Professionalism is a multidimensional concept, defined as conducting oneself with responsibility, integrity, accountability, and excellence; in fact, it is a combination of qualities. Professionalism refers to effective communication and finding a way to be productive. Therefore, professional workers should take responsibility for their own behavior and effectively cooperate with others.¹

High-quality work standards, honesty, and integrity are essential parts of professionalism. 1 In addition, professionalism is identified as a tool to increase functionality in many domains, such as medical and dental health. In fact, in order to gain public confidence, professionals, including physicians and dentists, need to familiarize themselves with these tools.²

The American Dental Education Association (ADEA) is committed to developing and maintaining institutional environments within the allied, predoctoral and postdoctoral dental education community that foster academic integrity and professionalism.

According to ADEA, the general characteristics of professionalism include competence, fairness, integrity, responsibility, respect, and service-mindedness.³ The available evidence suggests that growing consumerism, extreme attention to esthetics, and strong financial incentives of dentists can lead to a decline of professionalism among dentists.⁴

The main problems related to professionalism are divided into three categories. These problems reported by students include conflict between education and patient care, professional responsibility surpassing one's capabilities, and low quality of patient care. These issues clearly indicate the need for maintaining high standards of professionalism.⁵

Specifying the dimensions of professionalism is essential to determining the nature of the relationship between physician and patient. In addition, universities, by producing workforce, play a key role in forming professionalism.

The development of professional characteristics is among the most important educational objectives. Evaluation is an important element in achieving the objectives of professionalism. In fact, it provides a valuable feedback to foster people's professional development.

Since a vast majority of dental school graduates work in this field, it is important to determine the rate of students' perception of professionalism.

This study aimed to contextualize ADEA tools on professionalism and compare the concept of professionalism among students of different academic years using it. Another purpose of this study was to determine the relationship between the concept of professionalism, gender, and location. In addition, the practical purpose of this study was to determine the status of professionalism in order to plan for the improvement of professionalism.

This article is a descriptive-analytic study for confirming the psychometric properties of the ADEA Tool on Action on Professionalism in Dental Education. ADEA tool can help with understanding and defining professionalism and evaluating the performance of people in the field of dentistry. It is composed of 77 items and six values, defining professionalism in dental education, including competence, fairness, integrity, responsibility, respect, and service-mindedness.⁶ It was contextualized and validated following taking the permission of developers from February 2018 to June 2019 at Mashhad University of Medical Sciences.

Following ethical consideration, all 244 undergraduate dental students of Mashhad Dental School, Mashhad, located in the northeast of Iran during 2018–2019, who met the inclusion and exclusion criteria of the study, participated in the study. This sample was selected by census sampling. The dentistry students, who were studying in the 1^st to 6^th year of the undergraduate program were included in this study. The guests, transferred students, and students who would not like to participate in the study were excluded from the study.

The toolkit on translating and adapting instruments by Chávez and Canino⁷ was applied for the contextualization process. To check validity, first, the instrument was translated by two bilingual expert translators familiar with professionalism concepts separately. Two translation copies were integrated as one Persian copy. Then, the accuracy of the translation was checked by the expert panel. Two Delphi rounds⁸ were conducted for assessing face and qualitative and quantitative content validity, i.e., content validity index (CVI) and content validity ratio (CVR) using the Lawshe method.⁹ The translated instrument was given to the experts in the first Delphi rounds. The experts were ten people familiar with professionalism, and were members of the MUMS scientific committee of professionalism in this step of the study. Face validity and content validity were also observed through considering comments of experts, in which the statements could be understood well (qualitative) and scored it for CVI and CVR (quantitative). In the second Delphi round, the final copy was given again to professionalism scientific committee members for final confirmation. After reviewing the comments on the ADEA tool, one item of competence, five of fairness, five of responsibility, five of respect, and four of service-mindedness were deleted. In addition, 56 items were selected for evaluation in this study. The final copy was n 56-statement tool.

Factor analysis was carried out to confirm construct validity. The data were collected from 20 experts who were familiar with professionalism concepts; they also were working and researching professionalism. Confirmatory factor analysis was carried out using Lisrel software. According to the literature, if x²/df <3, RMSEA ≈ 0.1 and indices of comparative fit index (CFI), incremental fit index (IFI), goodness-of-fit index (GFI), and adjusted GFI (AGFI) are >0.7, the construct validity can be confirmed.¹⁰

To confirm reliability, test–retest was calculated. The data were analyzed through the SPSS version 16 (SPSS, Inc., Chicago, IL, USA) using Cronbach's alpha for internal consistency. Lisrel: 8.5 was used for factor analysis in confirming construct validity using Kaiser–Meyer–Olkin (KMO) and Bartlett tests. Ethical considerations were followed as rules and regulations of Mashhad University of Medical Sciences, in which participants were taken informed consent. The Mashhad University of Medical Sciences ethics committee also approved conducting this study (IRB: 901018).

The internal consistency of the modified tool was also assessed due to the deletion of some items by Cronbach's alpha (α = 83%). The modified ADEA tool was designed based on 10-point Likert scale based on statistical consultations. Cronbach's alpha was calculated as 0.83, which is higher than 0.7, i.e., the ADEA tool is reliable for applying in the Iranian context. The test–retest was also done for confirming reliability as well. Ten participants completed the checklist following watching the standard video in two steps at a 2-week interval. The correlation coefficient was calculated as 0.918. To compare students' perception of professionalism, the ADEA tool for action on professionalism in dental education was applied.

Following ethical considerations, explaining the aims and methods of study for students and taking informed consent, the inventories were distributed among dental students of different years in classrooms. Participants were assured about the confidentiality of data.

Both descriptive and inferential statistics were applied for data analysis, factor analysis, KMO and Bartlett tests, and mean and standard deviation was used. Kolmogorov–Smirnov test was performed to check the normal distribution of variables. In addition, ANOVA and Tukey's honestly significant difference were used to compare the study variables using SPSS: 16.

Confirmatory factor analysis confirmed construct validity of ADEA tool (x2/df <3, RMSEA ≈ 0.1 and CFI, IFI, GFI, and AGFI >0.7) Table 1.{Table 1}

To confirm reliability, test-retest was calculated. The data were analyzed through the SPSS version 16 (SPSS, Inc., Chicago, IL, USA) using Cronbach's alpha for internal consistency. Lisrel: 8.5 was used for factor analysis in confirming construct validity using KMO and Bartlett tests.

Of all dental students, 17.33% were studying in 1^st, 18.33% in 2^nd, 17.33% in 3^rd, 16.66% in 4^th, 17.66% in 5^th and 16.66% in 6^th years of dentistry. The mean and standard deviation of the age was 21.48 ± 1.64 years old. Around half of the participants (51%) were aged 18-21 years, 48.67% were between 22 to 25 years old, and 0.33% were in their 25th. In total, 53.7% of students were male and 46.3% were female. In addition, 65.7% were living in Mashhad.

The mean and standard deviation of subjects' professionalism scores are shown in ]Table 2]. According to the findings, the highest mean of professionalism scores was observed among 1^st-year students. The mean score of 1^st-year dental students was significantly higher than 3^rd-year dental students (F = 2.75, P = 0.002). Furthermore, the mean of 1^st-year dental students was significantly higher than dental students of 6^th year (F = 4.53, P = 0.001). However, there was no statistically significant difference between the mean of 1^st-year students and others.{Table 2}

The maximum and minimum mean scores of competence were allocated to 4^th- and 3^rd-year students, respectively. There was a significant difference between the mean of competence in students of 5^th and 4^th years (F = 2.75, P = 0.019).

This study indicated that the students who were in the 1^st year of dentistry got the maximum mean of fairness and 4^th-year students got the minimum mean. There was a significant difference between the mean of fairness among students of 1^st and 4^th years (F = 2.48, P = 0.032).

The students who were in the 1^st and 6^th years of college had the maximum and minimum means of integrity, respectively. There was a significant difference between the mean of integrity in students of 6^th and 1^st year, 4^th and 6^th year, and 3^rd and 1^st years (F = 4.13, P = 0.001).

There was a statistically significant difference between the mean of responsibility in students of 1^st and 2^nd, 1^st and 3^rd, and 1^st and 6^th years (F = 3.43, P = 0.005). Furthermore, there was a significant difference between the mean of respect in 1^st-year students and other students, except for the 4^th-year students (F = 6.39, P = 0.001). There was a statistically significant difference between the mean of service-mindedness subscale in students of 1^st and 3^rd years, and 1^st and 6^th year (F = 3.56, P = 0.004) Table 3.{Table 3}

The comparison of professionalism among dental students of 1^st to 6^th years of the college indicated that women obtained significantly higher scores in the honesty subscale (P = 0.001). However, no statistically significant difference was found between the total score of men and women regarding other subscales Table 4.{Table 4}

In addition, a comparison of professionalism among dental students from 1^st to 6^th year indicated that there was a significant difference between local and nonlocal students in the integrity subscale (P = 0.001). However, no statistically significant difference was shown between the total score of local and nonlocal students in other subscales (P = 0.006) Table 5.{Table 5}

According to the results, 1^st-year dental students had higher scores of professionalism in comparison with students of 3^rd and 6^th years. However, there was no statistically significant difference between the mean of 1^st -year dental students and other students. These results were consistent with studies of Quarantelli and Helfrich and Becker et al.¹¹,¹²

Unlike our results, study of Poirier showed that professionalism developed during 5 years of studying at university. However, Poirier believed that the development of professionalism was as a result of the training programs of Illinois University. She also revealed that individual feedback can lead to students' responsibility and development of professionalism.¹³

These results suggest that curriculum standards need to be reviewed. According to a study by Marino et al., the majority of students believed that the coverage of sociocultural aspects in the courses is not adequate to meet the desired educational objectives. They also emphasized that these evaluations have a tremendous impact on professionalism.¹⁴

The study of Smithers et al., indicated that the highest professionalism scores do not necessarily indicate that 1^st -year students are more professional than the rest of the students since the majority of university entrance examinations are predictors of academic behaviors, not behavioral skills and professionalism. Furthermore, there was a difference between academic behaviors and behavioral skills and professionalism.¹⁵

Furthermore, other factors are effective in shaping professional behavior. For instance, according to Chamberlin's study, personality is a predictor of professional behavior in dental schools.¹⁶

All the subscales of professionalism were assessed in this study. According to the results, a significant difference was found between the mean of professionalism subscales in students of different years. The maximum scores of the competence subscale were obtained by 5^th- and 6^th-year students. It seems that individual's experience of working in dental clinics leads to gaining higher scores in the competence subscale. Moreover, the maximum score of the respect subscale was obtained by students of 1^st, 2^nd, 3^rd, and 4^th year. In total, the minimum scores were related to the fairness subscale. The scores of intern students were significantly lower in fairness and service-mindedness subscales. This may be due to the biased treatment of teachers, unfair policies of university, and financial incentives of dental students.

The study of Crossley, conducted on 80 medical students and 80 dental students, was consistent with the present study. Crossley's study showed the majority of dental students have financial incentives for selecting dentistry as a profession in comparison with medical students.¹⁷

Consistent with Tsuen Chung's study (2005), our study indicated that there was a statistically significant difference between integrity, responsibility, respect, and service-mindedness among dental students of different years.

The relationship between professionalism and personal characteristics was also assessed in this study. According to the results, there was no statistically significant relationship between the total score of professionalism and gender; this finding was consistent with the study of Rowland et al.¹⁸ In addition, the total score of professionalism was not higher in local students compared with nonlocal students.

Findings of Paro et al. who conducted their study on medical students, were in agreement with present study. It showed no statistically significant differences between males and females, regarding empathy as the main subscale of professionalism.¹⁹

Unlike our study, Chamberlain et al. showed a significant correlation between professionalism and dependent variables such as age, gender, academic education, and personality traits.¹⁶ In addition, a study carried out by Kelly indicated a significant relationship between demographic characteristics and the conscientiousness index.²⁰

The relationship between demographic characteristics and professionalism was different in other studies. This may be due to differences in definitions of professionalism. Moreover, cultural and environmental variations may play a significant role in the observed differences.

Anderson and Irwin studied professionalism in students of physiotherapy through self-assessment. According to Anderson and Irwin, scores of integrity were higher in female students compared with males; these variations may be due to cultural and environmental differences.²¹

The individuals' personal differences and lack of performance assessment were other limitations of this study.

As to the findings, the ADEA tool is a valid and reliable tool for applying in the Iranian context. Dental students should be trained in professional behavior during their study.

Acknowledgment

The authors offer their special thanks to the dentistry students for their active participation in this research.

Financial support and sponsorship

This research was financially supported by the Research Council of Mashhad University of Medical Sciences.

Conflicts of interest

The authors of this manuscript declare that they have no conflicts of interest, real or perceived, financial or nonfinancial in this article.