study and randomly assigned to two groups. The control 

group did not receive any training, while for the intervention 

group; a 10-hour program through 16 weeks was organized 

based on the Holmes' reflection approach. The effectiveness 

of the program was evaluated by measuring three outcomes in 

both groups. Data analysis was performed using paired t-test 

and Multiple Linear Regression. Scores of judgment of 

professionalism increased in the intervention group (from 

7.56 to 10.17; P< 0.001), while there was no significant 

improvement in the control group’s scores. Students' attitudes 

towards professionalism and their professional behaviors did 

not change significantly. 

Based on our findings, the Holmes reflection approach helps 

students improve their cognitive base of professionalism. 

Long-term follow-up and further qualitative studies will help 

us better understand the effects of this approach on other 

desirable outcomes.  

Keywords: Professionalism; Holmes' approach; 
Unprofessional behavior; Medical students; Reflection. 

  



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Volume 13     Number 12     September 2020 

 

  Introduction 

Professionalism, one of the six core 

competencies proposed by the Accreditation 

Council of Graduate Medical Education (1), 

has become increasingly important for the 

medical community, as well as the public 

(2,3). The results of previous studies showed 

that demonstration of professional behaviors 

by physicians increases patients' satisfaction 

and trust, help patients adhere to their 

therapeutic plans, and reduce medical 

litigations (4-6). Hence, medical students 

should be trained to establish professional 

behaviors and provide high-quality patient-

centered care in the future (1). 

The development and maintenance of 

professionalism are one of the challenging 

issues in medical education. It is important 

to explicitly teach professionalism and 

actively reinforce the desired values, 

throughout both the undergraduate and 

postgraduate curricula (7). Apart from role 

modeling which seems to be the most 

effective technique for developing 

professionalism and besides didactic 

sessions which are regularly used to provide 

the cognitive base of professionalism, 

experiential learning, reflective practice, and 

methods of critical and guided reflection are 

strongly recommended for endorsing 

professionalism (8-10). 

Reflection is described as a core element of 

clinical competence and a fundamental 

element in teaching professionalism (11). 

Physicians often have to resolve complex 

problems with no predefined solutions. 

Hence, exposing students to the complexities 

of their professional life is essential and 

guided reflection can help maximize their 

learning (12). Despite its variability, 

reflection models are not usually integrated 

into medical education programs due to time 

constraints and feasibility issues (11). In this 

study, we decided to use the Holmes' 

reflection approach, which suggests a set of 

reflective competencies that are helpful, 

especially for medical students who have 

been exposed to unprofessional behaviors, 

during their transition from pre-clinical 

period to clinical settings (13, 14).  In this 

approach, similar to the Schön's model, it is 

assumed that reflective practice could take 

place when a person is faced with a real 

problem that has no simple solution. While 

the Schön's model could be applied for all 

individuals in any circumstances, the 

Holmes' approach is specifically designed 

for medical students who have been exposed 

to unprofessional behaviors in the clinical 

settings. This model is based on the 

observation of events in real situations: It 

focuses on unprofessional behaviors, which 

are inevitable parts of the hidden curriculum 

at the workplace; It targets students who are 

new in their clinical role, and therefore, are 

more likely to be sensitive toward the 

professional lapses that occur around them; 

and it facilitates reflection using certain 

four-step strategies, namely, priming, 

noticing, reflecting, and choosing.  

There is little evidence concerning the 

application and effectiveness of the Holmes' 

approach. Seen from a broader perspective, 

research in the field of medical 

professionalism is mostly composed of 

descriptive reports or qualitative studies, 



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Volume 13     Number 12     September 2020 

most of which have discussed the 

importance of professionalism or have 

elaborated on different methods of teaching 

professionalism (8, 9, 15). A limited number 

of studies have focused on the impact of 

teaching methods and have indeed evaluated 

the results of educational interventions on 

professionalism (11, 16-18). These studies 

have shed light on this area; however, to the 

best of our knowledge, they have failed to 

evaluate the impact of their program on the 

students' knowledge base or actual 

professional behaviors (15-16), nor have 

used a particular theoretical framework for 

reflection (16), or have not recruited an 

identical control group to provide a basis for 

more valid comparisons (16-18).  

In this study, we tried to provide robust 

evidence by evaluating the educational 

outcomes of our longitudinal program at 

different levels of reaction, learning, and 

behavior using the Holmes' reflection 

approach. We chose clerks (fourth year 

medical students) because noticing and 

observing unexpected behaviors, which are 

in contrast with the ethical values learned in 

the formal curriculum, more likely occurs at 

the beginning of a new period of training. 

 

Method 

Study design  

This pre-test post-test randomized controlled 

study was conducted in 2017-2018 on 

medical students. TUMS medical students 

are mainly admitted to the university from 

high school and the total duration of their 

training, including the internship, is seven 

years. The preclinical period is an integrated 

organ system-based curriculum that 

continues for three and a half years. These 

medical students have to follow two unit 

course in ethics in the pre-clinical period. 

While these students have an early clinical 

exposure during the pre-clinical period, their 

first clinical experience at the patient's 

bedside starts in the fourth year when they 

are assigned to the university-affiliated 

hospitals for their clerkship. The internal 

medicine clerkship was selected for this 

study, as it is the longest rotation (16 weeks) 

and the starting point of clinical practice for 

many students. In the briefing session at the 

beginning of the internal medicine clerkship, 

the study objectives and procedures were 

described for all students, and those who 

were willing to participate were enrolled in 

the study. For data analysis, we excluded 

students who were absent for two or more 

sessions as well as those who failed to 

complete the evaluations. A sample size of 

23 was estimated for each group as a prior; 

however, concerning the probability of 

dropouts, we considered a larger sample 

size. Students were randomly assigned to the 

control and intervention groups. The control 

group did not receive any training, while the 

intervention group participated in five 

sessions. To minimize the risk of 

contamination, participants were asked not 

to share program details with friends and 

classmates of the control group (Figure 1). 

 

 



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Figure 1- The study design and evaluated outcomes 

 

Design and delivery of the educational 

intervention 

The research team met regularly to discuss 

the details of the design and structure of the 

longitudinal program based on the Holmes’ 

approach. They made decisions on the 

schedule, teaching methods, content, and 

implementation of the intervention. 

We finally decided to organize the whole 

program as five 2-hour sessions within 16 

weeks. With regard to the teaching methods, 

we decided to use the small group technique. 

Hence, we randomly allocated the students 

into six small groups (five groups of six and 

one group of eight people). As we needed 

facilitators to coordinate discussions in small 

groups, we invited a number of medical 

interns who were collaborating with the 

Educational Development Office at the 



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Volume 13     Number 12     September 2020 

Medical School. These medical interns were 

previously trained to play the role of 

facilitators; yet, before the beginning of the 

program, we oriented them about our study 

objectives, the intervention procedure, and 

the purpose of the sessions. We also 

provided them with a written guideline. The 

facilitators were instructed to use their own 

experience to encourage discussions in the 

small groups. With regard to the content of 

the program, we decided to apply the 

Holmes' steps in five sessions: 

In the first session, the program was 

introduced, and the importance and necessity 

of teaching professionalism were discussed 

interactively. A notebook was given to the 

students to record daily diaries immediately 

to prevent contamination of the memory. 

Then, the first step of Holmes' reflection 

approach, priming, was implemented. For 

this purpose, some examples of how medical 

students in a clinical setting might yield to 

external pressures to engage in inappropriate 

behaviors were presented. The facilitators 

shared their experience in this area and 

encouraged the students to participate in the 

discussion. The students were asked to pay 

attention to unprofessional behaviors that 

might occur in upcoming days during their 

rotation and to document their daily 

memories in their clinical notebooks. In the 

second session, according to the second step 

of Holmes' reflection approach, noticing, the 

students described the ethical issues that 

they were exposed to. They were 

encouraged to share their notes of 

unprofessional behaviors, to express the 

emotion that they had felt at those moments, 

and to discuss their experiences. In the third 

session, the third step of Holmes' reflection 

approach, processing, was implemented. The 

objective of this session was to help students 

develop feasible action plans to deal with 

similar situations in the future. In the fourth 

session, we repeated the processing step, so 

that all students would have the opportunity 

to reflect deeply and critically on their 

observations and to receive feedback. In the 

last session, the fourth step, choosing, was 

implemented. The objectives of this session 

were to support students in identifying and 

adopting behaviors aligned with the 

profession's values and to avoid 

misconducts; help students apply their action 

plans (an outcome of steps 3) in a way that it 

reinforces their progress without alienating 

them from their peers or seniors, and show 

students how to politely disagree with 

others. In this session, a sample of poor 

reflections was compared with some good 

reflections, and group discussions were 

conducted. Each facilitator was assigned to a 

small group and encouraged students to 

reflect. The facilitators provided feedback 

about the students' reflection and helped 

them distinguish a poor reflection from a 

good one, using a guideline (19).  

Investigation of outcome 

The assessment of outcomes was carried out 

at the beginning of the study and one month 

after the program, for both intervention and 

control groups. We used several tools to 

determine the effectiveness of the program: 

We evaluated the cognitive base of 

professionalism (level 2A of Kirkpatrick's 

framework) using a Situational Judgment 

Test (SJT), consisting of 11 clinical 



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Volume 13     Number 12     September 2020 

scenarios (seven constructed-response 

questions and four selected-response 

questions). Some examples of this test are 

presented in figure 2. The test was designed 

and scored by a panel of experts, based on 

medical professionalism guidelines. The 

total score of this test ranged from 0 to 20.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2- Questions of Situational Judgment Test for  

assessing students' professionalism cognitive base 

 

The students' attitude toward 

professionalism (level 2B of Kirkpatrick's 

framework (20)) was assessed using the 

modified version of Queen’s University 

Belfast Professionalism Index (QUBPI) 

inventory. The original version of this 

questionnaire contains two sections. The 

first section, with 20 items, evaluates the 

person’s attitude towards professional 

behaviors and commitment, and the second 

part, with 19 items, evaluates the frequency 

of exposure to unprofessional behaviors 



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(21). In this study, only the first part of this 

tool was used. This part consists of two sub-

sections, to be rated on a five-point Likert 

scale (completely disagree= 5; completely 

agree= 1). We translated and validated the 

questionnaire according to the guideline 

developed by Sousa and Rojjanasrirat (22).  

Concerning content validity, which was 

evaluated by the help of faculty members 

and medical students, three questions (1, 10, 

and 20) were removed. Therefore, the score 

of the Persian version ranged between 17 

and 80. Moreover, the reliability of this tool 

was found to be desirable, based on the 

results of the Intraclass Correlation 

Coefficient and Cronach's alpha 

measurements (≥ 0.70).  

Moreover, the students' professional 

behaviors were evaluated (level 3 of 

Kirkpatrick framework) using the 

Professionalism Mini-evaluation Exercise 

(P-MEX). The content validity assessment 

showed that five items (items 4, 5, 12, 20, 

and 21) were not suitable for evaluating the 

TUMS clerks, and thus, were omitted. The 

internal consistency of the 16-item scale was 

found to be 0.95, based on Cronach's alpha. 

Since each item of the P-MEX is graded as 

follows: 1= unacceptable; 2= below 

expectations; 3= met expectations; and 

4=exceeded expectations, the total score 

ranged from 16 to 64. Interns, residents, 

fellows, and faculty members used P-MEX 

to assess participants. One of the researchers 

provided the necessary instructions on the 

tool before conducting the assessments. Data 

analysis was carried out only for students 

whose evaluations were completed before 

and after the intervention, and for those who 

participated in three sessions and more. 

Statistics 

The demographics of participants were 

summarized using frequency, mean, and 

standard deviation. The paired t-test was 

performed to compare means of SJT, 

QUBPI, and P-MEX scores. Multiple Linear 

Regression (MLR) was performed using 

medical students' post-test mean scores of 

SJT, QUBPI, and P-MEX as the dependent 

variables; and the pre-test mean scores and 

the group as the independent variables. All 

data analyses were performed using SPSS 

version 21(23). 

The study protocol was approved by the 

Ethics Committee of Tehran University of 

Medical Sciences (TUMS) (No. 

IR.TUMS.MEDICINE.REC.1395.1722). 

 

Results 

Among 105 eligible students, 75 (71.4%) 

voluntarily participated in this study and 

were randomly allocated to the intervention 

and control groups. The mean age of 

students in the intervention group was 22.12 

years (SD=0.95), and 44.7% (N=17) were 

female. The mean age of the control group 

was 22.77 years (SD=0.95), and 35.5% 

(N=11) were female. There was no 

significant difference between the mean age 

of the students in the control and 

intervention groups.  

The mean and standard deviation of pretest 

and posttest scores of judgment (SJT), 

Attitude (QUBPI), and behavior (P-MEX), 



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before and after the program is presented for the control and intervention groups in Table 1. 

 

Table 1- Results of paired t-test analyses to compare mean scores of SJT, QUBPI, and P-MEX in 

the intervention and control groups, before and after the educational program 

Test (Outcome) Group 

Pre-test Post-test 

Mean 
Standard 

Deviation 
t Sig. Mean 

Standard 

Deviation 
t Sig. 

Situational 

Judgment Test 

(Cognitive base) 

Intervention 

(n=31) 
7.56 2.49 

-1.60 0.11 

10.17 2.17 

4.81* <0.001 

 
Control 

(n=28) 
8.57 2.40 7.71 1.74 

Queen University 

Belfast 

Professionalism 

Inventory 

(Attitude) 

Intervention 

(n=36) 
56.72 5.48 

0.14 0.89 

59.17 6.65 

0.97 0.33 
Control 

(n=31) 
56.48 8.34 57.10 10.08 

Professionalism 

Mini Evaluation 

Exercise 

(Behavior) 

Intervention 

(n=25) 
47.42 4.17 

-0.53 0.59 

48.85 5.51 

2.24** 0.03 
Control 

(n=25) 
48.07 4.36 

45.74 4.18 

 

 * Correlation is significant at the level of 0.05. 

** Correlation is significant at the level of 0.01. 

 

Post-test judgment was improved in the 

intervention group, showing a significant 

difference between the control and 

intervention groups (P<0.001). Based on the 

results of the MLR of SJT, independent 

variables of “group” and “mean pre-test 

score” explained 64% (R2) of variance 

scores (dependent variable). Considering the 

students' attitude (QUBPI), the MLR showed 

that independent variables of "group" and 

"mean pre-test score" explained only 16% of 

the variance in the mean score. The MLR of 

students' behaviors (P-MEX) showed that 

independent variables of "group" and "pre-

test behavior score" could explain only 

0.23% of the variance in the mean score.  

It should be noted that R2 must be 

somewhere in the range of 0 and 1, where 0 

shows that the result can't be anticipated by 

any of the independent variables and 1 

demonstrates that the result can be 

anticipated without error from the 

independent variables. Based on the results 

of the MLR of students' judgment, by a one-

unit increase in the mean pre-test score, the 

mean score of the post-test increased by 0.66 

units (P< 0.001). Also, in line with the 

paired t-test results, after controlling the 

confounders using MLR, the students' 

judgment in the intervention group increased 

significantly in comparison with the control 

group (P< 0.001). Based on the results of the 

MLR, by a one-unit increase in the mean 



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pre-test score of the students' attitudes, the 

mean score of post-test increased by 0.46 

units (P< 0.001). However, after controlling 

the confounders using MLR, in line with the 

paired t-test results, there was no statistically 

significant difference between the two 

groups’ attitudes after the intervention (P= 

0.34) (Table 2).  

 

Table 2- Results of paired t-test analyses to compare mean scores of SJT, QUBPI, and P-MEX in 

the intervention and control groups, before and after the educational program. 

Test (Outcome)  Unstandardized 

Coefficients 

Standardized 

Coefficients 

Beta 

Sig. R2 

B SE 

Situational Judgment 

Test 

(Cognitive base) 

(constant) 10.40 0.96  <0.001 

0.64 
group -2.80 0.48 - 0.47 <0.001 

Pre-test 

score 
0.66 0.09 0.55 <0.001 

Queen University Belfast 

Professionalism 

Inventory (Attitude) 

 

(constant) 1.76 0.48  <0.001 

0.16 
group -0.10 0.11 -0.11 0.341 

Pre-test 

score 
0.46 0.13 0.39 <0.001 

Professionalism-Mini 

Evaluation Exercise 

(Behavior) 

(constant) 2.92 0.71  <0.001 

0.23 
group -0.17 0.09 -0.23 0.074 

Pre-test 

score 
0.77 0.23 0.43 <0.001 

 

In the intervention group, in comparison 

with the control group, the mean score of 

students' behavior increased by 0.17 units, 

provided that the variable pre-test value was 

considered constant (P= 0.07). Also, with a 

one-unit increase in the mean pre-test score 

of students' behavior, the mean score of the 

post-test increased by 0.77 units (P< 0.001). 

However, after controlling the confounders 

using MLR in line with the paired t-test 

results, professional behavior in the 

intervention group did not show any 

statistically significant difference (P= 0.07). 

 

Discussion 

To improve the cognitive base, attitude, and 

professional behavior of medical students, 

we conducted a pre-test post-test 

randomized controlled study by designing 

and implementing a 10-hour program 

through 16 weeks, based on the Holmes' 

reflection approach. We found that the 

students' judgment on professionalism 

improved in the intervention group 

compared to their baseline scores and 

compared to the control group; however, 

there were no significant difference in the 

students' attitude or performance. 



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There are few studies that have tried to 

investigate the impact of eliciting reflection 

as a method of professionalism training. 

Holtman et al. evaluated the effectiveness of 

a professionalism course in an academic 

plastic using a pre- and post-tests study 

design. They implemented a 12-hour course 

through 6-week for health care professionals 

in plastic surgery (faculty members, 

residents, nurses, and medical students). 

Teaching methods included didactic 

lectures, journal clubs, small group 

discussions, and book reviews. They 

assessed the outcomes using four levels of 

the Kirkpatrick model. Given the qualitative 

nature of the data extracted from levels 3 

and 4 in this study, outcomes were measured 

by the incidence of sentinel events. The 

results showed improvement in knowledge 

and professional behaviors. In addition, the 

participants were satisfied with the course; 

however, their attitude toward 

professionalism did not change. Since the 

authors did not use a randomized design, it 

is difficult to attribute all the changes to the 

training program. In addition, participants of 

the study included a diverse range of health 

professionals who were more involved in 

patient care, compared to the clerks in our 

study (24).  

Given the lack of comparable quantitative, 

randomized studies on teaching and 

assessing professionalism, our findings can 

be considered in a wider context including 

medical ethics and ethical judgement. 

Murrell conducted a cross-sectional study to 

evaluate medical students' ethical judgment. 

The results showed that there was no 

significant difference between students who 

participated in the professionalism course 

and those who did not (25). This finding is 

consistent with the findings of our study in 

which confounding factors in the clinical 

setting as well as the short duration of study 

might have caused the absence of any 

difference in the scores. Moreover, Goldie et 

al. in a quasi-experimental study evaluated 

the effectiveness of teaching ethics in small 

groups. Training had a significant positive 

impact on the students' potential ethical 

behaviors. It also created a supportive 

environment for promoting constructive 

criticism of peers' performance. In this 

study, again, the intervention group attitude 

towards professionalism did not differ 

significantly compared to the control group 

(26), which is consistent with the present 

findings. 

Clearly, there are many variables that could 

have influenced the professional behaviors 

of learners and their attitudes toward 

professionalism. Hence, we were not able to 

detect a significant improvement in these 

two outcomes. The hidden curriculum is a 

very powerful tool for encouraging 

professional values (7, 27); yet, it “also has a 

more pernicious side, whereby 

professionalism lapses and unethical 

behaviors are normalized, particularly in the 

clinical setting” (28). Students work in the 

clinical settings under the supervision of 

attending physicians and residents and as the 

lowest-ranking members of the clinical 

chain, they are subject to implicit learning 

(25). According to Coulehan and Williams 

"the tacit socialization process is powerful 

because it is continuous throughout the 

clinical training and is reinforced by doing 



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Volume 13     Number 12     September 2020 

rather than saying" (29). Based on the results 

of previous studies, conducted in hospitals 

affiliated to TUMS, it can be concluded that 

inappropriate or negative role models may 

contribute to the inefficacy of the training 

programs that aim to develop 

professionalism among students (27, 30). 

Having said that, there might also be other 

reasons for the lack of significant behavioral 

differences after the intervention in our 

study. First, the P-MEX might have not been 

the perfect assessment tool for our study, 

despite its previous validations and despite 

our modifications (31).  

To the best of our knowledge, this is the first 

true experimental research that evaluated a 

professionalism training program based on a 

guided reflection method. The current study 

had several strengths. First of all, we used a 

conceptual framework that facilitated guided 

reflection and feedback in multiple sessions. 

Interestingly, while the Holmes' approach is 

grounded in a theoretical basis, it is very 

practical and applicable to the real life. To 

make the most out of this approach, we 

managed to design our intervention as a 

longitudinal program, because standalone 

educational courses are considered to be less 

effective. Besides, to provide robust 

evidence on the effects of our program, we 

included a control group and performed pre-

post comparisons. We also used previously 

established instruments for all of our 

measurements, including the cognitive base 

and attitude of students, as well as their 

actual behavior, an outcome that has often 

been ignored in previous studies.   

On the other hand, our study had also a few 

limitations. Despite orientating the 

intervention group not to share material with 

the control group, information exchange was 

possible between the two groups. In 

addition, while we tried to minimize the 

differences between small group facilitators, 

through training and written guidelines, their 

diverse experiences might have resulted in 

different discussions that in turn could have 

caused inconsistency in our program. As the 

TUMS clerks are not involved in direct 

patient care, so direct observation of their 

performance using P-MEX might have not 

been always possible. Secondly, in spite of 

our effort to train the raters, it is possible 

that some of residents, fellows, or faculty 

members have failed to contribute to a valid 

assessment due to their high workload. 

Finally, our study was performed on a small 

scale, we did not evaluate the longterm 

outcomes, and we did not collect qualitative 

data which could have provided us with a 

deep understanding about the impact of the 

program. 

 

Conclusion  

The application of Holmes’ reflection 

approach improved the judgment of 

professionalism among medical students 

upon their transition to the clinical settings. 

It is recommended to conduct mixed-

methods studies with long-term follow-ups 

to better evaluate the effects of reflection on 

the attitudes and professional behaviors of 

students.  

 



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Acknowledgements  

This study was a research project approved 

under license No.35253 by the Research 

Department of Tehran University of Medical 

Sciences. We are very grateful to The 

Research Department for their financial 

support. We would like to thank Dr. Nasim 

Khajavirad and Dr. Mahbube Ebrahimipour, 

for their help with implementing the 

educational program and collecting the data. 

We also extend our gratitude to all students 

who participated in this study.  

 

Conflict of Interests   

The authors declare no conflicts of interest. 

  



Naeimi L., et al. 

 

 

 

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