Advances in Health Sciences Education

, Volume 17, Issue 5, pp 671–701

“It’s just a clash of cultures”: emotional talk within medical students’ narratives of professionalism dilemmas



Recent investigations into the UK National Health Service revealed doctors’ failures to act with compassion and professionalism towards patients. The British media asked questions about what happens to students during their learning that influences such behaviour as doctors. We listened to 200 medical students’ narratives of professionalism dilemmas during workplace learning (n = 833) to understand the range of dilemmas experienced and emotional reactions to them. 32 group and 22 individual interviews were held across three medical schools (England, Wales, Australia). Data were analysed thematically (Framework Analysis), for negative emotional content (Linguistic Inquiry and Word Count) and a narrative analysis of one exemplar narrative was also conducted. While a wider range of professionalism dilemmas than previously identified were found, most were classified to five main sub-themes. Within these sub-themes, clinical students’ narratives contained more negative emotion words than pre-clinical students’ narratives (p = 0.046, r = −0.36). Narratives of ‘patient safety and dignity breaches by students’ contained fewer anger words (p = 0.003, r = −0.51), ‘patient safety and dignity breaches by healthcare professionals’ contained more anger words (p = 0.042, r = −0.37), ‘identity’ narratives contained fewer anxiety words (p = 0.034, r = 0.38), and ‘abuse’ narratives contained more sadness words (p = 0.013, r = −0.47). The narrative analysis revealed a complex interplay between identities, attribution of blame, narrated emotions and emotional residue. Analysing emotional talk within narratives suggests that medical students sometimes struggle with contradictory formal and informal learning experiences around professionalism arising from a cultural clash. We provide educational recommendations to facilitate students’ coping with their emotional reactions to professionalism dilemmas and to facilitate cultural change.


Emotion Medical education Narrative Professionalism Professionalism dilemmas Qualitative research Text analysis LIWC 


  1. Alpers, G. W., Winzelberg, A. J., Classen, C., Roberts, H., Dev, P., Koopman, C., et al. (2005). Evaluation of computerized text analysis in an internet breast cancer support group. Computers in Human Behavior, 21(2), 361–377.CrossRefGoogle Scholar
  2. Ayoko, O. B., Callan, V. J., & Härtel, C. E. J. (2003). Workplace conflict, bullying, and counterproductive behaviours. International Journal of Organizational Analysis, 11(4), 283–301.CrossRefGoogle Scholar
  3. Barclay, L. J., Skarlicki, D. P., & Pugh, S. D. (2005). Exploring the role of emotions in injustice perceptions and retaliation. Journal of Applied Psychology, 90(4), 629–643.CrossRefGoogle Scholar
  4. BBC News. (2011a). ‘Distressing stories’ of NHS care. Today.
  5. BBC News. (2011b). Care should not be a lottery. Today.
  6. Becker, H. S. (1970). Field work evidence. In Sociological work: Method and substance (pp. 39–62). New Brunswick, NJ: Transaction Books.Google Scholar
  7. Bissonette, R., O’Shea, R. M., Horwitz, M., & Route, C. F. (1995). A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training. Academic Medicine, 70(11), 1035–1037.CrossRefGoogle Scholar
  8. Brotheridge, C. M., & Lee, R. T. (2010). Restless and confused: emotional responses to workplace bullying in men and women. Career Development International, 15(7), 687–707.CrossRefGoogle Scholar
  9. Caldicott, C. V., & Faber-Langendoen, K. (2005). Deception, discrimination and fear of reprisal: lessons in ethics from third year medical students. Academic Medicine, 80(9), 866–873.CrossRefGoogle Scholar
  10. Cassell, E. J. (2005). Medical ethics: consent or obedience? power and authority in medicine. New England Journal of Medicine, 352(4), 328–330.CrossRefGoogle Scholar
  11. Charon, R. (2006). Narrative medicine: honoring the stories of illness. New York: Oxford University Press.Google Scholar
  12. Christakis, D. A., & Feudtner, C. (1993). Ethics in a short white coat: the ethical dilemmas that medical students confront. Academic Medicine, 68(4), 249–254.CrossRefGoogle Scholar
  13. Cordingley, L., Hyde, C., Peters, S., Vernon, B., & Bundy, C. (2007). Undergraduate medical students’ exposure to clinical ethics: A challenge to the development of professional behaviours? Medical Education, 41(12), 1202–1209.Google Scholar
  14. Cruess, R. L., Cruess, S. R., & Steinert, Y. (Eds.). (2009). Teaching medical professionalism. Cambridge: Cambridge University Press.Google Scholar
  15. De Vogli, R., Ferrie, J. E., Chandola, T., Kivimaki, M., & Marmot, M. G. (2007). Unfairness and health: evidence from the Whitehall II study. Journal of Epidemiology and Community Health, 61(6), 513–518.CrossRefGoogle Scholar
  16. Department of Health. (2009). Reference guide to consent for examination or treatment, second edition 2009: Department of Health.Google Scholar
  17. Donaldson, L. (2006). In Department of Health. (Ed.). Safety first: A report for patients, clinicians and healthcare managers. London: DH Publications.Google Scholar
  18. Festinger, L. (1957). A theory of cognitive dissonance. Stanford, CA: Stanford University Press.Google Scholar
  19. Feudtner, C., Christakis, D., & Christakis, N. (1994). Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Academic Medicine, 69, 670–679.CrossRefGoogle Scholar
  20. General Medical Council. (2009). Tomorrow’s doctors retrieved 30th October 2009 from
  21. General Medical Council and Medical Schools Council. (2007). Medical students: Professional behaviour and fitness to practise. Retrieved 10.10.08, from
  22. Gergen, K. (2005). Narrative, moral identity and historical consciousness: A social constructionist account. In J. Straub (Ed.), Narration, identity and historical consciousness (pp. 99–119). New York: Bergham Books.Google Scholar
  23. Ginsburg, S. R., Kachan, N., & Lingard, L. (2005). Before the white coat: Perceptions of professional lapses in the pre-clerkship. Medical Education, 39(1), 12–19.CrossRefGoogle Scholar
  24. Ginsburg, S. R., & Lingard, L. (2011). ‘Is that normal?’ Pre-clerkship students’ approaches to professionalism dilemmas. Medical Education, 45(4), 362–371.CrossRefGoogle Scholar
  25. Ginsburg, S. R., Regehr, G., & Lingard, L. (2003). To be and not to be: The paradox of the emerging professional stance. Medical Education, 37(4), 350–357.CrossRefGoogle Scholar
  26. Ginsburg, S. R., Regehr, G., Stern, D., & Lingard, L. (2002). The anatomy of the professional lapse: Bridging the gap between traditional frameworks and students’ perceptions. Academic Medicine, 77(6), 516–522.Google Scholar
  27. Hanzel, I. (2011). Beyond Blumer and symbolic interactionism: The qualitative-quantitative issue in social theory and methodology. Philosophy of the Social Sciences, 41(3), 303–326.CrossRefGoogle Scholar
  28. Hicks, L. K., Lin, Y., Robertson, D. W., Robinson, D. L., & Woodrow, S. I. (2001). Understanding the clinical dilemmas that shape medical students’ ethical development: Questionnaire survey and focus group study. BMJ, 322(7288), 709–710.CrossRefGoogle Scholar
  29. Inui, T. S. (2003). A flag in the wind: Educating for professionalism in medicine. Washington: Association of American Medical Colleges.Google Scholar
  30. Jameton, A. (1984). Nursing practice: The ethical issues. New York, NY: Prentice Hall.Google Scholar
  31. Karnieli-Miller, O. P., Vu, T. R. M. D., Holtman, M. C. P., Clyman, S. G. M. D., & Inui, T. S. S. M. D. (2010). Medical students’ professionalism narratives: A window on the informal and hidden curriculum. Academic Medicine, 85(1), 124–133.CrossRefGoogle Scholar
  32. Kelly, E. M. D. M., & Nisker, J. M. D. P. (2009). Increasing bioethics education in preclinical medical curricula: What ethical dilemmas do clinical clerks experience? [Miscellaneous Article]. Academic Medicine, 84(4), 498–504.CrossRefGoogle Scholar
  33. Klein, S. M. (2009). Moral distress in pediatric palliative care: A case study. Journal of Pain and Symptom Management, 38(1), 157–160.CrossRefGoogle Scholar
  34. Knight, L. V., & Rees, C. E. (2007). “Enough is enough, I don’t want any audience”: Exploring medical students’ explanations of consent-related behaviours. Advances in Health Sciences Education, 1(-1), 1–20.Google Scholar
  35. Kosmicki, F. X., & Gilickauf-Hughes, C. (1997). Catharsis in psychotherapy. Psychotherapy, 341, 54–159.Google Scholar
  36. Labov, W. (1997) Some further steps in narrative analysis. The Journal of Narrative and Life History, 7, 395–415.Google Scholar
  37. Labov, W., & Waletzky, J. (1967). Narrative analysis. Oral versions of personal experience. In J. Helm (Ed.), Essays on the verbal and visual arts (pp. 12–44). Seattle: American Ethnological Society/University of Washington Press.Google Scholar
  38. Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press.Google Scholar
  39. Maxwell, J. (2010). Using numbers in qualitative research. Qualitative Inquiry, 16, 475–482.CrossRefGoogle Scholar
  40. Mead, N., & Bower, P. (2000) Patient-centredness: a conceptual framework and review of the empirical literature. Social Science & Medicine, 51, 1087–110.Google Scholar
  41. Monrouxe, L. V. (2009). Negotiating professional identities: Dominant and contesting narratives in medical students’ longitudinal audio diaries. Current Narratives, 1, 41–59.Google Scholar
  42. Monrouxe, L. V. (2010). Identity, identification and medical education: Why should we care? Medical Education, 44(1), 40–49.CrossRefGoogle Scholar
  43. Monrouxe, L. V., Rees, C. E., & Bradley, P. (2009). The construction of patients’ involvement in hospital bedside teaching encounters. Qualitative Health Research, 1(7), 918–930.CrossRefGoogle Scholar
  44. Monrouxe, L. V., Rees, C. E., & Hu, W. (2011). Differences in medical students’ explicit discourses of professionalism: Acting, representing, becoming. Medical Education, 45, 585–602.CrossRefGoogle Scholar
  45. Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., et al. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86(8), 996–1009.CrossRefGoogle Scholar
  46. New South Wales Medical Board. (2005). Code of professional conduct: Duties of a doctor registered with the New South Wales Medical Board Retrieved 16.10.08, 2008, from
  47. Parliamentary and Health Service Ombudsman. (2011). Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people.Google Scholar
  48. Pauly, B., Varcoe, C., Storch, J., & Newton, L. (2009). Registered nurses’ perceptions of moral distress and ethical climate. Nursing Ethics, 16(5), 561-573.Google Scholar
  49. Pennebaker, J., Booth, R., & Francis, M. (2007a). In N. Z. The University of Texas at Austin and The University of Auckland (Eds.). Operator’s manual, linguistic inquiry and word count: LIWC2007. Austin, Texas: Scholar
  50. Pennebaker, J. W., Chung, C. K., Ireland, M., Gonzales, A., & Booth, R. J. (2007b). The development and psychometric properties of LIWC2007 [LIWC manual]. Austin, Texas: Scholar
  51. Pennebaker, J. W., & Francis, M. E. (1996). Cognitive, emotional, and language processes in disclosure. Cognition and Emotion, 10, 601–626.Google Scholar
  52. Pennebaker, J. W., & Graybeal, A. (2001). Patterns of natural language use: Disclosure, personality, and social integration. Current Directions, 10, 90–93.Google Scholar
  53. Pennebaker, J. W., Mehl, M. R., & Niederhoffer, K. G. (2003). Psychological aspects of natural language use: Our words, our selves. Annual Review of Psychology, 54, 547–577.CrossRefGoogle Scholar
  54. Rees, C. E., & Knight, L. V. (2008). Thinking ‘no’ but saying ‘yes’ to student presence in general practice consultations: politeness theory insights. Medical Education, 42(12), 1152–1154.CrossRefGoogle Scholar
  55. Rees, C. E., Knight, L. V., & Wilkinson, C. E. (2007). Doctors being up there and we being down here: A metaphorical analysis of talk about student/doctor-patient relationships. Social Science and Medicine, 65(4), 725–737.CrossRefGoogle Scholar
  56. Rees, C. E., & Monrouxe, L. V. (2008). ‘Is it alright if I-um-we unbutton your pyjama top now?’ Pronominal use in bedside teaching encounters. Communication and Medicine, 5(2), 171–182.Google Scholar
  57. Rees, C. E., & Monrouxe, L. V. (2011a). Medical students learning intimate examinations without valid consent: A multicentre study. Medical Education, 45(3), 261–272.CrossRefGoogle Scholar
  58. Rees, C. E., & Monrouxe, L. V. (2011b). “A morning since eight of pure grill”: A multischool qualitative study of student abuse. Academic Medicine, 86(11), 1374–1382.CrossRefGoogle Scholar
  59. Rees, C. E., & Monrouxe, L. V. (in press). “Oh my God uh uh uh”: Laughter for coping in medical students’ personal incident narratives of professionalism dilemmas. In C. Figley, P. Huggard, & C. Rees (Eds.), First do no self-harm: Understanding and promoting physician stress resilience. Oxford: Oxford University Press.Google Scholar
  60. Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman & R. G. Burgess (Eds.), Analyzing qualitative data. London: Routledge.Google Scholar
  61. Roseman, I. J. (1991). Appraisal determinants of discrete emotions. Cognition and Emotion, 5(3), 161–200.CrossRefGoogle Scholar
  62. Rosenthal, R. (1991). Meta-analytic procedures for social research (2nd ed.). Newbury Park, CA: Sage.Google Scholar
  63. Royal College of Nursing. (2009). In R. C. O. Nursing (Ed.). Small changes make a big difference: How you can influence to deliver dignified care. London: Royal College of Nursing.Google Scholar
  64. Sandelowski, M., Voils, C. I., & Knafl, G. (2009). On quantitizing. Journal of Mixed Method Research, 3, 208–222.CrossRefGoogle Scholar
  65. Schiffrin, D. (1994). Approaches to discourse. Cambridge, USA: Blackwell Publishers.Google Scholar
  66. Tausczik, Y. R., & Pennebaker, J. W. (2010). The psychological meaning of words: LIWC and computerized text analysis methods. Journal of Language and Social Psychology, 29(1), 24–54.CrossRefGoogle Scholar
  67. Wiggleton, C. M. D., Petrusa, E. P., Loomis, K. M. D., Tarpley, J. M. D., Tarpley, M., O’Gorman, M. L. M., et al. (2010). Medical students’ experiences of moral distress: Development of a web-based survey. Academic Medicine, 85(1), 111–117.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  1. 1.Institute of Medical EducationSchool of Medicine, Cardiff UniversityCardiffUK
  2. 2.Centre for Medical Education, College of Medicine, Dentistry and Nursing, University of DundeeDundeeScotland, UK

Personalised recommendations