Epistemological principle: Is the concept clearly defined and distinct from other concepts?
Epistemology, a core philosophical principle associated with the nature of knowledge, essentially helps understand how well a concept is distinguished from others (76). Cain (16) defined e-professionalism as “the attitudes and behaviours (some of which may occur in private settings) reflecting traditional professionalism paradigms that are manifested through digital media”. Published literature had a consensus on this definition. However, Cleary (25), by using the term “netiquette”, extended its spectrum beyond simple online communication.
In an attempt to understand the epistemological maturity, we focused on what constituted as unprofessional online behaviour. However, despite a clear definition, we found diverging opinions between students and physicians (69). Current literature has shown a concord that socialization to professional behaviours is an important element, but itself, is an elusive concept with ambiguous boundaries. Transferring lives with intricate conversations, interactions, and socialization in the open world of web has distinctly blurred the divide of public and private lives by sharing personal persona in public (15, 19, 70). Far ranging professionalism lapses in the electronic realm include: inadvertent postings of photos; social and political affiliations; personal and religious preferences that are not generally revealed in a conventional doctor-patient relationship; disrespectful behaviours; poor self-awareness (21, 56, 65, 66). Ellaway (33) has argued that breaches in e-professionalism are analogous to a blurring of personal and professional boundaries due to SNSs usage owing to the nature of dynamics between computing devices and these digital platforms. At the same time, research has shown that intersecting personal and professional identities on SNSs posed major issues pertaining to personal privacy. Cain (15) highlighted the importance of a SNSs in the life of an information-fluent generation and an understanding of underlying mechanisms of ‘web works’ which are threatening the trust and privacy by posing risk, liability and copyright issues. However, on another instance Cain (20), argued that the privacy protection onus lies on the person posting the information by explicitly stating the expectations. Hence, Benetoli (43) rightly pointed out that unprofessional behaviours by HCPs and medical and allied health students on SNSs may influence public perceptions about their medical professionalism. Good patient care is built on strong professional values and behaviour and unprofessional behaviours online generally reflect the erosion of ethical boundaries (49). Every day digital natives face new risks for behaving in an unprofessional and unethical manner while using electronic medical records and social media.
Surprisingly, perceptions of medical students revealed inadequate awareness of the caveats and risks of the digital world, making them vulnerable and subjecting them to an increased probability of engaging in unprofessional online activities compared to qualified HCPs (24). Zalpuri (70) and Rukavina (2) narrated some important elements of e-professionalism ranging from confidentiality, boundaries issues, advocacy, netiquettes, integrity and loosening accountability. Recently, another report Rukavina (74) has shown a coding scheme to categorize unprofessional behaviours on SNSs with an intention to reduce the influence of subjective interpretation.
The literature has consistently suggested that SNSs constitute a rapid, interactive and modern ways for communicating, educating and advocating for patients but vulnerability occurs when new ethical challenges compromise their privacy and confidentiality (2, 29). Additionally, an added layer of complexity is imposed due to the generational differences in the use, perception, and acceptance of SNSs. A solid appreciation of the fact that current learners are adept at liberal information sharing manifests as same attitudes and behaviours to all opportunities to share digital information, leading to blurring personal and professional lives. Kaczmarczyk (27) has diligently proven that digital natives had a lack of insight into their professional identities while using SNSs. This narrative was recently supported again by the emerging importance of ‘context’, which points to a need for a new set of regulations and guidelines for web-based interactions (74). In this context, the ambiguous understandings of healthcare students regarding the appropriateness of SNSs postings is noteworthy (73). The disadvantages associated with the excessive use of SNSs include social disconnection, mental and physical stress, and societal disconnect. A consistent use of the concept of e-professionalism to insinuate a regulated and conscientious use of technology to safeguard both personal and professional identities is essential (62).
Another key challenge is to safeguard the societal and professional contract while using SNSs such as Facebook due to lack of awareness by HCPs of their professional vulnerability in social media (62). Researching social media and examining the available information on the online platforms has posed ethical risks that many users do not understand correctly due to a lack of privacy proficiency. This garnered a growing attention for a well-structured strategy to teach e-professionalism within health professions education (62, 73). Unfortunately, flustered responses to digital misdemeanours at institutional levels typically manifest as a binary approach (77), which creates a hidden curriculum of digital unprofessionalism. However, the reviewed literature showed the development of a novel framework aimed at the transpersonal level integrating the concept of ‘Mission’ to pre-existing values, behaviours, and identity-based frameworks. This framework enumerated the desired attributes, which provide a clarity for guidance to good e-professional behaviour (61).
In summary, using the epistemological principle, our concept analysis indicated a well-perceived concept of e-professionalism in all disciplines of the medical field, including medicine, dentistry, nursing, pharmacy, and all other related healthcare professions. The concept of e-professionalism was found to be a clearly defined, distinct entity and a recognizable area in medical education (16, 61). However, the concept of e-professionalism and its manifestations were being understood and interpreted in a varied manner. This paper outlines the beginnings of a new era where efforts are being made to implement a standard setting for a unified application of e-professionalism for HCPs. This highlights the need of a multi-construct frame of reference to compare, refine and enumerate the desired attributes to be digitally professional (61).
Pragmatic principle: Is the concept relevant and practical within the scientific realm of inquiry? Has it been in practice?
Pragmatism pertains to utilizing a discipline-specific concept evaluation to determine the pragmatic use and operationalization of the subject under consideration (13). The pragmatic principle explores the efficacy of the concept under consideration as to how it describes and elaborates the phenomena in a discipline. Finally, this principle demonstrates whether the published literature endorses and validates or limits a concept as useful and applicable and if it can be recognized as a useful entity in a field of interest (42). We assessed the pragmatic utility of our concept by exploring the published literature for the concept evaluation and its operationalization in both academic and clinical fields.
The need to evaluate the concept of e-professionalism dates back to Cain and Romanelli (16) and Aase (18) when patients feared that their private information be published publicly, jeopardizing their confidence among HCPs. Resultantly, patients were hesitant in sharing private medical information with their physicians (48). The threat of online unprofessional contents being viewed by unknown audiences posed a risk due to its associated legal and ethical issues and breach of patient confidentiality (23). However, since then there has been no concerted efforts for the construction of a single validated and reliable tool of e-professionalism measurement. In a study by Ness et al (28), most students agreed that their online profile could influence public’s opinions about them and believed that healthcare professional students should hold higher standards in cyber space. In addition, 53% of students remained cautious about the information they disclosed on SNSs. In several studies, investigators used self-administered questionnaires to gather knowledge about digital literacy, use of SNSs in daily lives, perceptions regarding e-professionalism and guidance about online communications and conduct (16, 17, 23, 26, 28, 42, 44). Only two studies used qualitative methodology to determine a deeper understanding of perceptions of pharmacists and nursing organizations respectively (43, 51).
A deliberate exploration of the selected studies in our analysis showed that the concept of e-professionalism has been applied in research focusing on three areas: applying e-professionalism instrument construction, using e-professionalism as a criterion in measuring professional behaviours, and its role in medical education curriculum (Table 2).
Table 2 The selected studies used in our review for pragmatic principle.
Pragmatic Category
|
Applying e-professionalism instrument construction
|
e-professionalism as a criterion in measuring professional behaviours
|
e-professionalism concept – role in medical education curriculum
|
Study designs
|
Descriptive
Gettig, 2013(26)
Dobson, 2019 (53)
Lee et al, 2019 (54) Lefebvre, 2020 (57) Karveleas et al, 2021 (64)
Viskić et al, 2021 (69)
Viskić et al, 2022 (75)
|
Descriptive
Cain, 2009 (17)
Cain, 2010 (19)
Kjos, 2012 (23)
Osman, 2012 (24)
Ness et al, 2013 (28)
Gupta, 2015 (34)
Gettig et al, 2016 (38)
Lefebvre et al, 2016 (40)
Yang et al, 2016 (42)
Duke et al, 2017 (44)
Barnable, 2018 (48)
Al-Qarni 2019 (52)
Bacaksiz, 2020 (56)
Griffin, 2021 (60)
Hussain et al, 2021 (63)
Nieminen et al, 2022 (72)
O’Connor et al, 2022 (73)
Kang et al, 2015 (35)
Qualitative
Bentoli et al, 2017 (43)
Mather, 2018 (51)
Mixed-methods
Rukavina et al, 2022 (74)
Reviews
Rukavina et al, 2021 (2)
Holden and Spallek, 2018 (49)
Guraya, 2021 (62)
|
Descriptive
Jackson, 2018 (50)
Mostaghimi et al, 2017 (46)
Conference proceedings
John, 2012 (22)
Association Notes and Reviews
Spector et al, 2010 (21)
Kaczmarczyk et al, 2013 (27)
Editorial and Commentary
O’Connor, 2020 (58)
Arif, 2020 (55)
Mattingly, 2010 (20)
Cleary, 2013 (25)
Qualitative
O’Connor, 2020 (58)
Mixed-methods
Guraya et al, 2021 (61)
Guraya et al, 2022 (71)
Case study
Orenstein, 2013 (29)
Westrick, 2016 (41)
Eijkholt, 2017 (45)
Zalpuri et al, 2021 (70)
Jones et al, 2016 (39)
Reviews
Cain, 2008 (15)
Cain and Romanelli, 2009 (16)
Aase, 2010 (18)
Grindrod, 2014 (30)
Benetoli, 2015 (32)
Ellaway et al, 2015 (33)
Kleppinger and Cain, 2015 (36)
Neville and Waylen, 2015 (37)
Schroeder, 2017 (47)
Mosalanejad, 2021(68)
|
Despite a consensus about the importance, value, and role of medical professionalism, e-professionalism has not been remitted to the same extent due to the emerging lapses in the digital realm. Professionalism in the electronic sphere is just beginning to be appreciated (27). However, multiple reviews in the literature revealed that there is a need to empower digital natives users to adopt better choices and options while using SNSs so as to protect their own reputation, profession and the interests of the public at large (2, 30, 36, 37, 47, 68). On a positive note, these reviews have eluded that healthcare professions students were willing to make changes to how they used SNSs but needed guidance and training. Overall pragmatism of being professional in the digital world was to practice personal and professional work by maintaining autonomy, and professional integrity while safeguarding societal contract, respect, and confidentiality.
In our analysis, literature has proposed that academic leadership must define the values, standards, behaviours, policies, and best practices for SNSs usage (2, 15, 16, 18, 27, 33, 36, 37, 52, 53, 56, 58, 62, 65, 66, 70). Thought he policies and statements that described e-professionalism were reported, however, due to the enormous proliferation of technological innovations with the resultant injudicious use of SNSs, society had yet to adjust to this new paradigm (29, 45, 49). Philosophically, a large segment of our population still struggles with how to work separately in public and private spaces in the digital world (53). Thus, Eijkholt et al (45) and Cleary (25) suggested that until society was able to champion the new paradigm, further discussion on online identity protection was warranted (59). Furthermore, there was a glaring absence of awareness regarding systems use of identifying, tracking, and remediating professionalism lapses, made even harder by the differing generational perspectives defining appropriate professional behaviour (21, 56–58). This may be partly due to the difficulty in anticipating new technological advances. Spector et al (21) reiterated the importance of e-professionalism in the era of technological advancements by pointing out the emerging challenges and threats to our professional standards and values. Some plausible recommendations included posting disclaimers, suggest against diagnosing on SNSs, use of the least biased educational material, and non-financial incentives in exchange of positive reviews or testimonials (29). In this context, e-professionalism offered a pragmatically mature concept in the fluid, diverse, autonomous, and connected world of digital media. However, a carefully drafted policy and use of checklists was deemed essential for its application across social, cultural, economic, ethical, and political levels (21, 41, 55). The paradigm shift of medical knowledge from health professionals to the larger social community, the online presence of healthcare professionals stems from SNSs being valuable in all undergraduate medical and related programs (30, 33, 36, 47, 50, 58, 62).
Empirical research in the nursing field, both at system and organisation levels, identified a growing need for professional academic programs to develop specific guidelines for online behaviours and to educate students on how online behaviours were linked to the basic tenets of professionalism (2, 38, 41, 44, 48, 50, 56, 57, 60, 73). However, Gettig (26) diverted the attention of the readers to the faculty’s perspectives and understandings of digital media before educating students on the consequences of its misuse. On the same note, Jones et al (39) and Zalpuri (70) suggested incorporating the use of Twitter, YouTube and other SNSs into curricula which may provide a significant upgrade to the nurse and healthcare educators’ toolbox. In one example, Gettig et al (50) used Twitter as an interactive and dynamic tool for education promotion and networking with nursing students, facilitating and promoting digital professionalism learning experience. On a more sensitive note, this kind of use and translation of the societal ethnography into cyberspace also permits the collection of data that is not free from bias and misbeliefs (49). This demands a comprehensive understanding of the SNSs usage, the associated connotations on personal and professional dominions in case of its irregularities and a support program and the need for further support relating to its use (44). However, recent research produced the Medical Education e-Professionalism (MEeP) framework with theoretical underpinnings of Theory of Planned Behaviour and showed promising results in terms of behavioural changes in the participants (71).
In summary, the analysis of published literature revealed a mild maturity under pragmatic principle suggesting a stark absence of clear methods to evaluate this concept. Further work was needed to clarify and understand the theoretical and operational utility in clinical and academic medicine. This principle will perhaps navigate us to further explore the use of sound methodological and philosophical paradigms while evaluating this concept.
Linguistic principle: Is the concept used consistently and appropriately within context?
The linguistic principle applies to the use of a subject for its consideration in a specific context, which will help in the evaluation of its consistency (13, 76, 78). Linguistics is a robust and focused mechanism which investigates the consistent use and its meaning of the concept under consideration. The selected area in science is also studied with regard to its context, whether it was wholly specific to a context or more abstract (13). As reflected from Walker and Avant's method, this principle corresponds to the empirical testing to support the validity or invalidity of the designated assumptions or theoretical propositions (9).
To fulfil the linguistic principle of our concept analysis, a search of published literature for the consistent use and meaning of e-professionalism was conducted. It was apparent that, linguistically, e-professionalism was a fledgling concept. Unfortunately, there was a lack of consensus about its nature and the variety of attributes needed to navigate the digital world while maintaining the respect of the societal contract. Although attributes of conventional professionalism in the online world seemed like a substantial extension of the conventional construct, the differences were remarkable when these attributes were considered within “private” environments (16, 61). Duke et al (44) highlighted that the terms “conduct unbecoming” and “appropriate use of self-disclosure” have some convergence with conventional professionalism. This indicates the non-binary nature of this multidimensional construct. However, recent research highlights the significance of ‘context’ applying a different set of rules and attributes while denoting the content and conduct unprofessional or potentially unprofessional (61, 62, 74).
The understanding of one’s online persona as a core element of e-professionalism has added different dimensions to several grey areas in e-professionalism, which are hard to interpret or predict (18, 19). These grey areas essentially stem from some contentious concerns; 1) evaluating alcohol or drug abuse from someone’s online persona to be considered as an e-professionalism issue and 2) how many online group affiliation violations should be used as a professionalism threshold? Generally, e-professionalism can be extrapolated as a modern extension of conventional professionalism, which also suffers from the same issues of vagueness (16, 23, 41, 46). Recently, objectivity was constructed through the development of a validated instrument to define potentially unprofessional behaviours with a sound focus on the context (74). However, a rapid upsurge in new applications and platforms demand parallel innovative research to address all such concerns and ambiguities which prevail around e-professionalism in the modern world.
A glaring finding in our review was an absence of comparison of cultural perspectives related to digital professionalism across medical education systems (55). It’s evident that the online rulebook is unwritten, and that policy makers were unable to influence guidelines about the professional use of SNSs. Its also evident that students were not aware of the proclaimed unethical behaviours on SNSs. A large body of literature showed a conflict in the standard design of the usage of SNSs due to cultural differences (24). This underpins the profound significance of revising the standard medical professionalism curricula to inculcate e-professionalism for the medical and allied health professional students (34). Gettig (26) suggested that a profound understanding of ‘respect for others’ is an essential conventional professionalism attribute which can assist students in developing as receptive professionals. Given the diverse understanding of confounding variables to be digitally professional, Guraya et al (61, 79) conceptualized and validated a multi-construct Mission-based MEeP framework enlisting all the desired attributes to be digitally professional.
To improve linguistic maturity, Kaczmarczyk’s (27) proposal of implementing initiatives to teach responsible use of SNSs and for the development of an appropriate online professional persona in medical school seems very reasonable. This strategy can enhance the participation of learners in this dynamic learning experience (36, 37, 71). Curricular interventions introducing the regulated professional use of SNSs can abreast the learners with the right tools to navigate through the potential pitfalls of the digital environment (50, 55, 70). Privacy demands ‘‘reasonable administrative, technical, and physical safeguards to prevent inappropriate access, use, or disclosure of individually identifiable health information in all forms: paper, electronic, and oral’’(29). The available resources and information about e-professionalism call for a constructive and comprehensive guidance for ‘digital professionalism’, not simply as an adjunct to the existing concepts of professionalism (62, 64, 73). Ellaway’s(33) review suggested to insert the professionalism principles and opportunities of digital media into a medical education setting. This may include training and education of medical and allied health students and faculty about the concept surrounding appropriate self-disclosures. Rukavina et al (2) and Mostaghimi et al (46) trenchant findings argued that dedicated training on e-professionalism in medical curricula should target students, faculty, and staff levels avoiding abstract and implicit descriptors. Keeping the rapidly technological evolution in focus, their research coined the use of behaviourally oriented practices of “encrypting mobile devices” as opposed to “keeping data private”. Another major challenge surrounding e-professionalism is that the versatility of people’s lives such as professional, family context, class reunion, partying, education, and networking flattens the contexts on SNSs (62, 71). Aase’s (18) narrative on e-professionalism as a big conversation with little or no control still holds true to some extent. Guraya et al’s (71) recent research exalted this approach where participants articulated their inadequacies of self because of the peculiar nature of context (digital world), however, a firm understanding of mission seemed an enabler of the digital self.
Lefebvre (40) reiterated the importance of protected health information and patient privacy in healthcare systems which became vulnerable in the digital communication due to blurring of personal and professional boundaries. At this time, avoidance of online presence can be misinterpreted by the patients as an inability of HCPs to communicate effectively in the digital age (36, 42, 49, 52, 66). Educating students and physicians to maintain a fine balance between professional yet distant, and depicting “to err is human” in the digital world seems crucial (38). The precarious nature of privacy and confidentiality in the online world, can give rise to ethical issues from perpetual tracing and data manipulation even presented anonymously (56). Unfavourable or leaked data can compromise an organization’s reputation, resulting in the loss of the patients’ and the public’s trust in the HCPs and other care providers (2, 45, 49). To ensure that patients and their information is safe with HCPs it must be stressed that e-professionalism should be defined, described and made explicit in the context of medical education (15, 38, 49, 62).
In summary, our deliberations have revealed consistencies and inconsistencies regarding the use, meaning, and depictions of e-professionalism. Due to the rapidly changing technology and its unpredictable manifestations of digital professional behaviours, highlighting its moderate maturity from a linguistic perspective is essential. However, Guraya et al (71) and Rukavina et al., (74) have used this principle as a guiding force in the methodological context of their respective research.
Logical principle: Does the concept under consideration maintain its distinct boundaries in theoretical integration with other concepts?
Logical principle refers to the mechanism for integrating certain concepts into theory so that it remains distinct from other relevant theoretical concepts (13). Furthermore, logical maturity is determined by the explicit boundaries of the concept under review with other related concepts. In other words, “logic is derived from the philosophical principle that considers the careful integration of the concept with other related concepts” (78). The logical principle investigates how a concept is related to theory and how well it can distinguish from other concepts (80). Walker and Avant have argued that the testability of a theory is important for generating medical knowledge and for its evaluation if further research is required on the phenomenon being explored (9). Furthermore, the soundness of a theory is critical when adopting it into practice and when it shapes how problems are thought of in relation to health and medical care. In this analysis, e-professionalism emerged as a relatively high level abstract concept encompassing a number of similarities yet distinct boundaries with the underlying, inter-related concept of professionalism (81). A complete understanding of e-professionalism can only be gained through a consonant definition providing core elements and basis of digital practices. Definitions solely stemming from the professionalism frame of reference seemed to limit the understanding of e-professionalism, ignore context extant, and negate the investitures of new perspectives. In this area, theory testing can be accomplished either by qualitative or quantitative methods to determine the empirical adequacy (82).
While looking at the concept boundaries, Ellaway (33) traced back the roots of e-professionalism to the concept of traditional professionalism where altruism, honesty, integrity, accountability, excellence, duty, respect for others and patient-centred service became entangled in the web of SNSs. This amalgamation of private and public life gave rise to a debate for professionals and students having varied generational perspectives. This concept analysis revealed that students socializing into professional communities of practices in this digital era need to be attentive to their attitudes, behaviours and online personas, hence expanding the professionalism paradigm (2, 18, 20, 59, 61, 71). Traditional definitions of professionalism fixated on life as a professional while keeping one’s private life away from societal scrutiny. However, the e-professionalism perspective broadened the jurisdiction of traditional professionalism to both personal and professional lives highlighting the need of a new framework and a revision of the key attributes (70). Keeping Clark’s extended mind theory (83) in focus, the developing cyborg relationships with digital media has made SNSs an integral part of our problem solving and intelligence skills (2). This new relationship has strengthened our cognitive abilities and critical skills signifying the need of a framework based on proficiency, reputation and responsibility and transpersonal psychology (33, 61). The key attributes defined by Guraya et al (61) may help to build on these new constructs of proficiency, responsibility, reputation, and transpersonal psychology.
Talking of digital proficiency, although digital natives assumed that they were well equipped with digital literacy, the published body of literature depicted a contradictory picture (17, 61, 74, 75). Gettig (26) identified two contrasting perspectives, students having a laxed approach while posting online content in a personal capacity while faculty believed in professionalism irrespective of personal and professional capacity. This sharp disconnect between the understandings of tech-savvy student posting unprofessional online content and the professional image being created was disconcerting (44, 66). A clear need to enlist the required professional digital behaviour was evident. Schroeder (47) urged the pressing need for professional digital behaviour discourse, which remained elusive due to lack of clear frameworks and guidelines. Breaches of confidentiality, violations of boundaries and unintended potential harm to patients demanded a cohesive characterization of e-professionalism (2, 62, 68). Kleppinger and Cain (36) coined the term digital identity in digital communications when the frustration of educators was evident due to erosion of societal trust, individuals’ responsibility and accountability (22). Numerous medical associations have worked on producing good practice guides and best practices to navigate through the online world of SNSs (24). However, Kang et al., (35) reported a lack of awareness of these guidelines by medical students. An absence of detailed, prescriptive set of guidelines and frameworks with an emphasis on key attributes needed to be aware of ‘e-professionalism’ and its compliance was evident (30).
Cain (19) described concerns about SNSs postings on three key aspects: reputation, privacy and productivity, highlighting responsible digital behaviour. The digital context became a confounding variable in the equation of effective online communication bringing personal life under scrutiny (70). In addition, Spector (21) notions of Public, Permanent and Powerful where online interactions are being projected to variety of unknown audiences showing wider reaching repercussions (27). In two studies by Jones et al (39) and Jackson et al (50) e-professionalism was considered an appropriate competency, but not through avoidance of social media by medical schools which was endorsed in the recent research (59). But rather a more proactive approach to inculcate reflective practice for use of SNSs aimed to harbour metacognitive skills. Also, a shift from paternalism to autonomy has led to empowered communities demanding a heightened awareness of e-professionalism attributes, development of policies, remediation strategies and curricular amendments to identify and track digital unprofessional behaviours (21, 29).
Cain and Romanelli (16) proposed the generational differences with an element of philosophical nuances that confused the paradigm of boundaries. Younger generations had a different understanding of e-professionalism where their private and personal lives did not fall under two jurisdictions despite a better understanding of technological advancements and their pervasive nature affecting online identities. Conversely, older generations, although digital immigrants, quickly identified the singularity of identities required in this digital context. Hence, digitally literate, and digitally professional seemed two entirely different competencies. This lead to a clear understanding that technological advancements demanded different skills set acquisitions to understand boundary violations (41, 43, 61), information ecosystem, self-disclosure, and appropriate use of health services so as to maintain high professional standards in the online environment (49). Guraya et al (62) advocated a proactive system-level approach to bridge the gap between policy making and the use of technology in the health care context. A need of continual education with frequent reminders and appropriate role modelling were the suggested areas to evaluate and understand unprofessional digital behaviours. Several areas of potential educational opportunities were identified included online privacy (40), confidentiality (15, 38), copyright, trade slander, libel laws, respecting boundaries (25) while Eijkholt et al (45) highlighted the dynamics of power and vulnerability in patient-physician digital relationship.
This analysis has grounded the concept of ‘e-professionalism’ with some theoretical integration alongside other related concepts, models or frameworks giving rise to peculiar conceptual components (Fig. 3). There is some evidence of conceptual boundaries, however, to ensure complete competency, core attributes are needed in the form of a framework which can encompass the epistemological, ontological, and axiological aspects (61).