____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________ 1 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Original Article Volume 13 Number 14 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. Clinical commitment and competence: a qualitative study *Corresponding Author Narges Shafaroodi No.4, School of Rehabilitation Sciences, Iran University of Medical Sciences, Maddadkaran St., Mother Sq., Mirdamad Blvd., Tehran, Iran. Tel: (+98) 21 22 22 09 46 Email: shafarodi.n@iums.ac.ir Received: 29 Mar 2020 Accepted: 1 Sep 2020 Published: 28 Sep 2020 Citation to this article: Zamanian Jahromi S, Shafaroodi N, Lajevardi L. Clinical commitment and competence: a qualitative study. J Med Ethics Hist Med. 2020; 13: 14. Somaye Zamanian Jahromi1, Narges Shafaroodi2*, Laleh Lajevardi3 1.Researcher, School of Rehabilitation Sciences of Iran University of Medical Sciences, Tehran, Iran. 2.Associate Professor, Occupational Therapy Department, School of Rehabilitation Sciences of Iran University of Medical Sciences, Tehran, Iran. 3.Assistant Professor, Occupational Therapy Department, School of Rehabilitation Sciences of Iran University of Medical Sciences, Tehran. Iran. Abstract Commitment, a component of clinical competence, includes accountability and responsibility for professional roles and tasks; and, it has a positive correlation with job satisfaction and performance. This study aimed to elaborate on the concept of commitment in the field of occupational therapy using qualitative content analysis. The data was collected through interviewing 13 occupational therapists both in a focus group interview (including four participants) and in one-to-one interviews (nine other participants). The collected data was analyzed based on the Grenheim method, and commitment concept was defined under three main themes: (i) commitment to patient (five subthemes), (ii) commitment to self (three subthemes), and (iii) commitment to profession (three subthemes). This study’s findings indicated that to acquire clinical competence, therapists should be committed to their patients, to themselves, and to their profession. Future research is needed to further examine how and to what extent these commitment themes affect clinical competence as well as the interaction among them. Keywords: Occupational therapy; Commitment; Qualitative research; Clinical competence. mailto:shafarodi.n@iums.ac.ir Clinical commitment and competence: a qualitative study … 2 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 Introduction Acquiring or enhancing competence, a significant concern in healthcare and therapeutic fields, has important implications for clinical practice, management, and education (1). However, competence is a controversial subject due to the complexity of its concept and difficulty of defining and evaluating it (2). Clinical competence refers to proficient and constant use of technical expertise, communication skills, knowledge as well as clinical reasoning, emotional support and values in clinical settings (3). Acquiring clinical competence includes a dynamic and complex process involving lifelong learning (4). As an element of clinical competence, commitment means accepting responsibility regarding the assigned tasks with satisfaction when conscientiously fulfilling professional obligations without any external supervisory system (5). Previous studies show that commitment, related to conscious awareness of responsibility and obligations, involves effective use of knowledge and expertise, leading to improved clinical competence (6). Considering that commitment concept is context-dependent, its definitions and interpretations depend on the followings: various environmental conditions, therapists with different specialties, patients with varied problems, professional duties and roles, as well as different laws and policies (7). Therefore, different countries worldwide have various understandings of commitment concept, and hence descriptions for it. For instance, in Canada, commitment is defined under the themes of "having professional responsibility", "formal appraisal process of performance", and "undertaking professional development" (8). In Australia, in definition of clinical competence, commitment is addressed using the following themes: "behaviors and attitudes of a professional", "intervention”," professional responsibility"," professional development, and training" and "evaluating services" (9). In Iran, Hagbaghery et al. in a study on nurses' clinical competence addressed commitment in the context of medical ethics (5). While emphasizing on the importance of commitment, Allami and Mohammadi (10) stated that residences in residency training programs need to acquire competency of fulfilling expected professional commitments, including the followings: (i) sympathizing with patients, (ii) responding to patients’ needs, (iii) seriously considering patients' preferences, (iv) upgrading their scientific knowledge, (v) enhancing their clinical skills; as well as, (vi) taking responsibility of their patients, community, and medical profession. As an integral part of clinical competence, ethical commitment plays a key role in commitment enhancement, and being aware of this concept is imperative for occupational therapists (10, 11). Despite its importance, commitment in the field of occupational therapy in Iran has not received adequate attention and has not been clearly defined, and hence this study aimed to elucidate the concept of commitment as part of clinical competence through a qualitative study, involving semi-structured interviews with occupational therapists. Zamanian Jahromi S., et al. 3 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 Method In this study, the conventional content analysis approach was used to explore the concept of commitment as part of clinical competence from occupational therapists’ perspective. In qualitative content analysis, written content is subjectively interpreted via systematic classification of codes and the determination of themes and patterns. Conventional content analysis is suitable in case of limited or sporadic literature on the under-study phenomenon. In this study, the researchers avoided the application of presupposed categories and managed to distill the categories from the data (12, 13(. Setting and Participants The participants were selected through purposive sampling. The inclusion criteria for occupational therapists were as follows: at least two years of clinical experience, at least a bachelor's degree, and consent to cooperate. From 13 occupational therapist participants, eight were women and five were men respectively, and they had three to 28 years of clinical experience. The interviews were held in a quiet room in participants’ workplaces at their preferred time and location. Data saturation was achieved after ten interviews; however, three additional interviews were performed to reach certainty. Respectively, four, one, and five of participants had doctoral, master’s, and bachelor's degrees, and five participants were doctoral students. In selecting participants, the researchers considered maximum diversity in work experience such as working in different settings (e.g., university, private clinics, and hospitals) and conditions (e.g., working with children and adults who suffer from physical or mental disabilities). Data Collection The data was collected through semi- structured interviews both in form of a focus group interview and individual interviews. In the focus group interview, four occupational therapists participated, and nine interviews were performed on an individual basis. The interviews were started with open-ended questions (e.g., "What does clinical competence mean?", "What is the definition of commitment in this field?"), and continued with detailed questions. The interviews lasted between 60 and 120 minutes. Ethical Considerations The Ethics Committee of Iran University of Medical Sciences approved this study through 1395.9411355003 code of ethics. The informed written and verbal consents were obtained from the participants. In addition, confidentiality of information was maintained, and the participants had the right to withdraw from the research at any time during the study as well as at the time of disclosure of the interviews and research results. Data Analysis The data was analyzed based on Graneheim method (14). The interview transcriptions were thoroughly read several times, and the meaning units were extracted and condensed (i.e., the threads of meaning were found throughout the interview transcriptions). Each meaning unit was conceptualized and Clinical commitment and competence: a qualitative study … 4 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 labeled with a code. The obtained codes were compared to extract similarities and differences. Then, similar codes were grouped together as a subtheme and later similar subthemes generated a theme (14). Credibility, transferability, dependability, and conformability of data was evaluated to assure data trustworthiness. To this end, the peer review method was used in which the researchers familiar with the qualitative research, concepts, classes, and extracted codes were asked to provide their perspectives on data accuracy. Based on their comments, necessary modifications were made, and ongoing contact with the mentors and advisors was maintained over the course of the study. Moreover, other data validation methods were employed as follows: (i) allocation of sufficient time for the research and interviews; (ii) active engagement of the researchers during this nine-month study; (iii) participant selection from different age groups with diverse academic and work experiences from various medical and educational centers; and, (iv) establishing good relationship with participants and effective communication. To ensure that the data were rich enough to provide answers to the research questions, the following methods were employed: (i) after data saturation, another three occupational therapists were interviewed; and (ii) following the interviews, audio files were transcribed and then transcripts were returned the participants to confirm that their words matches their intended beliefs. Results The participants included 13 occupational therapists with three to 28 years of clinical experience (Table 1). Analysis of the highlights of interview transcripts regarding participants’ experiences of clinical commitment in occupational therapy resulted in 48 initial codes and then 20 after merging similar codes. Finally, 3 main themes and 11 subthemes (sharing the same central organizing concept) were developed as summarized in Table 2. Based on data analysis, commitment of occupational therapists was classified into three abstract themes: "commitment to patients", "commitment to self", and "commitment to profession" (Table 2). In following sections, these themes are explained and related excerpt from the interview transcripts are attached. Table 1- The characteristics of the study participants Characteristics Number Gender Male Female 5 8 Education Level Doctoral degree Doctoral students Master’s degree Bachelor’s degree 4 5 1 3 Zamanian Jahromi S., et al. 5 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 Table 2- Emerged themes and subthemes Themes Subthemes 1.Valuing patients' available time 2.Providing information to patients 3. Patient differences 4.Judicious use of Best Evidence 5.Confidentiality Commitment to patients 1.Enhancing teamwork 2.Being up to date 3.Considering self-health and self- care Commitment to self 1.Accepting profession’s philosophy 2.Believing in professional identity 3.Acting within the paradigm Commitment to profession Commitment to patients According to the participants, competent therapists are committed to their patients by considering the importance of patients' time and providing the maximum possible and the most appropriate services in the patient's available time. A participant stated, “Therapists easily devotes less than necessary time to patients; instead, they go to their offices and take more time to rest disregarding the importance of maintaining patients' trust”. [Participant No. 10] Providing information and advice on choosing treatment options to patients and their families are among indispensable routines in clinical practice. Giving information and telling facts to patients help them and their families understand the circumstances better and realize the significance of treatment. Awareness raising leads to effective collaboration and communication between the patient and the therapist and assists patients in making informed decisions. A participant stated, "The explanations by the therapists to families are important because families can persuade the patients to go home and exercise”. [Participant No. 8] All patients deserve to receive treatment with no discrimination. Factors such as social class, race, ethnicity, education level, occupation, and total wealth should not affect the patient-therapist relationship as well as clinical assessment, diagnosis, and treatment. In addition, therapists' treatment location (e.g., private clinics, public clinics, or patient’s home) should not affect their attitude and how they treat patients. A participant stated, " Therapists can work in governmental settings, in private clinics, or in patients’ homes. In private clinics, therapists can apply long-term treatment plans for patients as well as can have specific purpose and direction. However, in public settings, customized individual treatment and providing advice are not routinely provided”. [Participant No. 9] A subtheme of "commitment to patient” emphasizes on the use of best evidences to develop the most effective treatment plan, meaning that therapists need to consider each patient's specific conditions to develop the most suitable treatment for that particular condition. A participant mentioned, "Effective treatment methods with shorter duration need to be used. Committed therapists should explore best scientific methods in their field to adopt the most suitable treatments for their patients”. [Participant No. 2] Clinical commitment and competence: a qualitative study … 6 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 Maintaining confidentiality is another professional obligation for therapists; they should not share or disclose patients' information unless in emergency cases defined by laws and regulations. A participant stated, "Therapists are required to keep their patients' information confidential, except in exceptional cases specified by law. Such information is completely private and all details should not be disclosed". [Participant No. 4] Commitment to self Occupational therapists are responsible not only for their patients but also for themselves. Commitment to self includes "enhancing teamwork skills", "being up-to- date”, and "valuing self-health and self- care". In commitment to teamwork, therapists, regardless of their relations and connections and regardless of their workplace rules for teamwork, should know about the importance of teamwork and get involved to help choose the best treatment solution. A participant said, "Individuals with cooperation and teamwork attitude can effectively communicate with their colleagues and easily exchange their information and opinions, which can improve both quality and result of treatments. Everyone should increase opportunities for teamwork, regardless of the field of work and compulsory or voluntary presence in the team”. [Participant No.13] Competent therapists should be committed to being aware of innovative and recent therapies and employing them in their practice. According to the participants, they could keep themselves updated through the following approaches: (i) attending workshops as well as scientific and clinical conferences, (ii) studying or pursuing higher education, and (iii) staying connected with universities and research centers. A participant said, " To be an ethics-adhering therapist, when I do not know how to treat a specific patient, I need to study and look for a treatment solution. Some therapists use outdated treatments for their patients for many years and not even update their obsolete isolated clinics. They are unaware of the new proposed treatment approaches, and they do not care and evaluate whether new approaches are worth trying ". [Participant No. 9] The physical and mental health of therapists is another factor affecting their competence and performance. According to the participants, occupational therapists should take care of their health and maintain a healthy work-life balance. A participant said, "Many therapists work at full capacity for a limited number of years and then their efficiency decreases due to burnout. Some of them even have to change jobs. Caring about personal health is very important and I always try to keep my work-life balance”. [Participant No. 11] Commitment to profession According to participants, competent therapists should understand the philosophical basis of a profession, referring to values, beliefs, facts, and principles that guide the therapist’s actions in their profession. The philosophy of a profession defines the nature of the profession, the theories, actions, reference framework, and Zamanian Jahromi S., et al. 7 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 interventions functioning as compass in practicing that profession. Knowing the philosophy of the profession leads therapists to design their goals and treatment plans to implement this philosophy. A participant said, "Having perspectives regarding the philosophy of profession is very important. For example, occupational therapists should be aware of the occupational therapy philosophy to act according to it in their clinical practice and help patients enhance their quality of life. My view is based on a medical background and does not necessarily focus on occupational therapy, but is applicable to both areas.". [Participant No. 6]. Another participant stated, "First, I should believe in philosophy of occupational therapy, and then get involved in its context and enhance patients’ quality of life ". [Participant No. 2] Professional identity of therapists is defined through view of themselves in their profession and through being recognized as a member of that profession. Professional identity consists of their beliefs, attitudes, understandings, values, motives, and experiences about their professional role; such view is formed though activities and duties involved in practicing of their domain of expertise and affects their professional growth and practice. According to participants, therapists should believe in their profession and perform their designated duties and roles based on that belief. A participant said, "During school years, the identity of the future profession should form the mindset of students of the related academic field of study. As a medical doctor, I am familiar with the identity of medical profession, and do my duties and responsibilities defined based on that identity. I am committed to do my professional role and related activities. Similarly, the identity of the field of occupational therapy affects the occupational therapist's competence". [Participant No. 7] Competent therapist should act within the paradigm of professional expertise, where paradigm refers to framework within which the philosophy of profession is being implemented. The participants defined acting within the paradigm in terms of "being patient-centered", "being holistic" and "having a humanistic perspective". The participants identified patient- centered care in the following divisions: (i) involving patients and their families in treatment and decision-making processes, (ii) giving patients the right to choose, (iii) understand patients’ priorities and address them, and (ii) emphasizing on patient consent and satisfaction and empowering the patients to achieve satisfaction. A participant said, "Occupational therapists should involve their patients in making decisions. Patients should be considered as a source in information gathering and decision-making". [Participant No. 12]. Another participant mentioned, “Therapists need to listen to their patients, understand their needs, and respect their values and beliefs". [Participant No.13] According to the participants, occupational therapists with a holistic outlook could Clinical commitment and competence: a qualitative study … 8 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 evaluate patient’s problems from various perspectives, thereby avoiding treatment based on fragmental interpretations. A participant said, “We should have a holistic perspective and an extensive framework through which we can evaluate various causes of an effect from different angles “. [Participant No. 2] A competent occupational therapist should have a humanistic perspective with a strong concern for human welfare, values, and dignity. A participant stated, “Therapists as human beings need to have humanistic perspectives. When a pediatric patient goes to the therapist's office or is visited by the therapist at home, the first thing on the therapist mind is the financial situation of the child's father. Such mindset contradicts the philosophy of occupational therapy as therapists behave differently depending on the father's job (e.g., a doctor or a worker). The treatment of the child based on biased views and such background information affects the provided treatment”. [Participant No. 3 ] Discussion This study’s findings showed that the occupational therapist participants refer to commitment as a key component of clinical competence and consider it an ethical concept within the context of occupational therapy. Such commitment was defined in three major themes as commitment to patient, to self, and to profession, respectively. Such commitment enables therapists enhance their knowledge and skills and effectively employ them in practice. Many previous studies suggested that enhancing competence improves work performance. Nonetheless, few studies stated that competence does not always lead to effective performance (15). However, the participants in this study referred to commitment as one of the influential factors in improving performance. Therapists do their best to provide patients with the maximum and best medical services through various aspects of commitment, thereby earning patients' trust and leading to an effective therapeutic relationship between the therapist and the patient. Establishing such relationship is important because rehabilitation is a lengthy process. The consequents of this study indicate some similarities to the articles have been performed in ethic fields which is stated in the following paragraphs. This study’s findings indicated that “commitment to patients” is a significant factor in clinical competence. Studies in the field of occupational therapy in Iran show that, due to lack of compassion, therapists often do not focus on providing the most and best services to the patient, or in other words, they do not provide the opportunity for patients to have the maximum possible benefits. Vahidi et al. indicated that compassionate occupational therapists respect patients’ available time, give them essential information, use the best therapeutic methods; they also enhance their expertise, employ their potentials, and do not abuse their position or influence (16). According to the participants, providing information to the patients is also one of the most prominent obligations of the therapists. Zamanian Jahromi S., et al. 9 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 The American Occupational Therapy Association (AOTA) has addressed truthfulness under the title of “veracity” and defined it as conveying “comprehensive, accurate, and objective” information to the patients and promoting their comprehension of such information. Veracity is necessary for establishing a therapeutic relationship between the patient and therapist, and decrease the possibility of misunderstanding and help occupational therapists avoid moral distress (12). Maintaining confidentiality is another subtheme of “commitment to patients”. In a study regarding the invasion of privacy, the patients highlighted the following cases: (i) the invasion of personal territory, (ii) lack of privacy, (iii) insufficient or lack of attention and care from nurses and healthcare team, and (iv) not allocating enough time and patience. Parsa Yekta et al. found that among the causes of such invasion were the lack of awareness of patient rights and lack of care ethics, as well as lack of proper education on how to reserve patients' rights and observe care ethics (1). The study’s participants also emphasized on lack of professional ethics knowledge as another important factor in clinical competence, and they suggested learning and advanced levels training on related topics to compensate such lacks. Brown et al. suggested that continuing education, including courses to develop knowledge and skills in a specific area, may be required to ensure evidence-based treatment and research utilization among pediatric occupational therapists (17). Kalantari et al. indicated that ethics educational courses and workshops for Iranian occupational therapists should be accommodated in curricula for students (12). In addition to “commitment to patients”, the participants highlighted “commitment to self” as another factor in clinical competence. Committed therapists take on responsibilities and have valuable work experience (6). The participants also stated that occupational therapists should consider the importance of self-health and self-care as well as should maintain life-work balance. The participants believed that therapists constantly working at full capacity would experience early burnout, adversely affecting clinical competence. “Commitment to profession” is another fundamental factor in clinical competence. According to Santos and Not-Land, “commitment to profession” is part of professional identity, enhancing a sense of attachment to a job and increases the interest in engaging in that job (18). The participants also highlighted the importance of professional identity and commitment to the profession. Professional commitment is typically discussed through social identity theory, where individuals are categorized into different social classes based on their profession, group membership, organization, and other factors (19). According to Wallace, in “commitment to profession”, individuals are identified by their profession, a profession to which they adhere and have a high sense of Clinical commitment and competence: a qualitative study … 10 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 responsibility in performing designated tasks. Furthermore, they emphasized on the importance of professional commitment in increasing clinical competency. They also believed that professional commitment enables individuals to increase their knowledge and skills to manage difficult or unforeseen situations, which means that professional commitment and ethical conduct are closely related to sense of responsibility (20). According to the participants, despite the importance of commitment as part of clinical competence, not all occupational therapists bind themselves to a course of actions required under that concept of commitment due to various organizational and individual reasons. One of the reasons is lack of courses in educational system’s curricula to teach ethics and professional commitment topics that raise awareness of future therapists in clinical practice. Vanderkaay et al. also emphasized on the necessity of teaching ethics, including ethical theories and their clinical use, to occupational therapists (21). The participants also stated that individual factors, such as patience, self-esteem, altruism, honesty, generosity, motivation, and interest in the profession could affect clinical competence. Several studies in the field of nursing have emphasized on the significance of the aforementioned factors (1, 5, 22). Ghamari et al. conducted a research on motivational power of occupational therapy profession among occupational therapists considering volition factor. The low scores obtained in occupational therapy profession indicated that this profession itself did not provide sufficient motivation for practitioners and factors decreasing individuals’ volition were personal (e.g., inability of occupational therapists to perform clinical work) or organizational (e.g., lack of occupational therapy centers and lack of funding from departmental and organizational authorities). Given that in occupational therapy, the term "profession" does not reflect its role and identity, the negative feedback of individuals and organizations on the term "profession" and the complicated concept of occupational identity adversely influence occupational therapists' attitudes towards this profession and reduce their job motivation. Some of the factors involved in reducing job motivation in the occupational therapists are as follows: (i) higher recruitment rates in various branches of rehabilitation compared to that of occupational therapy, (ii) underestimation of occupational therapy in medical centers, (iii) reluctance of managers to set up occupational therapy centers; and, (iv) inequality in healthcare tariff in various fields (23). Conclusion This study’s findings indicated that commitment to patient, commitment to self, and commitment to profession are integral components of occupational therapists' clinical competence. Professional commitment and ethical conduct are closely related to sense of responsibility. Hence, accommodating courses in curricula on ethics, covering customized topics for occupational therapy students at Zamanian Jahromi S., et al. 11 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 undergraduate or higher education levels can enhance prospective occupational therapists’ commitment and improve the clinical competence. Future research is needed to further examine how and to what extent these commitment components affect clinical competence as well as the interactions among these components. Acknowledgments The researchers would like to thank all the participants for their sharing their valuable experiences. Conflict of Interests The authors declare no conflicts of interest in relation to this article. Clinical commitment and competence: a qualitative study … 12 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 References 1. Parsa Yekta Z, Ahmadi F, Tabari R. Factors defined by nurses as influential upon the development of clinical competence. Journal of Guilan University of Medical Sciences. 2005; 14(54): 9-23. 2. Watson R, Stimpson A, Topping A, Porock D. Clinical competence in nursing: a systematic review of the literature. J Adv Nurs. 2002; 39(5): 421-31. 3. Carr SJ. Assessing clinical competency in medical senior house officers: how and why should we do it? Postgrad Med J. 2004; 80(940): 63-6. 4. Boyt Schell BA, Glen Gillen G, Scaffa M, Cohn E. Willard & Spackman's Occupational Therapy, 12th ed. USA: Lippincott Williams & Wilkins; 2014. 5. Adib Hagbaghery M, Salsali M, Ahmadi F. A qualitative study of Iranian nurses' understanding and experiences of professional power. Hum Resour Health. 2004; 2(1): 9. 6. Memarian R, Salsali M, Vanaki Z, Ahmadi F, Hajizadeh E. Professional ethics as an important factor in clinical competency in nursing. Nursing Ethics. 2007; 14(2): 203- 14. 7. Turner A, Alsop A. Unique core skills: exploring occupational therapists' hidden assets. British Journal of Occupational Therapy. 2015; 78(12): 739-49. 8. Anonymous. Association of Canadian Occupational Therapy Regulatory Organizations (ACOTRO). Essential competencies of practice for occupational therapists in Canada. [Cited 2020 Sep]; available from: https://www.coto.org/docs/default-source/essential-competencies/3rd-essential- competencies_ii_may-2011.pdf?sfvrsn=2. 9. Rodger S, Clark M, Banks R, O’Brien M, Martinez K. A comparison of international occupational therapy competencies: implications for Australian standards in the new millennium. Aust Occup Ther J. 2009; 56(6):372-83. 10. Allami A, Mohammadi N, Shirazi M. Faculty members experience about teaching of medical professionalism in Qazvin university of medical sciences. Research in Medical Education. 2015; 7(2):1-11. 11. Thorner S. The essential skills of an occupational therapist. British Journal of Occupational Therapy. 1991; 54(6): 222-3. 12. Kalantari M, Kamali M, Joolaee S, Rassafiani M, Shafarodi N. Perception of professional ethics by Iranian occupational therapists working with children. J Med Ethics Hist Med. 2015; 8: 8. 13. Barkhordari-Sharifabad M, Ashktorab T, Atashzadeh-Shoorideh F. Obstacles and problems of ethical leadership from the perspective of nursing leaders: a qualitative content analysis. J Med Ethics Hist Med. 2017; 10: 1. 14. Shafaroodi N, Kamali M, Parvizy S, Mehraban AH, O’Toole G. Factors affecting clinical reasoning of occupational therapists: a qualitative study. Med J Islam Repub Iran. 2014; 28: 8. eCollection 2014. 15. Kak N, Burkhalter B, Cooper M. Measuring the Competence of Healthcare Providers. Operations Research Issue Paper. 2001; 2(1):1-28. 16. Vahidi H, Shafaroodi N, Joolaee S. Occupational therapists’ perception of unethical practice in adults’ physical dysfunction field. Scientific Journal of Rehabiliation Medicine. 2015; 4(2): 70-8. 17. Brown T, Tseng MH, Casey J, McDonald R, Lyons C. Research knowledge, attitudes, and practices of pediatric occupational therapists in Australia, the United Kingdom, and Taiwan. J Allied Health. 2010; 39(2): 88-94. Zamanian Jahromi S., et al. 13 J o u rn a l o f M E D IC A L E T H IC S A N D H IS T O R Y O F M E D IC IN E Volume 13 Number 14 September 2020 18. Santos S, Not-Land E. Factors related to commitment of extension professionals in the Dominican Republic: Implications for theory and practice. Journal of Agricultural Education. 2006; 35(3): 57-63. 19. Mael, F.A. Ashforth, B.E. Loyal from day one: biodata, organizational identification, and turnover among newcomers. Personnel Psychology. 1995; 48(2):309- 33. 20. Wallace JE. Organizational and professional commitment in professional and nonprofessional organizations. Administrative Science Quarterly. 1995; 40(2): 228- 55. 21. Vanderkaay S, Jung B, Letts L, Moll SE. Continuing competency in ethical decision making: an interpretive description of occupational therapists’ perspectives. Can J Occupl Ther. 2019; 86(3): 209-19. 22. Ballard P, Trowbridge C. Critical care clinical experience for novice students: reinforcing basic nursing skills. Nurse Educ. 2004; 29(3): 103-6. 23. Ghmari N, Derakhshanrad SA, Ghamari M. Examining the motivational power of occupational therapy profession among occupational therapist in Fars providence in 1390. Journal of Modern Rehabiliation.2012; 6(3):5-12.