In delivering safe and high-quality patient care, there has been a notable realization of the importance of upholding professional standards. This has led to a call for the establishment of professional behaviors (PB) in future healthcare professionals (HCPs) through modern health professions education (HPE) (1). However, the current state of HPE not only falls short in responding to this call but also impedes progress toward the right direction in some ways. Martimianaks et al. (2), highlighted the increasing recognition of a hidden curriculum in negatively influencing PBs and professional identity formation Haferty (3, 4), described this HC-driven phenomenon as a source of implicit messages, values, and norms conveyed to learners through informal deliberations. These subtle influences can significantly shape students’ perceptions of their physician roles. This pervasive and often negative influence of HC on professional teaching in contemporary medical education is now increasingly being acknowledged (5–9).

The current state of formal curricula in HPE may explicitly outline professional expectations and competencies, while hidden ones may give conflicting messages or reinforce stereotypes and biases that negate these efforts (10, 11). For instance, in a qualitative study of medical students perceptions, Lempp and Seale (9) highlighted how senior clinicians’ role modeling of hierarchical power dynamics and negative cultures in hospitals can inadvertently promote unprofessional behaviors or attitudes among medical students and doctors in training. Therefore, HPE programs realize it is incumbent upon them to act by incorporating explicit training on professionalism and HC into the formal curriculum (12). By integrating discussions on professionalism, ethical decision-making, and the impact of organizational culture into didactic sessions, workshops, and clinical skills training, educators can raise students’ awareness of HC and may provide them with the knowledge and skills to navigate its complexities effectively (13).

However, there remains a need for fundamental changes to mitigate and counteract the impact of HC on medical professionalism (MP) by using multifaceted approaches at all levels of undergraduate medical education (9, 14, 15). Sheeran (16) reminds us that this requirement can only be met effectively using scientific methods with experimental studies to identify the exact mechanisms involved in behavioral change interventions. This includes a detailed examination of the behaviors and theories of behavioral change underpinning the educational intervention and the use of these behavioral change models to marshal cumulative factors. Behavioral change research primarily forces educators to look for who, what, when, where, and how they need to do differently to motivate learners to adopt, adapt or pursue certain behaviors. This starts with a detailed analysis of identified behaviors and highlights its relationship in the wider individual or social behavioral networks (17). This, in turn, leads to the identification of professional, financial, organizational, or regulatory factors and self, peers, supervisors, family, and social media actors, which may influence the behaviors in question (18).

At this point, there remains a curiosity about what would guide the educational interventions targeting behavior change. To help us understand, a theory can provide a logical relationship between various abstract concepts that explain the world around us (19). This can help educators develop interventions that may be applied to different situations and contexts to achieve learning outcomes and behavior change (20, 21). Nevertheless, it’s crucial to note that merely identifying theoretical constructs will not serve as a magic bullet. Identification of behavioral change strategies (22, 23) to influence the identified theoretical constructs are the frequently missed pieces of the puzzle in the intervention design (12, 24). Reflecting on the fundamental “master question” in education research: What should be taught to whom, when, and how? we recognize that effective educational planning must address not only what and to whom but also how behavioral change strategies align with educational objectives (22, 23). Hence, the educational intervention should identify the behavior-predicting determinants (theoretical framework), behavior change strategy targeting those determinants, and the practical application keeping the target population in mind (22, 25). This alignment forms the foundation of design-based research (DBR) (26), an innovative approach that emphasizes designing, testing, and refining educational interventions in real-world settings. DBR’s pluralistic nature supports crossing theoretical and methodological boundaries, integrating theories to explore the interactions between context and behavioral mechanisms in complex environments.

In an attempt to respond to the identified gaps and the call for the promotion of PBs in future HCPs, borrowing DBR principles, we have proposed an educational intervention entitled the PROfessionalism in Partnership for Education Research (PROPER) study. PROPER uses a four-step experimental design approach, namely: (1) specifying the PBs, (2) analyzing PBs, (3) designing the intervention, and (4) measuring the change in PBs. Additionally, we incorporate a realist perspective by identifying underlying causal mechanisms and exploring how they work under specific conditions. Through this realist perspective, we aim to understand what, how, for whom, and under what circumstances complex interventions function most effectively (27). In this perspective piece, we strive to describe our PROPER educational intervention and its theoretical framework to support HPE educators and faculty who are interested in using theory-driven approaches to target PBs in MP education.

The PROPER study, funded by the Higher Education Authority, North–South Research Program, was designed to foster the development of PBs among early clinical undergraduate medical students. The intervention involved theory-driven workshops for students from two distinct educational contexts on the Island of Ireland: the Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences in Dublin (Republic of Ireland) and Queen’s University Belfast (QUB) in Belfast (United Kingdom). At RCSI, professionalism is taught as an explicit strand focused on personal and professional identity formation, while QUB integrates professionalism within the basic sciences curriculum, embedding it seamlessly rather than through a dedicated module. Importantly, all participating students were at a comparable stage in their training; either in pre-clinical education or newly entering clinical placements which ensured a similar level of cognitive maturity and understanding across both groups. This consistency provided a reliable foundation for evaluating the intervention’s impact across different curricular approaches. We have reported the PROPER study using TIDiER framework (28) throughout our perspective paper (Appendix 1).

PROPER workshops were designed in such a way that they could be conducted both in-person and virtually. We conducted four 90-min structured workshops on themes relevant to the HC which were identified as important by expert consensus (nominal group process) (29, 30), involving experts in medical education and medical students. These themes were:

Box 1 entails the objectives of one of the workshops which can be used for all the identified themes.

The PROPER intervention contained pre-workshop resources followed by a structured 90-min workshop as outlined in Figure 1.

The salient feature of the intervention entailed identifying the desired behavior, behavioral analysis, intervention as a means of finding a mechanism to achieve the target behavior, and the perceived outcome of measuring the expected change in PBs (Figure 2).

Our previous research work shaped our perspective (24) in the field of MP in the context of undergraduate medical education and we built on our understanding of behavioral change theories (32). In reflecting on the “master question” in education research; What should be taught to whom, when and how?, we recognized that effective educational planning must address not only what and to whom but also how behavioral change strategies are mapped onto educational objectives (22, 23). This perspective highlights the complexities of developing, designing, and implementing contextually appropriate educational research. This aligns with the principles of DBR, where educational interventions function as sites for systematically studying and refining learning phenomena and where the complexity of these settings gives rise to emergent insights (26).

In this light, the PROPER study is informed by design-based research. It operates within a robust theoretical framework, drawing from both Bandura’s SCT and TPB, to enhance behavioral capacity in HPE. Nevertheless, we recognize that learning cannot be fully addressed using a few theoretical frameworks or methodological approaches. Acknowledging that SCT and TPB focus on personal and social influences, we realize that broader contextual factors such as organizational support, policies, and time constraints play a significant role in healthcare settings. We encourage our HPE community to address these systemic factors in future iterations, which could expand the intervention’s relevance and predictive power.