beatleyweb.simmons.edu€¦ · Web viewPerceptions of Nurse Anesthesia Students Regarding...

Running head: PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA i

Perceptions of Nurse Anesthesia Students Regarding Professionalism and Professional

Attributes and Behaviors

Anne Tierney MSN, MA, APRN, CRNA

Simmons College School of Nursing and Health Sciences

For the Degree Doctorate of Nursing Practice

December 2, 2017

PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA



In partial fulfillment of the requirement for the degree of Doctorate of Nursing Practice

for the Simmons College School of Nursing and Health Sciences

Anne Tierney MSN, MA, APRN, CRNA

Eileen M. McGee Ph.D., R.N.

Judy Beal DN.Sc., R.N., FNAP, FAAN

ii


Abstract

Concern has been raised regarding the demonstration of professional attributes and

behaviors, particularly in health care. The display of unprofessional attitudes and behaviors

affects providers, the practice environment, and ultimately the patient. Inconsistent or lack of

professionalism through the demonstration of attitudes and behaviors can erode the public trust

in the professional and the profession (Foster & Horton, 2011; Sullivan & Benner, 2005).

Registered nurses enrolled in a nurse anesthesia program of study are engaged in an

intense program involving academic and clinical preparation for the specialty. The accrediting

body for the nurse anesthesia profession, Council On Accreditation of Nurse Anesthesia

Educational Programs (COA)(accessed February 23, 2016), requires that the curriculum of each

nurse anesthesia program contain 45 hours addressing the professional aspects of nurse

anesthesia practice without specifying content. Professional attributes and behaviors during the

nurse anesthesia education experience have not been studied.

A qualitative study was conducted utilizing focus groups of student registered nurse

anesthetists (SRNAs). This study examined the perceptions of professionalism and its attitudes

and behaviors on the part of SRNAs. A sample of 57 SRNAs participated in one of seven focus

groups that took place in Connecticut, Massachusetts, New York or Rhode Island. Results of the

focus groups revealed five themes in the perception of SRNAs regarding this topic. Suggestions

from participants for nurse anesthesia education included formation of a code of conduct and

practicing professional communications and the management of situations involving

unprofessionalism through simulation. This examination of the perceptions of professionalism

and the attitudes and behaviors that exemplify professionalism can guide curriculum

development in nurse anesthesia programs.

iii


Acknowledgements

I wish to express my sincere thanks to Dr. Eileen McGee for her knowledge and guidance

during this project. Her words of encouragement and direction kept me on track throughout the

entire process. Thank you as well to Dean Judy Beal for her editorial input and support. I am

also grateful to the entire DNP faculty for their effort and assistance in my educational journey.

I want to convey my appreciation and thanks to each of the nurse anesthesia program

directors that contacted their student body for me in order that I could ask for their participation

in this study. Finally, my sincere and deep appreciation goes to the student nurse anesthetists.

These students took some of their meager and valuable time to share with me their thoughts and

impressions regarding professionalism and their experiences or witnessing of the behaviors that

impact professionalism. I am grateful for the suggestions for learning and development that

were shared in order to advance the education for future student registered nurse anesthetists.

iv


Table of Contents

Introduction 7

Statement of the Problem 7

Purpose Statement 9

Significance of Problem 9

Literature Review 11

Professionalism in Physical Therapy 13

Professionalism in Law 14

Professionalism in Pharmacy 14

Professionalism in Medicine 15

Professionalism in Nursing 17

Professionalism in Nurse Anesthesia 17

Education and Measurement of Professionalism 18

Perspectives on Professionalism 20

Methods 23

Design 23

Setting 24

Description of Sample

25

Data Collection Procedures 28

Data Analysis 31

Rigor 32

Cost Analysis 34

v


Human Subjects Protection 34

Results 36

Themes 36

Defining professionalism 36

Development of professionalism 42

Role of mentors and/or preceptors 46

Reflections on treatment of themselves as SRNAs 50

How professionalism should be taught 53

Discussion 57

Limitations 63

Implications for Practice 65

Conclusion 69

Appendices 70

References 77

vi

Running head: PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA 1



Introduction

Designation as a profession is a privilege granted by society and is a compact between

the profession and the society based on trust. There is trust that the profession will place the

needs of the society above that of the profession. This trust by society and its representatives and

agencies grants the profession the right to self-regulation, oversight of the profession’s

education, certification and disciplinary processes (Brennan & Monson, 2014; Bowman, 2013;

Foster & Horton, 2011; Sullivan & Benner, 2005). Qualities of professionalism include

integrity, truth, skillfulness, duty, accountability, service to others and fairness (Brennan &

Monson, 2014; Bowman, 2013; Foster & Horton, 2011). Discussions about the lack of

professionalism can be found in the nursing literature but little is found regarding the perspective

nurses and nursing students have of professionalism. Keeling and Templeman (2013) explored

the perceptions of undergraduate nursing students regarding professionalism. Shepard (2014)

urged nurse educators and nursing clinicians to develop the skill of professionalism in nursing

students in an effort to reduce the unprofessional behaviors in the workplace such as bullying

and verbal abuse, which can jeopardize patient safety. Emblad, Kodjebacheva & Lebeck (2014)

examined incivility and burnout among CRNAs. Nurse anesthesia literature does not reveal an

examination of the perspective of student registered nurse anesthetists regarding professionalism

and what constitutes professional attitudes and behaviors.

Statement of the Problem

Understanding and conveying professionalism and professional attributes and behaviors

are an important aspect of nursing’s interactions with the public and other health care colleagues.


Incivility, just one aspect of unprofessionalism, carries negative consequences for learners in the

nursing discipline as well as faculty (Clark, 2008; Clark & Springer, 2007; Keeling &

Templeman, 2013). Lapses in professionalism affect the environment of patient care delivery

and communication and collaboration among health care providers (Clickner & Shirey, 2013;

Emblad et al, 2014; Shepard, 2014).

The medical profession has been concerned about professionalism and the display of

professional attributes as expressed in their literature for over a decade. Ginsburg, Regehr,

Hatala, McNauhton, Frohna, Hodges,… and Stern (2000) and Van Zanten, Boulet, Norcini and

McKinley (2005) expressed their concern with the inadequacy in evaluation of professionalism

and professional behaviors in medical students and Klein, Jackson, Kratz, Marcuse, McPhillips,

Shugerman… and Stapleton (2003) announced the 2007 mandate by the Accreditation Council

for Graduate Medical Education for formal education and evaluation of professionalism as a

component of standards. Professionalism and professional behaviors have often been addressed

informally and are expected to develop through a socialization or mentoring process. Medicine

and nursing have acknowledged that unprofessional behaviors affect providers and ultimately

patients.

Expressions of unprofessional attitudes and behaviors have been reported in both

educational and clinical settings. Nagler, Andolsek, Rudd, Sloane, Musick and Basnight (2014)

examined the understanding of first year medical residents regarding professionalism and found

behaviors inconsistent with knowledge of professionalism. Clark and Springer (2007)

discovered unprofessional behaviors on the part of faculty and students disrupting the learning

environment with implications for qualified, ethical nursing graduates. Keeling and Templeman

(2013) in a study of final year nursing students in the U.K. revealed that both positive and

2


negative role modeling influenced the student nurses’ perception of professionalism. The

perception of professionalism or the expression of professional attitudes and behaviors is

unknown regarding student registered nurse anesthetists. Recognition of the perceptions of

students regarding professionalism and what constitutes professional attitudes and behaviors can

begin the process of self-reflection and impact curriculum in teaching this important component

of the education of nurse anesthesia practitioners.

Purpose Statement

The purpose of this study was to examine the perceptions of professionalism by student

registered nurse anesthetists (SRNAs). The perceptions of what constitutes professional attitudes

and behaviors in nurse anesthesia may differ from the perceptions held by clinicians and faculty.

These perceptions of professionalism may influence the education environment of SRNAs and

impact the educational curriculum.

The questions examined were:

1. What is the definition of professionalism as perceived by SRNAs?

2. What is the perception of students in nurse anesthesia programs regarding professional

attributes and behaviors?

The aim of this project was to examine the perception of professionalism and professional

attributes and behaviors as defined by SRNAs. This information may assist educators in the

education process of SRNAs and formation of curriculum.

Significance of Problem

Bowman (2013) pointed out that professionals are self-controlled and self-motivated in

working with others towards a shared goal. Expression of professionalism by the professional in

a discipline is dependent on the strength of trust built over time (Bowman, 2013). The

3


demonstration of professionalism and professional attributes and behaviors are crucial for the

CRNA in order to build trust with team members in the operating room and with each patient

prior to their surgery or procedure. Professional behaviors and communications hold

ramifications for the quality of patient care and outcomes (Brennan & Monson, 2014). Foster

and Horton (2011) highlighted a vital objective in nurse anesthesia education regarding

professionalism, to enable students “to inculcate the values that are the foundation of effective

patient care and anesthesia services as well as values that promote the well-being, public image,

longevity, and the leadership role of nurse anesthetists” (p.10). A decline in professionalism and

professional attributes and behaviors can undermine the trust needed for safe patient care.

As Foster and Horton (2011) identified, the concept of professionalism is applied broadly

and a clear understanding is often hard to devise. An understanding of the perceptions held by

nurse anesthesia students regarding professionalism and professional attributes and behaviors

may contribute to an understanding of the learning needs of SRNAs, ultimately leading to

improved communication and practice. The Certified Registered Nurse Anesthetist (CRNA) who

is educated with a Doctorate in Nursing Practice (DNP) is positioned to promote professionalism

and lead a cultural change in an organization. CRNAs need to exhibit professionalism and

leadership skills in the team-based environment of health care.

The adoption and maintenance of professionalism and professional attributes and

behaviors are important to the continuance of the CRNA’s ability to practice with relative

autonomy and to be viewed as respected providers. The policy implications of potential

diminished trust in the profession and CRNA professionals can impact the role of the CRNA in

their organization and society. It is essential for CRNAs to advocate for and maintain

professional attributes and behaviors.

4


Literature Review

A review of the literature revealed the struggle to define the term professionalism as well

as the qualities of being professional and exhibiting professional attributes and behaviors. In

graduate programs for advanced practice nursing and nurse anesthesia in particular, the topic of

professionalism and professional attributes has not been well described. Tanaka, Yonemisu and

Kawamoto (2014) described professionalism as the “conduct, qualities, and/or goals that

characterize a profession and usually describes behaviors that are expected of the profession’s

members” (p.579). Nagler et al (2014) have asserted that the topic of professionalism is of prime

importance in medical education but that defining professionalism and the perceptions of

professional attitudes and behaviors has been a challenge for the medical profession.

The expression of unprofessional attitudes and behaviors takes place in educational

environments as well as the patient care areas of health care. Bowman (2013) noted “ the toxic

effects of incivility on campus, including destructive behaviors such as gossip, condescension,

angry outbursts, and collegial and programmatic sabotage” (p.19). Shepard (2014) decried the

increasing incidents of unprofessional behaviors and communications in nursing. Incivility, an

aspect of unprofessional behavior, and its consequences have been examined in nursing

academic and clinical environments (Clark, 2008; Clark & Springer, 2007; Clickner & Shirey,

2013).

Berk (2009) reported the use of derogatory and cynical humor by medical personnel

directed at patients and contended that this behavior was a form of verbal abuse, and disrespect

affecting both patients and the personnel. Hammer (2006) expressed concern regarding reports of

greedy, unethical or uncaring pharmacists. Bahaziq and Crosby (2011) asserted that problem

behaviors in medical school often resulted in patient complaints and disciplinary action. Brennan

5


and Monson (2014) contended that respect and the consistent expression of professional attitudes

and behaviors “increases patient safety, reduces medical errors, and reduces the incidence of

sentinel events in hospital care” (p. 647).

Much of the work examining this topic has been conducted in the field of medicine

(Bahaziq & Crosby, 2011; Brennan & Monson, 2014; Cook, Sobotka, & Ross, 2013; Ginsburg et

al, 2000; Hilton & Slotnick, 2005; Jha, Bekker, Duffy, & Roberts, 2007; Klein et al, 2003;

Nagler et al, 2014; Wagner, Hendrich, Moseley & Hudson, 2007; Woloschuk, Harasym &

Temple, 2004). Other disciplines such as pharmacy, physical therapy, law, and nursing have

been concerned and have explored this topic as well. Pharmacy has identified domains of

professionalism that are important for their doctor of pharmacy educators and students (Hammer,

2006; Kelley, Stanke, Rabi, Kuba, & Janke, 2011; Noble, Coombes, Shaw, Nissen, & Clavarino,

2014; Rutter & Duncan, 2010). Montgomery (2007) voiced the need for explicit education in

professionalism in legal education in the face of declining public trust.

Nursing voices have been examining the topic of incivility and the educational process

for promoting professionalism (Baumann & Kolotylo, 2009; Clark, 2008; Clickner & Shirey,

2013; LeDuc & Kotzer, 2009; Rhodes, Schutt, Langham & Bilotta, 2012; Shepard, 2014; Weis

& Schank, 2009). Shepard (2014), Clickner and Shirey (2013) and Clarke (2008) discussed

incivility in nursing. The reports and interviews revealed an increase in the episodes of incivility

in students, faculty, and staff in nursing and concern regarding the demonstration of

unprofessional behaviors. LeDuc and Kotzer (2009), Weiss and Shank (2009) and Baumann and

Kolotylo (2009) each developed questionnaires or evaluation methods in order to examine

professional values and attributes among these groups. Rhodes et al (2012) examined the result

6


of a seminar discussing nursing professionalism and professional behaviors in pre-licensure

nursing students.

Foster and Horton (2011) presented a professional definition of the Certified Registered

Nurse Anesthetist (CRNA) as one who is educated at the graduate level and is certified as

competent in the field of anesthesiology. The Code of Ethics developed by the professional

association, the American Association of Nurse Anesthetists, presents a guide for professional

obligations through statements of the CRNA’s responsibility to patients and maintaining

competency in practice (American Association of Nurse Anesthetists, 2005). The Code of Ethics

includes statements pertaining to responsibility and accountability for the services the CRNA

provides and the actions that are taken (American Association of Nurse Anesthetists, 2005).

Foster and Horton (2011) asserted that professionalism is more than clinical competence. It is

the incorporation of the ethics and values, along with integrity, which needs to be shared with

those who are learning to become part of the profession (Foster & Horton, 2011).

The accrediting body for the profession, the Council On Accreditation of Nurse

Anesthesia Educational Programs (COA), requires that the curriculum of each nurse anesthesia

program contain 45 hours addressing the professional aspects of nurse anesthesia practice though

does not specifically refer to the teaching of professionalism and professional attributes or

behaviors (Council On Accreditation of Nurse Anesthesia Educational Programs, 2014). The

glossary definition by the COA of this requirement is broad and includes topics such as business

aspects and practice management.

Professionalism in Physical Therapy

Physical therapy defines their core values of professionalism as accountability, altruism,

compassion/caring, excellence, integrity, professional duty, and social responsibility (Johanson,

7


2005). A school’s effort to inculcate professionalism in their physical therapy students has been

seen as vital to the development of the individual and the profession (Johanson, 2005). The

American Physical Therapy Association has developed the Clinical Performance Instrument

(CPI) in order to assess student competence in clinical practice (Santasier & Plack, 2007). This

tool includes 9 categories that are related to professional behaviors to be used by faculty and

clinical evaluators (Santasier & Plack, 2007). Santasier and Plack (2007) declared that

professional behaviors are complex and difficult to capture and that the CPI evaluation tool

constrains responses in assessing professional behaviors.

Professionalism in Law

Montgomery (2007) pointed out that law schools presume that professionalism is

somehow being addressed but explicit preparation of law students is needed. He maintained that

a standard definition of professionalism is lacking and the view of professionalism in law

includes competency in knowledge and skills necessary for professional work, respect for the

justice system and its participants, and an attitude of altruism (Montgomery, 2007).

Montgomery (2007) voiced the concern that professionalism of lawyers has been declining as

noted in the incivility in dealing with clients, other lawyers and even judges, overly aggressive

tactics, and insufficient attention to the responsibility to the justice system. Montgomery (2007)

contended that legal education gives insufficient recognition in the curriculum to professional

skills and professionalism to the potential detriment of the profession.

Professionalism in Pharmacy

The profession of pharmacy defined professionalism as “including altruism,

accountability, excellence, duty, honour and integrity, and respect for others” (Schafheutle,

Hassell, Ashcroft, Hall & Harrison, 2012, p.118). Kelley et al (2011) declared that

8


professionalism though abstract contains domains for the pharmacist of reliability, responsibility

and accountability; lifelong learning and adaptability; relationships with others; upholding the

principles of integrity and respect; and citizenship and professional engagement. Schafheutle et

al (2012) asserted that while defining professionalism is difficult, common attributes and

behaviors of professionalism were described by students and teachers. Professionalism and the

demonstration of professional attitudes and behaviors have been described as a critical

component of a doctor of pharmacy education (Kelley et al, 2011).

Rutter and Duncan (2010) found few schools of pharmacy engaged in formally teaching

professionalism. Hammer (2006) emphasized the need for positive role modeling in pharmacy

education during student clinical experiences. Concern was voiced by Hammer (2006) regarding

the hidden curriculum and the adoption of attitudes and behaviors not formally taught. An

identical concern was voiced by Noble et al (2014). This hidden curriculum can exert both

positive and negative effects on professionalism and professional behaviors. Noble et al (2014)

cautioned educators that the intended curriculum experience may not be the learning gained by

the student during the actual learning experience. Positive role modeling is seen as the most

important way for students to learn professional behaviors expected of practitioners (Hammer,

2006).

Professionalism in Medicine

Medicine has been concerned with professionalism for more than a decade. It is

suggested that more complaints filed against physicians relate to unprofessional conduct rather

than a lack of technical skills or knowledge (Bahaziq & Crosby, 2011; Ginsburg et al, 2000;

Nagler et al, 2014). Brahaziq and Crosby (2011) found that “there is a correlation between

unprofessional physician behaviours and patient dissatisfaction, complaints, and lawsuits as well

9


as adverse outcomes of care” (p.1039). Hilton and Slotnick (2005) discussed the breach in the

implied social contract as a factor in the decline in professional behaviors and pointed to the

focus on professional self-interest predominating over altruism in medicine.

Professionalism in medicine has imprecise definitions but centers around themes of

reflection/self-awareness, responsibility for actions, respect for patients, teamwork, and social

responsibility (Ginsburg et al, 2000; Hilton & Slotnick, 2005; Klein et al, 2003; Wagner et al,

2007). The need to enhance the teaching of professionalism and professional attitudes and

behaviors has been addressed in the medical literature. Nagler et al (2014) in a study of 495 first

year residents found that 76% had rated 46 behaviors in the survey as unprofessional. The

investigators found that 15 behaviors despite being rated as unprofessional had from 10% to 55%

of respondents reporting that they had personally participated in these unprofessional behaviors

(Nagler et al, 2014).

Klein et al (2003) identified eight components of professionalism that needed to be

integrated into the curriculum for pediatric residents including: honesty/integrity,

reliability/responsibility; respect for others, compassion/empathy, self-improvement, self-

awareness/knowledge of limits, communication/collaboration, and altruism/advocacy. A

weeklong retreat focused on professional issues and professional attributes and behaviors was

conducted for beginning pediatric residents incorporating a variety of learning methods to

address issues, decisions and interactions that will be encountered in practice (Klein et al, 2003).

Goldie, Dowie, Cotton, and Morrison (2007) discussed incorporation of professional concepts

into an undergraduate medical curriculum in Scotland through the use of self-refection and

portfolio construction in order to develop professional attitudes and skills needed for clinical

10


practice. Cook et al (2013) surveyed pediatric residency programs and found that most teaching

of ethics and professionalism continues to be unstructured.

Professionalism in Nursing

Weis and Schank (2009) discussed The Code of Ethics (ANA, 2015) for nursing and the

themes delineated as: fundamental values and commitments of the nurse; duty and loyalty of the

nurse; and social nature of the profession and responsibility to the public. LeDuc and Kotzer

(2009) asserted that The Code of Ethics serves to define the ethical obligations and duties of

members of the profession and the expression of the commitment to society.

Clickner and Shirey (2013) identified a culture of incivility, nurse aggression and

compromised patient safety with a lack of professional comportment. As analyzed by Clickner

and Shirey (2013), professional comportment reflects the attitudes and behaviors of

professionalism of self-regulation, accountability, respect, commitment and collaboration.

Rhodes et al (2012) reported on a seminar in a baccalaureate nursing program that

utilized small group discussions to develop the learning of professional concepts using Miller’s

Wheel of Professionalism in Nursing. The characteristics of professionalism in Miller’s model

include: education and training, skill based on theoretical knowledge, a code of ethics, a

professional organization, and service (Miller, Adams, & Beck, 1993). Rhodes et al (2012)

stated that use of this framework in junior and senior students with student-led discussion of

professional nursing issues was a foundation for the development of professional behavior.

Professionalism in Nurse Anesthesia

The Code of Ethics for the Certified Registered Nurse Anesthetist (American Association

of Nurse Anesthetists, 2005) details the responsibility to patients and the preservation of human

dignity and respect. Additionally The Code of Ethics for the CRNA contains statements

11


regarding competency, responsibility/accountability as a professional and to society, as well as

statements of integrity and truthfulness regarding the endorsement of products, and engaging in

research and business practices (AANA, 2005). Foster and Horton (2011) described a

fundamental value of professionalism as integrity and the display of honesty and ethical

behaviors in the CRNA’s interactions with others. Tunajek (2011) stressed that the “profession

as an institution serves as a normative reference group for individual practitioners” and standards

of practice provide the benchmark for expected behaviors (p.150). Foster and Horton (2011)

have pointed to the slow erosion of professionalism. They cautioned professionals to be mindful

of the display of professionalism even when tempted to act otherwise (Foster & Horton, 2011).

In conclusion, physical therapy, pharmacy, law, medicine and nursing have undertaken

the work to define professionalism and provide direction to educators and students regarding the

attributes and behaviors that should be displayed. Advanced practice nursing provided by

CRNAs requires the displays of professionalism and awareness of the characteristics that make

up professionalism. The effort to measure professionalism has importance for educators and

students in determining the components of professional attributes and behaviors.

Education and Measurement of Professionalism

Throughout the educational process of students in professional disciplines, an assumption

could be made that the student is learning attributes and behaviors for the discipline. Few reports

regarding measurement of professionalism and attainment of these attributes and behaviors are

found.

The measurement of professionalism among pharmacy students has been reported

through the use of questionnaires or assessment tools (Chisholm, Cobb, Duke, McDuffie &

Kennedy, 2006; Kelley et al, 2011; Poirier & Gupchup, 2010). Chisholm et al (2006) and Poirier

12


and Gupchup (2010) each developed questionnaires in an effort to measure the attainment of

professionalism during the pharmacy curriculum. Kelley et al (2011) indicated the difficulty in

measuring professionalism in pharmacy students and the few reports on assessment. The use of

assessment tools was encouraged in an attempt to measure the effect of the curriculum and co-

curricular activities in fostering professionalism in pharmacy students (Chisholm et al, 2006;

Poirier & Gupchup, 2010).

In physical therapy Wise and Yuen (2013) developed a self-assessment tool to enable

their students to evaluate their professionalism during a community service-learning project.

Self-evaluation was viewed as a crucial part of professionalism and a way to increase student

awareness of the profession’s values (Wise & Yuen, 2013).

Medicine has published a significant portion of the work on the subject of incorporating

professional attributes and behaviors into the medical curriculum and the difficulties of

measurement. Assessment of professional attributes and behaviors has been reported through the

use of standardized patients, self-evaluation tools and questionnaires (Klein et al, 2003; Van

Zanten et al, 2005; Woloschuk et al, 2004). Assessment was advocated by Goldie (2013) and

Woloschuk et al (2004) in order to guide students and for any remediation. Ginsburg et al (2000)

found that faculty evaluation was affected by fear of litigation and a difficulty in documenting

unprofessional behavior. In their systematic review Jha et al (2007) reported the need to teach

and assess professionalism throughout the medical education curriculum and urged an

examination of the link between attitudes and behaviors.

Woloschuk et al (2004) contended that attitude influences behavior and examined the

changes in attitude of student cohorts as they progressed through medical school. Findings from

the survey and questionnaire revealed a decline in several attitude scores as the student

13


progressed through the medical education program and raised concern for subsequent clinical

performance (Woloschuk et al, 2004). Though Woloschuk et al (2004) never define the term

attitude in the report of their study, they proposed the effect of the hidden curriculum as a

possible factor. The student observations of professionalism in role modeling, faculty behaviors,

clinical and hallway encounters, and the interaction of mentors with ancillary health personnel,

often termed as the hidden curriculum, might have been responsible for the decline in

professional attitude during the educational process thereby effecting the intended curriculum

(Woloschuk et al, 2004). The same concerns regarding the hidden curriculum, especially

negative role modeling during clinical education, was found in interviews conducted by

Stephenson, Adshead and Higgs (2006).

In nursing Rhodes et al (2012) described the start of each academic year with a

professionalism seminar utilizing Miller’s Wheel of Professionalism in Nursing as the

framework. Rhodes et al (2012) described the students as engaged and pointed to the absence of

disruptive side conversations as an indicator of success in this approach to address

professionalism with nursing students.

Educators have used surveys, questionnaires, and evaluation tools in an effort to assess

the attainment of professional behaviors by students in the professions. Self-evaluation tools for

students have been administered and seminars conducted in an effort to assess professional

attitudes and engage students in topics involved with professionalism. These instruments have

not assessed the perspectives held by students.

Perspectives on professionalism

The perspective of students, educators and practitioners in paramedicine, occupational

therapy and podiatry were investigated through focus group discussions by Burford, Morrow,

14


Rothwell, Carter and Illing (2014) and by Robinson, Tanchuk and Sullivan (2012). Results

suggested that the complexity of defining professionalism might require experience and a focus

on specific skills and behaviors (Burford et al, 2014; Robinson et al, 2012).

Investigators in medicine have examined the perspectives of medical students, residents

and faculty. Wagner et al (2007) conducted focus groups to explore the beliefs and perceptions

of medical students, residents, academic faculty and patients at a single institution. Thrush,

Spollen, Tariq, Williams and Shorey (2011) surveyed medical students to determine their

perceptions of the clinical learning environments for professionalism. Findings indicated

differences, which were ascribed to the stage of learning of the participants (Thrush et al, 2011;

Wagner et al, 2007).

Blue, Crandall, Nowacek, Luecht, Chauvin and Swick (2009) assessed the knowledge

and attitudes towards the traditional definition of professionalism in medical students at two

institutions. The results indicated that students enter medical school with positive attitudes but

lack the knowledge of how professional attributes function in practice (Blue et al, 2009). Blue et

al (2009) also discovered that many students’ perception of professionalism differed from

traditional definitions. It was suggested that awareness of student perspectives by medical

educators could assist in the development of curricular activities and the development of self-

assessment tools for students (Blue et al, 2009).

Nagler et al (2014) surveyed first year residents from two successive cohorts regarding

their perception of the professionalism involving specific behaviors and their participation in

those specified behaviors. The behaviors in the survey ranged from resident appearance,

attendance at drug representative dinners to making disparaging remarks about patients or

another member of the healthcare team, not reporting mistakes or inappropriate relationships

15


with attending physicians or patients. Nagler et al (2014) found that despite the majority of the

residents rating the behaviors as unprofessional, a majority had observed or participated in each

behavior. Nagler et al (2014) concluded that the challenge of teaching and assessing

professionalism relates to the difficulty in defining professionalism and the detachment between

recognition and behavior. These findings in the literature regarding medical students and

residents are revealing and disturbing to educators in the health care professions.

Nursing literature shows the development of surveys, a questionnaire and interviews in

order to examine the perspective of pre-licensure students regarding professionalism. Keeling

and Templeman (2013) in a study of final year nursing students in the U.K. found role modeling

as an important theme. The semi-structured interviews revealed that both positive and negative

role modeling influenced the student nurses’ perception of professionalism (Keeling &

Templeman, 2013).

LeDuc and Kotzer (2009) administered the Nursing Professional Values Scale with three

groups, nursing students, new graduates, and seasoned nurses, in order to evaluate differences

between the groups. LeDuc and Kotzer (2009) discovered no statistically significant differences

in responses among the groups. The Nurses Professional Values Scale-Revised developed by

Weis and Schank (2009) is derived from the Code of Ethics for Nurses (American Nurses

Association, 2015). Weis and Schank (2009) explained the five factors assessed: caring,

activism, trust, professionalism, and justice. Weis and Schank (2009) tested the instrument in a

random sample of baccalaureate and master’s students as well as practicing nurses and found that

it to be a psychometrically sound instrument for measuring professional nurses’ values.

Baumann and Kolotylo (2009) developed a questionnaire in order to determine

professionalism attributes and environmental attributes that influence professionalism of nurses

16


in their work environments. The self-report instrument was tested in three phases and resulted in

stimulating discussion of professionalism and its relationship to the practice environment

(Baumann & Kolotylo, 2009). Discussions of the perspectives of SRNAs toward

professionalism or evaluation of professional attributes and behaviors have not been found in the

nurse anesthesia literature.

Methods

Design

This descriptive, qualitative study utilized focus group methodology in order to answer

the research questions. Polit and Beck (2012) described a descriptive qualitative study as a study

that does not fit neatly into one of the qualitative categories. This study design searches for new

insights that are able to guide practice. Sandelowski (2000) described the descriptive qualitative

study as one that gains information from participants and usually provides the who, what, where

of experiences. Sandelowski (2000) pointed out that this study design usually employs a method

of data collection that involves moderate open-ended focus group interviews. The use of a focus

group design enables the collection of information about attitudes, beliefs and experiences about

a topic in a social setting and promotes interaction among the participants (Connelly, 2015;

Doody, Slevin, & Taggart, 2013a; Lawrence, 2014; Then, Rankin, & Ali, 2014). Powell and

Single (1996) declared that a focus group would be useful when the existing knowledge of a

subject is inadequate. The use of focus group methodology revealed the perspectives and

experiences of SRNAs regarding professionalism during their education in the advanced practice

specialty of nurse anesthesia. Information regarding the perspective of SRNAs on the topic of

professionalism or what constitutes professional attributes and behaviors is lacking.

17


During the process of participation in the focus group, participants may modify their

responses based on group interaction (Doody et al, 2013b; Then et al, 2014). Then et al (2014)

indicated that one of the advantages of a focus group would be the ability to encourage

participant interaction in a relaxed group setting. The shared experiences of SRNAs during their

education encouraged discussion of their views on professionalism and professional behaviors

and attitudes.

Conducting a focus group in a neutral area allowed participants to feel safe and

comfortable to express their views. Krueger and Casey (2015) have pointed out that the

moderator of a focus group should be asking questions, listening, keeping the conversation on

track and making sure everyone is able to participate. Since the SRNAs comprising each focus

group were from the same program, it was anticipated that interaction would be facilitated. The

settings for the implementation of this design needed to be convenient for the participants.

SRNAs have a full clinical schedule with many having rotations to hospitals away from the sites

of their nurse anesthesia programs.

Setting

Powell and Single (1996) suggested that a neutral setting for focus group meetings might

allow for frank discussion. The settings for the focus groups were neutral and convenient for the

participants. The locations for the groups ranged from conference rooms or classrooms on

college campuses to conference rooms in hospitals. Each of these settings was private without

disruptions. The groups were conducted informally with participants at most sites able to

continue with their food and drinks throughout the conduct of the interviews. SRNAs were able

to respond to interview questions, engage in discussion and describe their experiences in a non-

18


threatening environment. Focus groups from each institution were conducted in a setting that

was private and away from the nurse anesthesia program offices.

Then et al (2014) discussed the reluctance to express opinions in front of colleagues or

lethargic and dull groups as disadvantages in the use of focus groups. Because each group of

SRNA participants was from the same program, the reluctance to express opinions might have

been a factor. Some group discussions were slow to start but conversation increased as the

interviews progressed. Each group had members who participated intermittently and others who

participated much of the time. Powell and Single (1996) cautioned that the investigator must

consider the potential ‘group effect’. Participants may self-censor and conform to influences of

perceived social expectations in the group (Powell & Single, 1996). SRNAs have experience and

backgrounds in critical care and often have had experiences of participating in discussion groups.

SRNAs were recruited from five COA accredited nurse anesthesia programs located in

Connecticut, Massachusetts, New York and Rhode Island.

Description of Sample

SRNAs in most nurse anesthesia educational programs are enrolled in what is identified

as a front-loaded program. This entails enrollment in foundational academic coursework with

little or no exposure to clinical preceptors or clinical experiences in the operating room.

Following completion of foundational courses, SRNAs begin their clinical practicum/internships.

It is during this phase of their education that SRNAs are engaged in the clinical application of

their learning while continuing coursework of basic and advanced skills in anesthesia. The

clinical environment of the operating room can be a very stressful experience for both student

and clinical preceptor. In the setting of the academic courses conducted by faculty, interactions

with students take place within the context of their courses and possibly in a simulation lab.

19


These environments can be stressful as well, as SRNAs can be very competitive regarding grades

and academic standing.

The sample was SRNAs in nurse anesthesia education programs located in New York,

Massachusetts, Rhode Island and Connecticut. A goal was to have 5 to 10 participants for each

focus group. The size of the groups ranged from 5 to 13 participants with a total of 57 SRNAs

participating. Of the 57 participants, 22 were male. The distribution of gender for each focus

group can be seen in Table 1.

Table 1: Number and Gender of Participants

Groups Total F MFocus G 1 5 3 2Focus G 2 13 9 4Focus G 3 6 4 2Focus G 4 10 5 5Focus G 5 6 4 2Focus G 6 9 5 4Focus G 7 8 5 3Totals 57 35 22

The SRNAs were composed of pre-clinical students as well as those engaged in clinical

experience in addition to their academic courses. The participants ranged in age from 25 years

of age to 47. There were 27 participants in their 20’s and 27 participants in the 30’s with only 3

participants in the 40’s. The distribution of the ages in each focus group can be seen in Table 2.

Table 2: Ages of Participants

Groups 25 to 29 yrs. 30 to 34 yrs. 35 to 39 yrs. 40 to 44 yrs. 45 to 49 yrs.Focus G 1 3 2Focus G 2 8 5Focus G 3 3 3Focus G 4 6 3 1Focus G 5 2 3 1Focus G 6 4 2 2 1Focus G 7 4 3 1

20


The majority of the SRNAs were in their 2nd or 3rd year of their nurse anesthesia program.

There were 12 participants who self identified as being in the first year of their program. Table 3

contains the length of time that participants identified as being in their nurse anesthesia

programs.

Table 3: Years in the nurse anesthesia program

Groups First Year Second Year Third YearFocus Group 1 5Focus Group 2 9 4Focus Group 3 2 4Focus Group 4 10Focus Group 5 6Focus Group 6 9Focus Group 7 8

The majority of participants had experienced 12 to 18 months of clinical practice thus far.

Clinical experiences in the participants’ nurse anesthesia program varied widely. There were 2

participants who indicated that they had not yet participated in any nurse anesthesia clinical

activity. A group of 10 SRNAs indicated that their experiences were minimal regarding clinical

practice in nurse anesthesia. The remaining participants indicated a range of nurse anesthesia

clinical experiences from 7 months to 24 months. This can be seen in Table 4.

Table 4: Months of nurse anesthesia program clinical experience

Groups 0 to 6 months 7 to 12 months 13 to 18 months 19 to 24 monthsFocus G 1 5Focus G 2 9 4Focus G 3 2 4Focus G 4 10Focus G 5 6Focus G 6 9Focus G 7 1 4 3

21


Doody et al (2013a) stated that focus group participants should be of similar knowledge

and experience concerning the topic that is being investigated. SRNAs share a similar

experience throughout their curricula. Purposive sampling was used for gathering information

on the topic of professionalism and perspectives on professional attitudes and behaviors.

According to Speziale and Carpenter (2007), “This method of sampling selects individuals for

study participation based upon their particular knowledge of a phenomenon for the purpose of

sharing that knowledge” (p.67). Sandelowski (2000) proposed that purposive sampling achieves

the goal of gaining rich information for a study. The shared knowledge and experience of

SRNAs was needed for the research questions.

SRNAs were recruited by sending each program administrator a letter via email

explaining the study and its purpose. The letter to the CRNA program administrators can be

seen in Appendix A. The email requested the distribution of an attached letter for the request of

SRNA participation. The letter described the study and requested the student participation in the

focus group as seen in Appendix B.

Perceptions of the learners hold potential significance for nurse anesthesia educational

programs. Consideration of focus group results may lead educators to initiate changes in the

education process based on the SRNA perceptions. An informed view of these perceptions could

lead the way to changes in curriculum and the need for discussions of ethics and topics of

professionalism in nurse anesthesia educational curriculums.

Data Collection Procedures

Data collection took place through semi-structured focus group interviews. The

environment was private with a goal of being comfortable for all participants. Doody et al

(2013b) emphasized the need to have all participants see each other and suggested that a circle

22


formation be used. Most of the focus groups took place at conference tables that had sufficient

space for the participants. One focus group took place in a classroom seating style setting. This

was the large group of 13 participants.

At the beginning of each focus group, the description and purpose of the study was

briefly reviewed with any participant questions answered. Guidelines created by Krueger and

Casey (2015) for the conduct of focus group interviews was utilized. Each participant reviewed

and signed informed consent. The informed consent can be seen in Appendix C. A copy of the

signed consent was given to each participant. Participants completed a demographic sheet, as

seen in Appendix D, prior to the start of the interview.

A multidirectional microphone was suggested for use during the recording of the focus

group discussion and tested prior to the interviews (Doody et al, 2013b). The recorder used for

the interviews contained microphones on the front and rear of the device capable of capturing

sound from every direction. The participants were notified regarding recording of the interviews

in the request for participation and reminded during the introduction and consent process. The

interviews were stored in a WAV format on the recorder’s internal SD card. Using the recorder’s

USB connection for the computer, each file containing a focus group interview was sent to the

transcriptionist who transcribed the audio-recorded interviews verbatim.

Since the focus group is conducted as a semi-structured interview, the moderator was

advised to create a guide to serve as a ‘map’ for the discussion (Then et al, 2014). An interview

guide was created for the focus group interviews. This interview guide, seen in Appendix E, was

used during the focus groups with the sequence of questions modified over the course of the

interviews in response to discussions by participants. Data collection on the demographic sheet

included age and gender of the participants and their length of time in the program. The

23


demographic sheet requested the length of clinical experience by the participant in the nurse

anesthesia program.

As pointed out in Polit and Beck (2012), the objective is to reach data saturation.

Krueger and Casey (2015) stated that, “saturation is a term used to describe the point where you

have heard the range of ideas and aren’t getting new information” (p.23). This was accomplished

during the interviewing and audio recording process of the focus group participants until

repeated information was obtained. Note taking should accompany the audio recordings and

participants informed that notes would be taken in addition to the recording (Doody et al, 2013b;

Krueger & Casey, 2015). Participants were notified that notes would be taken and were able to

visualize the interviewer taking notes. Note taking during the focus group sessions was limited as

there was no second person available for this role during the focus groups. A written summary

of the focus group session was done following completion of the focus group discussion.

The focus group meetings were at a time and place to optimize convenience for the

participants. Lawrence (2014) emphasized the need for careful planning. Arranging dates, times

and locations that are convenient for the participants can be a challenge (Lawrence, 2014). The

focus groups for each group of SRNAs took place on or near the academic campus in order to

maximize convenience for the participants. Most of the focus group sessions took place at the

academic campus in a conference room or classroom. Two of the groups took place in a

conference room at the primary clinical site for the nurse anesthesia program. Responses for

participation in the focus group were directed to the investigator’s personal email, phone or

address. Responses were primarily received through email. At the beginning of the focus group,

the investigator introduced herself along with re-introducing the purpose of the study. The

24


duration of the focus group was to be no greater then two hours, as recommended (Doody et al,

2013; Lawrence, 2014; Then et al, 2014). The focus groups were completed within 90 minutes.

Data Analysis

Data analysis was accomplished with the guidance of an experienced qualitative

researcher. Krueger and Casey (2015) projected that the early focus groups that are conducted

will give the investigator some clues as to how the analysis process will be. Experience with

early focus groups and transcription review lead to a change in the sequence of the interview

guide questions.

Then et al (2014) reported several analysis techniques. These include constant

comparison analysis, discourse analysis, keywords-in-context, and content analysis (Then et al,

2014). Doody et al (3013c) asserted that the analysis starts with a focus on the intention and

purpose of the study. A first step is to develop a clear procedure to analyze the large quantity of

data generated by focus group interviews (Doody et al, 2013c). The raw data included the

recorded interviews, the transcripts, field notes and summaries. Doody et al (2013c)

recommended that summary observational notes be recorded immediately after the focus group

interviews. Krueger and Casey (2015) indicated that focus group analysis is continuous and

begins in the first focus group interview. Krueger and Casey (2015) pointed out that “doing

analysis as you go improves data collection” (p. 141).

Data were transcribed verbatim. Qualitative content analysis requires reading and re-

reading the transcripts. The verbatim transcription of the interviews was compared to the audio

recording and the field notes written during and after the focus group meetings. Re-reading the

transcripts and a line-by-line analysis yielded categories. Adjusting the categories took place

following further reading. Key words were identified, coded and emerging themes found.

25


Krueger and Casey (2015) identified coding as “placing similar labels on similar things”

and that comments need to be sorted into similar categories (p.146). The codes are grouped

into categories and, finally, themes are identified indicating the content of each group (Doody et

al, 2013c). It is recommended that the analysis of one focus group should take place before the

next scheduled focus group in order to create the opportunity to collect richer data (Doody et al,

2013c; Krueger & Casey, 2015). This allows the researcher to assess emerging themes, compare

the themes of the groups and assist in recognizing the achievement of data saturation (Doody et

al, 2013c). Transcription of the data took place after each focus group session. The review of

the transcripts and comparison to the audio recordings took place following receipt of the

transcripts. Analysis followed completion of the focus group interviews.

Krueger and Casey (2015) have guidance for categorizing the quotes from participants in

focus groups. The process advocated by Krueger and Casey (2015) allows the researcher to

become immersed in the data, arrange it and compare and contrast it. De-identified examples are

presented for each theme.

Rigor

Several approaches to maintaining rigor of study findings are employed including:

bracketing of biases, collection of data until thematic saturation occurs, creation of an audit trail

with review by an expert in qualitative research and focus group methodology, as well as

member checking. In focus group research the words of the participants are used to discover

their perceptions regarding the topic of discussion (Krueger & Casey, 2015). Data were collected

until completion of the seventh focus group when the transcripts revealed repeated information

that was discussed in previous focus groups.

26


An audit trail is a record of the study’s methods, procedures, results, analysis and

interpretation for use by the investigator and others (Krueger & Casey, 2015; Then et al, 2014).

The audit trail contained the recorded interviews, the transcripts from each focus group and field

notes attempting to capture the nonverbal communication of the group members. Field notes

were limited and contained seating arrangements of each group, some one-word responses by

group members and the interviewer’s impressions. Description of the settings of each of the

focus groups, the summaries written after each focus group interview, the lists of participants,

and the interview questions were part of the audit trail. Summaries included reflections on the

progress and process of the focus group interviews including decisions that were made

throughout the study process as well as personal reflections.

Then et al (2014) advised that an experienced qualitative researcher, who is not part of

the project, independently review and validate the themes that have emerged from the data. The

independent review of the data promotes reliability and confirmability of the study (Then et al,

2014). The review was conducted by a Simmons College faculty member who is a qualitative

researcher. Krueger and Casey (2015) stated that “systematic analytic procedures help ensure

that findings reflect what was shared in the groups” (p.139). The procedure should enable the

researcher to articulate the process and provide transparency.

According to Houghton, Casey, Shaw and Murphy (2013), member checking allows the

participants to read the transcripts of their interviews to make sure they were accurately

recorded. By showing participants their verbatim transcripts, the participants are given the

opportunity to respond to their own words (Houghton et al, 2013). Polit and Beck (2012) advise

moderators of focus groups to conduct member checking at the conclusion of the focus group

session. The moderator develops a summary of the main themes or viewpoints and presents the

27


summary to the participants in order to get their feedback (Polit & Beck, 2012). It was not

possible to share the written transcriptions with the participants since there was no collection of

personal information such as email addresses or other contact information. At the conclusion of

each focus group, a brief summary of the SRNA’s responses to the interview questions and

discussions was written after the groups dispersed. The participants in the groups were given the

investigator’s contact information if they wished to have results of the study or had questions

regarding the focus group information.

Cost Analysis

Costs for the capstone project included transportation in order to drive to the sites for

interviews with participants. The cost of the transcription service was modest. Participants

received a light meal such as pizza and soft drinks. The costs for the refreshments for the

participants varied dependent on the type of refreshments and the size of the groups. There was

neither potential costs nor savings for the nurse anesthesia programs or clinical facilities where

SRNAs engage in clinical experiences. There could be potential benefits by engaging the

participants in their consideration of professionalism that could effect quality in patient care and

improve patient satisfaction if a consistent display of professionalism takes place.

Human Subjects Protection

The project was approved by the Simmons College Internal Review Board as seen in

Appendix F. Participation in the focus groups and interviews was voluntary. The request for

participation was sent by email via the nurse anesthesia program directors. The focus groups

took place in a neutral area, on or near the SRNAs’ campuses. Participants were notified that the

focus group discussions would be recorded and assured that those in authority in their nurse

anesthesia programs would not be notified of remarks made during the focus group discussion.

28


The potential risk for SRNAs would be the concern that authorities in their nurse anesthesia

programs would be aware of individual comments.

Following introductions and reviewing the aim of the study, discussion about

confidentiality was initiated prior to beginning with interview questions. Then et al (2014)

emphasized that participants need to be assured that they can say what they believe without

repercussions from authority figures. Participants were notified that recordings of the focus

group would be secured and remain confidential. Access to the recordings was given to the

investigator, the Simmons College faculty advisor for the study and the transcriptionist. A copy

of the written verbatim transcripts was shared with the faculty advisor. Benefits for the

participants were the knowledge that they were contributing to the profession and increasing

their awareness of professionalism and professional behaviors and attitudes.

The audio recordings were secured in the file cabinet of a locked office. The digital

copies have been secured in the same fashion. Participants have not been identified by name and

have been given pseudonyms in written transcripts. Identification of participants has not been

documented. A risk/benefit evaluation of participation in the study identified participation in

focus groups or interviews as minimal risk (Polit & Beck, 2012). The contents of student focus

group discussions remained confidential. Only de-identified results were made available.

The informed consent contained a description of the study and the focus group procedure.

The potential risks, potential benefits and the plan for confidentiality was described. Participants

were informed that they could withdraw from participation at any time during the focus group

and that any participation in the focus group was voluntary. Contact information regarding the

research was included. Informed consent was obtained at the beginning of each focus group

29


session. Each participant was given a signed copy of their consent. The informed consent

document was approved by the Simmons College IRB.

Results

The purpose of this study was to examine the perceptions of SRNAs regarding

professionalism and the construction of professional attitudes and behaviors in nurse anesthesia

practice. The semi-structured focus group interviews were performed to answer the following

research questions: 1. What is the definition of professionalism as perceived by SRNAs? 2.

What is the perception of students in nurse anesthesia programs regarding professional attributes

and behaviors?

The majority of the SRNA participants were in the second year of their nurse anesthesia

program. These participants attended a focus group at one of the 5 nurse anesthesia educational

programs located in Connecticut, Massachusetts, New York, or Rhode Island.

Five themes emerged from the qualitative content analysis of the focus groups. These

themes were: defining professionalism, development of professionalism, role of mentors and/or

preceptors, reflections on treatment of themselves as SRNAs, and how professionalism should be

taught. These themes were the principle findings of information that emerged from the focus

group interviews. Sub-themes were found within the themes of defining professionalism and the

development of professionalism.

Themes

Defining professionalism.

The SRNA focus group participants offered an assortment of terms to define

professionalism. Participants gave personal definitions of professionalism. The following sub-

30


themes were revealed: respect and respectful communication, integrity, preparation and

competency, and awareness of boundaries.

Respect and respectful communication.

A component of the definition of professionalism voiced across the groups was respect

and respectful communication. SRNAs found this particularly important in their interactions

with patients and their families.

“I want to say you treat your patients as if you want to be treated,

how you want to treat your family member. You want to treat that

person with that kind of respect. Also when you’re

communicating with a doctor.”

The demonstration of mutual respect between colleagues was seen as an important as well.

There were participants who spoke of communication and especially respectful communication

as their primary definition of professionalism.

“Personally, I address everybody as sir and ma’am. That’s the

polite way and it’s just to make sure that the room stays in that area

because if you are present, you’re at the head of the table, and

you’re going to take care of the airway, and if you’re presenting

yourself in a non-professional manner inside a room then I think

that can project and make other people feel that it’s free to act in

such a manner. So for me, I’m always very polite and I’m always

double-checking, asking. I’m always respectful to all the staff.”

31


Mutual respect in communication indicated the need for this aspect of

professional behavior and professionalism in the high stress area of operating

rooms.

“Navigating how to behave if somebody puts you in a situation,

being asked to do something that might not necessarily be what

you would envision as a professional, how you tactfully explain to

that person that maybe you had a different idea about how the

situation should go or that maybe you’re not comfortable with the

conversations being had or you kind of felt like somebody was

being aggressive or even if it’s just you’re in a situation in an OR

where there’s people talking to each other in kind of a more heated

way and you’re trying to keep things calm in the room. I think that

that’s also an aspect of professionalism is how you communicate

with others.”

Conversely, one SRNA described an example of behavior and communication that she felt was

not professional:

“I think any time you have a conflict or just a difference of

opinions in terms of plan of care of the patient, the way you

portray yourself and communicate shows your professionalism or

not...For instance, a clinical situation that I saw is that we brought

a patient out from the PACU and the CRNA that I was with and

the nurse had a disagreement and they proceeded to have this

disagreement and argue over the patient in the PACU and I

32


remember standing there at the moment in time and being like, this

is so unprofessional right now, and later people asked me what I

thought about it and I was like, you know, I thought it was so

incredibly unprofessional to be doing this in front of a fresh post-

op patient. The way it should have been handled is that if there

was a problem you should have taken them aside and spoken to

them privately after the situation had already been completed. So I

feel like it’s just the way you communicate and portray and handle

situations which portrays professionalism.”

She then added:

“I think that what helps with professionalism is that you have to

remember that you’re not the priority and you’re not the center of

attention in this situation. You’re just there to perform the function

and it’s the patient who is the priority and I think if people have

that in mind perhaps situations like this wouldn’t happen.”

The terms respect, mutual respect and respectful communication were repeated across the

focus groups. At times these terms were about interactions with patients. Other times the

discussion was regarding interactions with others in their clinical environment, primarily focused

on professionalism or the lack of professionalism involving the SRNA as an observer or recipient

of unprofessional communication. This was exemplified by a participant who stated:

“There’s plenty of times that you can say something to the

circulating nurse or surgeon but they don’t reciprocate that

professionalism back.”

33


Integrity.

Another definition of professionalism that emerged was integrity. This was seen as an

important ingredient in nursing practice and particularly important to the public. Participants

described the importance of the public’s view of nursing and nurses.

“I think the integrity of a nurse is extremely high. Advanced

practitioners are going to hold the same amount of integrity as

well. Most nurses I see are the pinnacle of integrity and honesty.

Most nurses are very honest and very good moral character

because we’re trusted to do things that people tell us to do and we

still have to fight back when we feel that it’s not beneficial for the

patient. So we’re as far as nurses one of the most professional

professions out there, in general.”

Preparation and competency.

Other terms defining professionalism voiced by participants were preparation and

competency. Many SRNAs described preparation for the patient and clinical situation as a

critical aspect of professionalism due to its affect on patient care and outcomes.

“I think another good example of professionalism is, also knowing

your patient preoperatively. Like really reviewing their past

medical history, knowing what they’re here for, what brought them

here and things like that just so when you are approached by your

attending, you’re not just a nurse that’s giving anesthesia. You’re

the advanced practice nurse that knows your patient, knows your

plan of anesthesia.”

34


“I think doing the right thing when nobody’s watching. That’s what is

important.”

In one of the focus groups a participant spoke about portraying competency:

“I think the nature of the work that we do requires us to be

professional. We have to conduct ourselves in a manner that

presents competency and convey a persona that’s going to gain

trust and we’re going to provide good care to our patients.”

Awareness of boundaries.

Awareness of boundaries was voiced as an aspect of professionalism as well, both in

patient interactions and interactions with other members in the healthcare team. The ability to

speak and act in response to the situation was viewed as an addition to the definition.

“I think boundaries like knowing when and when not to speak up, I

think is important. You choose your situations; choose your

battles.”

The definition of professionalism was varied and personalized. One of the SRNAs in a

focus group illustrated the personalized view of many SRNAs regarding the definition of

professionalism:

“I think that our definition at this point in our life is slightly

narrowed as compared to a grand professional scheme because we

live a certain reality and it’s geared towards the reality that we’re

in, but in terms of lack of professionalism, yes of course,

accountability, do no harm---and all that matters, but it’s not the

focus.”

35


The SRNAs revealed perspectives that included definitions of professionalism as respect,

integrity, preparation, competency, and boundary setting/awareness. The emphasis by SRNAs

focused on respect in discussion of respect as it is displayed toward patients, CRNAs and

physicians in the operating room and respect displayed toward the SRNAs. Many SRNAs

described disrespect directed toward them by others in the operating room environment.

Development of professionalism

The development of professionalism was a second theme found in the focus group

interviews. The SRNAs expressed a range of opinions regarding how each one felt that they had

developed professionalism. Sub-themes that emerged as further descriptions of this development

were: life experience and upbringing, clinical experiences, education experiences and common

sense.

Life experience and upbringing.

Some of the participants in the focus groups credited the contribution of their parents and

their upbringing to their development of professionalism and professional behaviors. One

participant described their life experience with developing professionalism.

“I think I learned professionalism throughout my entire life from

my parents, in elementary school, in high school and once we got

to the nursing school it got labeled and by a certain set of

behaviors, got labeled as professionalism and it was brought to

your attention that if you exhibit these things then you are acting in

a professional manner.”

The matter of upbringing and learning from adult family members provided the

basis for respect and professionalism exemplified by a participant:

36


“I think professionalism is really closely tied to being respectful,

which in being respectful is something you learn as a child, the

way you were raised. I think that has a lot of carryover into

professionalism.”

Clinical experiences.

Many participants described experiences in the clinical area as a nurse as the way they

learned and developed professionalism. Learning from fellow nurses, especially senior nurses,

was expressed. Most of the participants described learning professionalism on the job:

“I think it’s going along with what everyone is saying. You kind

of pick up on things when you’re in the clinical setting or even as

nurses when we were working on the floor and kind of see how

other people act and you kind of just incorporate certain aspects of

that to your practice or on the other hand you, say use an example

of how you’re not going to conduct yourself. So I think it’s more

also, just I guess a natural part of being a human in a profession,

deciding on how, the person you want to be.”

There were reports of negative as well as positive examples where development in the clinical

environment took place as described by one participant:

“Even through experience too, you see how people react in certain

situations where you’re in one environment that’s hostile and it

trickles down and kind of has an effect on everything that

happened versus a good working environment where mutual

respect and everyone knows their role.”

37


Some participants acknowledged the contribution of the orientation process to their development

of professionalism in their first position as a nurse:

“I had to do a whole six months nurse orientation outside of

clinical and we basically went over when to approach a physician,

how to call in the middle of the night, what to say to them, what’s

appropriate to call, what’s not necessarily appropriate and it was a

course for anyone that graduated with a Bachelor’s and was a new

grad on that campus.”

Education experiences.

Several participants did describe the contribution of their education to their development

of professionalism and professional behaviors, both in their previous nursing program and their

present nurse anesthesia program.

“I think for my nursing undergraduate program we had a

professional development class. So I think it was definitely a

combination of that plus seeing professionals in the clinical

workspace.”

“I feel like in nursing school we definitely did have those courses.

Like the nursing leadership and just extraneous courses, taught you

how to be a professional and then in practice you kind of learn how

to act and how to be in a way that’s more appropriate to the clinical

situation. So in nursing school we got a sort of ideal. Definitely

like A said, dress a certain way, act a certain way, look a certain

38


way. You don’t want to offend people. You’re there to do a job.

Then when we get into practice it’s a little looser, I think.”

“So I learned about professionalism in the same way, through my

professionalism in nursing class, but I think also through clinical

experience and you see role models and people acting in the same

profession in that sense of an example and that provides that

mutual respect among professionals and that’s kind of how I feel

like I learned about professionalism.”

On the other hand many of the SRNAs denied learning anything about

professionalism in their pre-licensure nursing programs.

“I don’t remember my professionalism class in nursing school at

all and every time it’s actually brought up you kind of roll your

eyes back and you’re like, it’s more of kind of an insulting thing

when somebody tells me, you’re not behaving properly, but I think

basically, it’s our experiences. We see how others behave and

situational awareness is really a key part of it and I think that the

more a person is aware of basically the environment that they’re

working in and what they’re impression is, the more likely they

will, too, have professional behavior.”

The majority of the focus group participants described their development of

professionalism through their upbringing, education and clinical experiences in nursing or their

nurse anesthesia program. There were a small number of participants who asserted that the

39


expression of professionalism and professional behaviors could be attributed to common sense or

was innate.

Role of mentors and/or preceptors

The role of mentors and clinical preceptors in the operating room environment was a

third theme to arise from the focus groups. It carried significance for the SRNAs regarding their

thoughts on professional attributes and behaviors. The impact of competent role models who can

provide an introduction to the new, developing role of a nurse anesthetist could foster

professionalism among SRNAs. The participants appreciated the CRNA and physician mentors

or preceptors that took time with and interest in them while they were in the clinical area. There

were positive statements as well as negative statements made by participants about CRNA or

anesthesiologist mentors and role models during the clinical learning experience:

“There’s been multiple CRNAs that I’ve worked with in the OR

who go out of their way when you’re seeing a patient to introduce

you as a student and not just let you stand there awkwardly staring.

So I think people who are willing to acknowledge you and

acknowledge that you’re learning and giving you the opportunity,

that’s it.”

SRNAs expressed appreciation of preceptors demonstrating a professional interest in the

student’s level of knowledge and skill:

“…when you’re with a CRNA, especially early on, they ask a lot

of questions that kind of get your knowledge base and there’s such

a difference between someone who is asking you the questions so

40


that you can learn from it and become a better CRNA and someone

who just wants to make you feel small and stupid.”

The preceptor’s approach to clinical teaching and learning was seen as an important impact on

not only the quality of the SRNA’s learning but as a model for professional behavior:

“I think it’s important for them to quiz you on things. Like that’s

why you’re there for, is to learn, but I feel like there are definitely

people who give it to you very rough and that’s a pretty hostile

environment depending on who you’re with, like inappropriately

so.”

“I think collegial communication is a huge one. That’s one thing I

learned best when it’s not an aggressive interaction, they’re not

conveying a stance of superiority and belittlement, but really a

collegial facilitation of communication really is the best way and I

feel that most of the professionals that I have encountered so far.”

Role modeling of professional behaviors was observed by participants. One participant

described his role model’s professional conduct in a clinical situation in the operating room.

“I’ve seen her in action where she confronted a situation that could

have escalated but she handled herself in a way that didn’t escalate

but she handled it professionally and she exhibited competency

and confidence.”

The SRNA’s desired professional attributes of clinical preceptors were described:

“People that take active roles like the head preceptors at clinical

sites that are willing to help out the students and really don’t get

41


any kind of compensation for it or the people that go ahead and

pass on old notes or textbooks, that’s the kind of thing that as a

student it really makes you feel welcome and good. It doesn’t

make you feel like everybody’s against you.”

Another participant described how he felt when being precepted by a CRNA that he considered

to be a role model and mentor.

“He’s always positive and always is communicating in such a

positive manner. I mean his instruction exemplifies

professionalism. Because we come in, we feel like we’re at the

bottom of the totem pole, he still brings us up. He still makes you

feel that you are valued and that you are worth something. He is

the epitome of professionalism I think. I want to be like him.”

Discussion of negative examples of behaviors by preceptors took place throughout the

focus groups. The negative statements about the preceptors as role models and mentors

surrounded unprofessional behaviors directed at the SRNA:

“I’ve heard of CRNAs who actively like to make SRNAs cry and I

don’t know if they think its tough love or what their rationale is.”

“I think some of them fall into the category of the old phrase of

how nurses eat their young. Some of them view it as a trial by fire.

Like how hard can I be on you until you break kind of a deal,

which you don’t get that with everybody, but you see that kind of

theme as nurses.

42


Concern was expressed regarding the preceptor’s clinical teaching method and what the SRNA

detected as information that conflicted with their class or textbooks:

“I think that as CRNAs, I think knowing your own limitations is

one of the best things you can do for us as students and not

pretending you know something or trying to teach us something

that’s wrong, I guess. I think another thing is, I’m all about

learning something that I can do better. I think finding a way to

constructively criticize somebody as opposed to just criticize

somebody is a skill that not everybody has, as silly as that sounds.”

The use of social media by the clinical preceptors was brought up as impacting the image of

professional attributes and behaviors.

“There have been moments when we’ve seen people from whom

we were expected to learn from may not always exhibit the same

standard of professionalism that we may have thought was

appropriate or how we think that we would conduct ourselves.

Something that comes to my mind is social media. So I think that

some of the CRNAs that we work with, maybe you’re friends with

on social media and maybe something as a student you aren’t

seeking out social media friendships, but I think if you were in a

situation to become friends on Face Book, for example, and you

get to see kind of their more personal side of life and I think as a

CRNA you want to kind of balance that out so maybe it isn’t the

best idea to be putting pictures on there that you don’t want other

43


people to see or that may portray you in an unprofessional

manner.”

Discussions in the focus groups described the impact of both physician

anesthesiologist and CRNA preceptors as role models and/or mentors in the

clinical learning environment. These discussions yielded both positive and

negative descriptions of professional attributes and behaviors exhibited by the

preceptors.

Reflections on treatment of themselves as SRNAs

All of the focus groups contained comments by the SRNAs regarding how they were

being treated and the professionalism, or lack of it, being directed at them or at others in the

clinical environment. They gave examples of unprofessional behaviors they had experienced or

witnessed. The SRNA participants did not report incivility and unprofessionalism in their

classrooms by faculty. Each focus group gave accounts of unprofessional behaviors in clinical

education environments. An example of this is a statement made by one of the participants.

“Like you have to be almost more professional because you go

through this certain level of hazing and you’re going to have

providers that make comments to you, to get to you or to see how

thick your skin is. Just to test you as a person, I feel like

sometimes, and so you almost have to be able to be professional

enough to let those comments or let those situations roll off your

back a little bit.”

44


“You really have just a thick skin as a student. That’s part of being

professional and also being professional in gaining confidence to

defend what you’re doing.”

Examples of what participants felt to be demeaning behavior or attitudes towards them as

SRNAs were given in the focus groups. One participant stated:

“They tell you you’re at the bottom now. You’re nobody now.

You’re a student now. You know nothing about nothing and your

mind fits into it and feeds off of it.”

The treatment of SRNAs by anesthesiologists was reflected in the groups as well:

“There’s one MD in particular that I can think of, right in front of

patients, like we have discussed already, have gone out of their

way to tell some of our classmates, ‘in New York State you are

nothing more than a nurse’, like right in front of a patient! I think

that’s one of the most unprofessional things you can say especially

in front of a patient that you’re about to provide anesthesia to.”

Several participants voiced their opinions regarding professionalism and professional behaviors

in the operating room surrounding their participation in clinical cases. Participants were

concerned about how it affected them and their learning.

“I can’t tell you how many times it’s like, it’s only crazy, when

I’ve been doing this case all day and the attending comes in and

doesn’t address me. He looks right past me and addresses the

CRNA who’s been sitting in the corner. I think just talking to me

and addressing me directly does a lot for my confidence I guess.”

45


Other comments were about what SRNAs perceived as a passive aggressive environment in the

operating room as exemplified by one participant’s comment:

“I think from a student perspective, like focusing on SRNA’s, it

takes an incredible level of patience as a student to be professional

for the whole time you’re in school and it’s something you have to

be very conscious of because first of all you’re in a learning role so

no matter what, no matter how it’s delivered to you, how rude

people are to you, you do what they say and I heard students give a

lot of pushback and I’m surprised by it and I quite frankly am like,

you’re making your life way harder than it needs to be because

you’re going to, at the end of the day, do what your attending

wants to do it.”

Participants felt that education of others was needed in order to improve the treatment that they

receive.

“I think it’s spreading education within the patient population and

also through other medical disciplines that we deal with in the OR,

within that whole perioperative team, of what we are, what we

stand for and what is our education level. I think there’s a huge gap

in that, that kind of portrays to that lack of professionalism we

sometimes get.”

SRNAs throughout the focus groups expressed feelings of being the recipients of

unprofessional attitudes and behaviors in the clinical learning environments. Many felt that there

was no credit given for their knowledge and previous experiences as critical care nurses.

46


How professionalism should be taught

Thoughts on how professionalism should be taught and learned varied among the

SRNAs. Many of the responses were related to teaching and learning professionalism and the

display of professional behaviors in the clinical area. A substantial number of SRNAs agreed

with the impact of learning throughout their clinical experiences as exemplified by these

comments:

“It’s kind of like you learn by following your preceptor, which

there have been unprofessional preceptors, but for the most part

how they interact with doctors, how they interact with the nurses,

receiving the patient, even the patient themselves. When first

learning, I’ve had people discuss with me, this is how we approach

the patient, you should always do this, you should always do this.

This is a chart; this is a legal document. Go over the legalities of it.

So for the most part I exhibit what my preceptors have exhibited.”

“I think from watching people, observing. From our program

director, I think she’ll probably teach us a bunch about that, but yes

mainly my experiences, taking things away from clinical, maybe

conferences.”

Several SRNAs disagreed with the ability to teach professionalism in a classroom or ensure the

development of professional behaviors whether in classroom or clinical. For the most part these

were the same participants who voiced the opinion that the foundations of professionalism were

learned as a child or were part of the individual’s characteristics.

47


“I don’t think you could really get the true aspect of

professionalism from a formal classroom type setting.”

“The other thing about teaching professionalism is, yes it’s

modeled, yes it’s top down, but I’m not sure whether you can

convince people that it’s also a personal choice that you have to be

professional and if you could convince somebody. So I think it’s a

personal choice and one of the things about being professional is

the realization quite clearly that not everyone will be professional.”

“Like what D was saying before, I think professionalism isn’t

something that… it’s just taught later in life. I think it’s something

that you are taught from the day you can talk …like she said her

parents instilled the idea, the way they worked, the their work

ethic, the way they handled situations. Those are the foundations of

professionalism. That’s where you begin to see it to where it’s

taken and so I think those foundations are just built upon later in

school.”

The utility in witnessing or enduring unprofessional behavior was seen by some as one way of

learning what not to do.

“It’s important to have the people that are not professional because

you kind of learn from them how you don’t want to be.”

“I was thinking about it and I felt like professionalism is hard to

teach because we all come from different backgrounds and

48


cultures. So that we all have different interpretations of what is

professionalism”.

SRNAs referred to their course containing classes about professionalism and expressed a desire

for change in the classes. This participant voiced a concern on the part of many SRNAs of what

to expect and how to manage when encountering situations of unprofessionalism or

unprofessional behavior.

“We have to take these classes about professionalism. Like E was

saying, we all have different perceptions of professionalism. So

yes, the class might be stupid and it’s annoying but it’s something,

I think, for educators to us, as a school, to say you’re going to face

these experiences that are very tough and might be degrading to

you but it’s something to say, this is who we are, this is what we

stand for as a student nurse anesthetist, this is what you have to

look forward to as being part of this group, this profession as a

nurse anesthetist. So I think in an education setting and to teach

us… I think that kind of would be nice to get some... saying this is

who we are, this is what we can do in these situations to kind of

play forth what SRNAs, you’re about to face and you’re going to

go into. So I think that’s a good way to say this is what’s going to

happen, we’re together, we’re here for you and this is what we can

do to show our professionalism as a profession. You’re going to

become a nurse anesthetist and to bring that forward in your

practice.”

49


Several participants indicated the need for positive role modeling and suggested educational

support for clinical preceptors.

“Like if it’s maybe having classes or having periodical meetings

with CRNA’s because precepting is not an easy…it’s not a walk in

just not good and some people are. So just having, I would say

meetings and stuff that people can discuss these things and like

you mentioned [referring to another participant] just talking on

how to be professional.”

Participants proposed ideas that could be used by SRNAs and their faculty for teaching and

learning professionalism and the accompanying professional attitudes and displays of

professional behavior through the use of simulation.

“I remember thinking that when I worked on the floor that it’s

really beneficial to have mock hospitals or mock hospital boards

where all medical professionals or nursing professionals had to go

and stay for a day and be treated like a patient, like a simulation.”

Other SRNAs suggested the development of a code of conduct and felt that there should be

consequences for exhibiting unprofessionalism while in the nurse anesthesia program or the

clinical area.

“That needs to be written somewhere so you can come back and

say, this is our code of professionalism, or whatever, and this is

what we abide by here.”

The SRNAs expressed a variety of definitions for professionalism with the majority of

their comments focused on respect and respectful communication. The focus groups revealed

50


the perception of SRNAs regarding how professional attributes and behaviors were learned and

developed across their lifespan and experiences within their nurse anesthesia educational

programs. The role of preceptors and mentors in the clinical learning environment made a major

contribution to the view of the SRNAs about professional behaviors, particularly how these

behaviors were demonstrated toward the SRNA. The SRNAs had suggestions for how

professional attributes could be learned and thoughts regarding the display of professional

behaviors. The perspectives of SRNAs regarding the topic of professionalism indicate an

increasing importance for educators to address professionalism in curriculum content.

Discussion

Interest in professionalism, its attributes and displayed behaviors remain. These reflect

concern regarding the potential impact on teamwork, patient care and the desired culture of

safety in healthcare delivery. Dubree, Kapu, Terrell, Pichert, Cooper and Hickson (2017)

asserted that professionalism encompasses, not just the technical delivery of care but also the

behaviors that support a culture of safety. Individual nurses may carry a personal definition of

professionalism, which guides their behaviors. These nurses bring these perceptions into the

classrooms and clinical environments of their advanced practice education in nurse anesthesia.

The further development of professionalism, professional attitudes and professional behaviors

takes place during the nurse anesthesia education process. This project was developed to

examine the perspectives of the SRNAs through the use of focus group interviews.

The definition of professionalism expressed by the SRNAs reflected their personal

thoughts with little recognition of possible definitions put forth by their educators or professional

associations. This is similar to what has been described as the elusiveness of the definition of

professionalism in other health care professions (Finn, Garner & Sawdon, 2010; Gambescia &

51


Sahl, 2015; Zafiropoulos, 2017). Blue et al (2009) surveyed medical students finding that these

students differed in their knowledge and attitudes in many ways from the traditional definitions

that medicine uses regarding professionalism.

A primary component of a definition of professionalism for the SRNAs was mutual

respect when interacting with operating room area team members. This was a consistent theme

across the focus groups. Zafiropoulos (2017) surveyed medical, chiropractic and nursing students

in a hospital in Great Britain. He found that student nurses emphasized communication,

teamwork, leadership, respect and sharing information in their definition of professionalism and

professional behaviors more than the other two groups (Zafiropoulos, 2017). The SRNA focus

groups’ definitions included respect and respectful communication, integrity, preparation and

competency, and boundary awareness/setting. Many of the SRNA definitions are included in the

codes of ethics developed by the ANA (2015) and AANA (2005). Much of the discussion by the

SRNAs highlighted respect. In addition to talking about the need to demonstrate respect towards

patients and other members of the health care team, the SRNAs focused on the lack of respect

that was frequently directed towards them by others in their clinical environment. The SRNAs

gave their impressions of what they witnessed and the communications that they received from

others.

Most SRNA participants described their development of professionalism through

experiences in clinical environments and in their jobs as nurses prior to enrollment in their nurse

anesthesia programs. The SRNAs downplayed the influence and effect of the formal education

process received in their pre-licensure programs. The development of professionalism can be

positive or can be strongly influenced by negative experiences. Several SRNAs spoke of clinical

situations where they either witnessed unprofessional behavior or were subject to

52


unprofessionalism. Many authors have studied the negative effects of lateral violence,

professional misconduct, and incivility involving nurses and students in clinical situations

(Anselmi, Smith Glascow & Gambescia, 2014; Clark & Springer, 2007; Sanner-Stiehr & Ward-

Smith, 2017).

A minority of participants in the focus groups felt that the development of professional

attributes and demonstration of professional behaviors was an innate characteristic or a reflection

of common sense. This opinion is in opposition the findings of Gambesica and Sahl (2015) who

asserted that “there is not innate sense or natural acquisition of professionalism” (p.141).

Gambesica and Sahl (2015) further stated that it is a “characteristic developed in the overall

education, training, and socialization of a health professional” (p.142).

Secrest, Norwood, and Keatley (2003) described the developmental nature of

professionalism in their study of baccalaureate nursing students. They advocated for the

introduction of experiences to build professionalism early in the educational process (Secrest et

al, 2003). Zafiropoulos (2017) asserted that unprofessional behavior in students may affect the

future professional life and pointed out that these individuals often blame their behavior on their

educators. This information highlights the importance of the development of professionalism

and the assertion by Gambescia and Sahl (2015) and Rhodes et al (2012) that this component of

a student’s education is challenging.

Role models and mentors were another theme, which emerged from the focus

group discussions. SRNAs are exposed to a wide range of role models in their clinical

placements. These models or mentors extend beyond their nurse anesthesia faculty to CRNAs

and anesthesiologists who perform the role of clinical preceptor. The importance of mentors in

enhancing professionalism was described by Brockopp, Schooler, Welsh, Cassidy, Ryan,

53


Mucogenburg and Orr Chleboey (2003) as providing a safety net and role model of competency

for nursing students. Keeling and Templeman (2013) found that both positive and negative role

models impacted the professional development of nursing students. The SRNAs closely observe

the practice and interactions of the CRNAs and anesthesiologists with patients, other health care

providers and each other in the clinical environment of the operating room area. Finn et al

(2010) and Keeling and Templeman (2013) found student imitative behavior with regards to

their role models. Finn et al (2010) found that students seem to imitate those individuals that they

identify as their role models and acquire their professional behaviors. Many comments were

made by the SRNAs on positive experiences but there was much description and discussion of

negative experiences. This hints at the hidden curriculum described by Bahaziq and Crosby

(2011) and Stephenson et al (2006) as an important influence on professionalism and

professional behavior by the role model. Medicine has referred to the informal curriculum or

hidden curriculum where students witness inappropriate, disruptive and unprofessional behaviors

conducted by preceptors or clinical role models (Bahaziq & Crosby, 2011; Stephenson et al,

2006). Felstead (2013) asserted that negative behaviors by the role model could be considered

acceptable and emulated by the student. This is indicated as being directly opposed to the formal

curriculum espoused by the educators of their programs. Stephenson et al (2006) found that

directors of the medical schools in the United Kingdom felt that the greatest threat to

professionalism and professional behavior was poor modeling especially in clinical experiences

thereby indicating the impact of the hidden curriculum. This reinforces the need for nurse

anesthesia educators to provide the SRNA with the knowledge and skills to develop the attitude

for the positive display of professionalism. Gambescia and Sahl (2015) urged educators to adopt

54


“one definition, normative professionalism characteristics, and the overarching importance of

professionalism” for their student handbooks (p.153).

Another theme to emerge from the focus groups was the SRNAs’ reflection on treatment

by others directed at the SRNA. Many spoke of demeaning, belittling, and outright hostility

directed towards them as examples of unprofessional behavior. Incivility, a component of

unprofessionalism, has been described in undergraduate nursing education and other levels of

nursing education as well (Clark, 2008; Clark & Springer, 2007). Clark & Springer (2007) and

Clark (2008) reported studies with findings of incivility described by students about faculty and

by faculty about students. Zafiropoulos (2017) ascribed the lack of professionalism and poor

professional behaviors directed at students and others to stress, fatigue, a lack of confidence, a

lack of experience, overwork, professional conflicts and arrogance. Clark (2008) and Berk

(2009) discussed the consequences of unprofessional behaviors resulting in the disruption of

learning and the delivery of care. Focus group participants gave examples of disruption,

interference in the clinical learning process and negative experiences that affected their

anesthesia care delivery. SRNAs gave some descriptions of unprofessional behaviors exhibited

toward others in the clinical environment. The majority of examples involved unprofessional

behaviors demonstrated towards the SRNA. There were no examples given of unprofessional

behaviors directed at patients. Since Gambescia and Sahl (2015) and Secrest et al (2003) have

found that professionalism is developed, therefore learned, consideration must be given to the

possibility of learning unprofessional behaviors.

Sanner-Stiehr and Ward-Smith (2017) urged educators to address instances of lateral

violence in clinical rotations. They indicated that educational endeavors should focus on

preventing, identifying and responding to lateral violence in order to avoid the formation of

55


maladaptive coping mechanisms and the perpetuation of unprofessional behaviors in the future

professional. Clark and Springer (2007) urged faculty and students to work together to develop

and implement codes of conduct in order to prevent unprofessional behaviors such as incivility.

The SRNAs had a variety of opinions regarding instruction of the topic of professionalism in

nurse anesthesia.

Exploration of the SRNA participants’ thoughts on how professionalism could be taught

and learned was the final theme revealed in the focus groups. Discussion led back to role models

and the need for positive role models in clinical rotations. The interpersonal interactions that

SRNAs have with their preceptors impact their professional development. The importance of

professionalism and its development in nurses and advanced practice nurses like nurse

anesthetists have been stressed by Gambescia and Sahl (2015). Gambescia and Sahl (2015)

asserted that the teaching of professionalism has changed from a “nice to know” (p.142) to an

essential competency.

Nurse anesthesia programs utilize clinical rotations for achievement of a variety of

clinical skills and case types. CRNA and physician anesthesiologist clinicians provide clinical

experiences and precepting for the SRNA. Since teaching and learning in the clinical

environments takes place under the guidance and supervision of these clinicians, there is a need

by educators in nurse anesthesia education to arm SRNAs with strategies to build and maintain

professional behaviors in this environment. Some of the SRNAs encouraged nurse anesthesia

program involvement in professional development for CRNA preceptors as a way to improve the

preceptors’ interactions with the SRNAs. SRNAs recommended the development of a code of

conduct within their nurse anesthesia program as a guide for their professional attributes and

exhibition of professional behaviors. The use of simulation in teaching professionalism and

56


professional behaviors and options for the management of difficult professional situations was

suggested.

The definition of professionalism as expressed by SRNAs in the focus groups contained

many of the qualities described in the Code of Ethics for the Certified Registered Nurse

Anesthetist (AANA, 2005) such as competency, integrity and demonstration of respect towards

patients. However, SRNAs described a major component of their definition of professionalism

as the mutual respect and respectful communication that should take place among the health care

providers in the clinical environment of the operating room. The personalized definitions of

professionalism expressed by the SRNAs have been found by other authors examining

professionalism in health care (Finn et al, 2010; Gambescia & Sahl, 2015; Zafiropoulos, 2017).

Tunajek (2011) asserted that the professional association has a role as the normative reference

group for the practitioner. This emphasizes the connection to be made to the professional

association statements concerning professionalism and professional behaviors during the

education of the future practitioner in that specialty. Gambescia and Sahl (2015) support the

need to develop norms for learners in a health profession to provide a strong education in

professionalism. An examination of professionalism and the development and expression of

professional norms in the specialty of nurse anesthesia needs further exploration.

Limitations

This study examined the perspectives of SRNAs on the topic of professionalism at 5

nurse anesthesia programs in the Northeastern United States. The limitations of this work

include the experiences and perspectives that may apply only to these locations and therefore,

would not be transferable to SRNAs in other nurse anesthesia programs or in other areas of the

country. An additional consideration is the voluntary nature of the focus groups. Those SRNAs

57


with an interest in the topic of professionalism or with concerns that they wished to express may

have been the likely participants in the focus groups. Thematic saturation was achieved in the

seventh focus group conducted. It is possible that additional focus groups outside of New

England may have revealed additional new information.

Focus group participants may have been concerned about the confidentiality of their

views and opinions. Prior to the start of the focus group discussions, this author emphasized the

importance of the maintenance of confidentiality. The field notes taken by this author during the

focus group interviews was limited by the lack of available assistance to capture most nonverbal

communication in the group. Bracketing of biases took place through the maintenance of a

journal where a record of the process and impressions of interviewing were kept. The interview

questions were examined for openness to focus group participant responses. The findings as

reported from the 7 focus groups were based on the transcripts from the audio recordings of each

group. The attempt to minimize bias in interpreting the data was carried out by having the

transcripts reviewed by an experienced qualitative researcher.

Further research into the perspectives of SRNAs regarding the professional attributes

needed in the nurse anesthesia specialty and the display of professional behaviors should be

conducted. A survey tool could be developed and administered electronically to SRNAs in nurse

anesthesia programs throughout the United States in order to gain a broader view of the

perspectives held regarding professionalism. Through this survey, a differentiation could be

made between those SRNAs who are in the academic phase of their educational program and

those that have entered the clinical component during their program.

Additional focus groups could be held at national and regional nurse anesthesia

professional association meetings that include attendance of SRNAs. These focus group

58


meetings could possibly increase the variety of views and opinions regarding professionalism.

Participation may be improved by the convenience for SRNAs of conducting the focus group at

the professional meeting site. Additionally, the use of a moderating team as recommended by

Krueger and Casey (2015) would improve the capture of data. The moderator and assistant

moderator would each have their role in the conduct of the focus group. The assistant moderator

would be free to take comprehensive field notes including nonverbal communication. Having an

assistant moderator would enable a brief summary of key points of the discussion to be presented

at the conclusion of the focus group meeting (Krueger & Casey, 2015). Additional findings by

increasing the breathe and depth of data would improve the understanding on this topic and

would give educators and leaders in the nurse anesthesia profession further insight into the

development of curriculum for the future nurse anesthetist.

Implications for Practice

Implications for the expression of professionalism and demonstration of professional

behaviors emerged from the focus group interviews with SRNAs. Suggestions for nurse

anesthesia educators were made by SRNAs to improve the knowledge and expression of

professionalism. These suggestions highlighted two areas for change in nurse anesthesia

education and practice:

The development of a code of conduct in nurse anesthesia education programs.

Simulation activities with CRNAs and SRNAs focused on interprofessional

communication.

Development of a code of conduct can be created by the nurse anesthesia students in

conjunction with nurse anesthesia faculty. The call to develop codes of conduct has been found

59


in the literature. Berk (2009) noted the spread of unprofessional behaviors beyond medicine to

other clinical professionals and urged department chairs to communicate and model rules of

conduct. Clark and Springer (2007) urged development of comprehensive codes of conduct by

nursing faculty and students as a result of their findings on incivility in undergraduate nursing

education. Sanner-Stiehr and Ward-Smith (2017) echoed Clark and Springer’s call for the

development of codes of conduct in nursing education. They emphasized that unprofessional

and inappropriate behavior, if not addressed, were likely to escalate in professional practice

(Sanner-Stiehr & Ward-Smith, 2017). The development of codes of conduct for both students

and faculty were recommended as a method of preventing the development of unprofessional

behaviors and creating the development of behavioral norms for future practice (Sanner-Stiehr &

Ward-Smith, 2017).

Anselmi et al (2014) described the development of a code of conduct in an undergraduate

nursing program. A task force was organized and developed a document following a process of

literature review, discussion and analysis (Anselmi et al, 2014). Anselmi et al (2014) described

the creation of a nursing student conduct committee, which performs an advisory role in matters

of student unprofessionalism and potential discipline. It was posited that one of the reasons for a

decrease in violations of professional standards was due to the widespread distribution of the

nursing student code of conduct (Anselmi et al, 2014). Anselmi et al (2014) urged establishment

of a code of conduct due to the implications for professional licensure and practice in addition to

patient safety.

Nurse anesthesia students as adult learners are capable of developing a code of conduct

for SRNAs. Adults have a degree of self-direction and the faculty member can be the promoter

and facilitator of this self-direction in the learning process (Brockett, 2015). A task force of

60


SRNAs with faculty member guidance could create a code of conduct for their nurse anesthesia

program. This code of conduct should rely on the ANA Code of Ethics with Interpretive

Statements (ANA, 2015) and the AANA Code of Ethics for the Certified Registered Nurse

Anesthetist (AANA, 2005) along with the standards, which guide nurse anesthesia practice. As

Brockett (2015) points out, adult learners that have a greater control over the process will be

more motivated. This motivation could translate into an improvement in the SRNAs’ expression

of professionalism and demonstration of professional behaviors. SRNAs can develop codes of

conduct, which go beyond the usual directives about academic dishonesty to social behavior and

methods of communication.

There are possibilities in the contribution of simulation activities. Inclusion of situations

involving unprofessional behavior or communication can be integrated into simulation scenarios

to enable the SRNA to rehearse appropriate management strategies. Bailey (2014) pointed out

the advantage of simulation in nursing education. She indicated that the use of simulation could

provide the replication of real clinical situations for students and the faculty with the ability to

guide students in reflection on the experience along with exploring alternative strategies to

manage the situation (Bailey, 2014). Learning scenarios could be customized to a variety of

situations and students. Bailey (2014) discussed the use of simulation in team-based scenarios in

the effort to improve team performance in health care.

SRNAs in each of the focus groups spoke about role models and their positive as well as

negative effect and influence. Felstead (2013) asserted that the role play of clinical scenarios

during academic learning can give faculty an opportunity to role model desired behavior and

professionalism. He indicated that adult nursing students have a variety of influences on their

development of professionalism and the use of role modeling and role-play should incorporate

61


professional behaviors and not just skills competence. Sanner-Stiehr and Ward-Smith (2017)

similarly expressed the importance of faculty role modeling in influencing student behaviors and

communication patterns.

Aspects of professionalism, professional behavior and communication could be

incorporated in clinical simulation scenarios that included CRNAs and SRNAs. The

enhancement of team building could take place through the use of interdisciplinary participation

and scenarios. The use of human patient simulation to create clinical education situations

requiring professional communication skills and the display of professional behaviors can also be

useful as professional development activities for clinical preceptors as they navigate the clinical

patient situation as well as the expression of the role of clinical instructor. These activities could

be submitted for continuing education credit for licensed providers in order to attract and build

participation in team based simulation scenarios.

The issue of professionalism is on the minds of all educators. How to teach and mentor

the expression of professional attitudes and behaviors has been and currently remains a major

concern in the health professions including advanced practice nursing. Gambescia and Sahl

(2015) declared that ‘professionalism is not merely a “soft skill” at all, rather it is one of the most

challenging components of a student’s formation in a health profession’ (p.153). Course

objectives with learning outcomes addressing aspects of professionalism should be woven

throughout the academic curriculum. Creation of learning objectives and clinical competencies

could be developed throughout the program of study. The academic and clinical objectives can

be developed utilizing the ANA Code of Ethics (ANA, 2015) and AANA Code of Ethics

(AANA, 2005). Integrating professionalism throughout the curriculum through the use of small

group discussion, case-based instruction or seminars has been advocated (Cook et al, 2013;

62


Rhodes et al, 2012). The learning activities ought to engage SRNAs in reflecting on the topic of

professionalism along with the expression of professional attitudes and behaviors.

It is important for nurse anesthesia educators to acknowledge the SRNAs’ perspective

regarding professionalism. This perspective can inform nurse anesthesia educators in the need

for curriculum development and change in order to address this concern in the health

professions. Development of a code of conduct from CRNA faculty and SRNAs along with

simulation activities with preceptor CRNAs emphasizing professional communication and

behaviors could comprise one of the steps to impact the SRNA perspective. Nurse anesthesia

educators could enhance the SRNAs’ capacity and growth in self-directed learning as well as

creating learning experiences to promote the development of professionalism for the good of the

future nurse anesthetist and the patients that they serve.

Conclusion

The definitions of professionalism provided by the SRNAs were varied as found by

others in the literature. The perceptions of SRNAs regarding professional attributes and

behaviors focused on witnessing these expressions of professionalism in the clinical learning

settings, especially surrounding SRNAs. Creation of codes of conduct and accompanying

policies were suggested, which could encourage SRNA participation and inclusion in this

process. Additionally development of interprofessional simulation experiences incorporating

management of difficult interpersonal situations and communications were suggested for the

nurse anesthesia educator community. The admonition by Clark (2008) “to improve the

academic milieu” remains relevant in advanced practice nursing education (p.289). Recognition

of the learners’ perspectives about professionalism could result in improved student engagement

and learning environments.

63


Appendix A–Letter to CRNA Program Administrators

Program administrator@

Dear ,

I am a post-master’s DNP student at Simmons College in Boston, MA. My DNP capstone project involves exploring the concept of professionalism in nurse anesthesia students. Many disciplines, including nursing, have attempted to describe the concept of professionalism. What is less well understood is how the concept of professionalism is taught and actualized in nursing practice. Virtually nothing is known about the perspectives of nurse anesthesia students about this concept. The demonstration of professional attributes and behaviors in student populations impacts CRNA providers, the SRNA education environment, clinical practice and ultimately our patients.

The goal of this research is to better understand how SRNA students understand the concept of professionalism. Knowledge of the SRNA perspective may add to the body of knowledge about the concept of professionalism and assist educators in the educational processes and curriculum development.

Focus group interviews will be conducted with groups of SRNAs to examine the perceptions of this group regarding professionalism. Participants will be asked to describe how they conceptualize professional attributes and behaviors.

I ask for your help by forwarding the attached letter of request for participation regarding the focus group to all of your SRNAs. This study has been approved by the Institutional Review Board of Simmons College. If you have any questions regarding this project, please contact me by email at [email protected] or 401-523-1955.

I look forward to listening to your students’ perspectives!

Sincerely,Anne Tierney MSN, MA, CRNARIC School of Nursing/St. Joseph Hospital School of Nurse Anesthesia200 High Service Ave.North Providence, RI 02904

64

mailto:[email protected]


Appendix B–Recruitment letter to SRNAs

Dear SRNA,

My name is Anne Tierney. I am a student in the Simmons College Doctorate of Nursing Practice Program. As part of my DNP Capstone project, I am conducting a study using focus group methodology to explore the concept of professionalism. I am interested in your thoughts about this important topic, specifically your personal perspectives regarding professional attributes and behaviors in nurse anesthesia.

This research will utilize focus groups. A focus group is a planned discussion on a selected topic, in this case professionalism in nurse anesthetists. Focus groups for this study will be conducted in a quiet, private space near you at a time convenient to you. I hope to have 5 to 10 participants in each group. Of course, food and refreshments will be available. I know that SRNAs are pressed for time so will make the focus group no longer than one to two hours.

Your participation is completely voluntary. Measures will be taken to guarantee confidentiality. Come let your voices and thoughts be heard about professionalism in nurse anesthesia. Information about a date, time and place will follow.

If you are interested in participating and/or have any questions, please contact me at the address below, by phone (401)456-3639 or by email at [email protected]. I would appreciate your participation in the focus group and look forward to talking with you!

Sincerely,Anne Tierney MSN, MA, CRNARICSON/SJHSNA200 High Service Ave.North Providence, RI 02904

65



Appendix C–Informed Consent

Participant Informed Consent

Name of study: Perceptions of Nurse Anesthesia Students Regarding Professionalism and Professional Attitudes and Behaviors

Investigator: Anne Tierney, a DNP student at Simmons College in Boston and CRNA for the past 26 years, adjunct faculty at Rhode Island College School of Nursing and Program Administrator of the St. Joseph Hospital School of Nurse Anesthesia.

You have been asked to take part in a research study examining the perceptions of professionalism by SRNAs. This study can be a benefit to nurse anesthesia programs and the profession by informing educators regarding the education process of future practitioners in nurse anesthesia. This study will be conducted by participation in a focus group.

This discussion is voluntary. You do not have to participate if you do not wish to. If you do not participate, it will have no effect on your grades or clinical experiences. You may leave the group at any time for any reason.

There is minimal risk in taking part in this study. The authority figures in the nurse anesthesia program will not have access to information, comments or the discussion of the focus group. Each participant is asked to maintain the confidentiality of the discussion.

The discussion will be audio recorded to ensure accuracy of the comments of each participant. The privacy of this information will be protected. No names will be used in any report. Data will be reported in aggregate. Pseudonyms will be assigned to any quoted comments in a report. The discussion will be kept strictly confidential. The audio recording will only be available to the researcher, a transcriptionist and the researcher’s faculty advisors at Simmons College. The recordings will be stored in a secured location in the researcher’s office and will be destroyed three years after this project’s completion.

There are no personal benefits to taking part in the research. However, your insights may be helpful to nurse anesthesia education and the profession.

If you have questions about this study, please contact Anne Tierney at [email protected] or 401-523-1955 or St. Joseph Hospital School of Nurse Anesthesia, 200 High Service Ave., North Providence, RI 02904. You may also contact the faculty advisor, Dr. Eileen McGee at [email protected].

66




Questions or concerns about the administration of the study protocol may be addressed to Valerie Breaudrault, Simmons College IRB administrator at [email protected] or 617-521-2415.

If you agree to participate in the focus group, please check the box and sign your name in the space below.[ ] Yes, I agree to take part in the focus group study.

Name __________________________________________ Date__________________

Signature________________________________________

Investigator______________________________________ Date__________________

This research project has been approved by the Simmons College Institutional Review Board for the period of one year.

67



Appendix D–Demographic sheet

Demographic Survey

1. Age: _________

2. Gender: _____Male ______Female

3. Year in Program: _____First ______Second ______Third

4. Months of Clinical Experience as an SRNA: ____________

68


Appendix E–Interview Guide

Interview Guide

Can you give me an example of a behavior that exemplifies professionalism?

How did you learn about professionalism in nursing, in a classroom, in practice?

Can you give me an example of how you learned about professionalism?

Is professionalism in advanced practice different from professionalism as a registered nurse?

Do you think differently about professionalism now that you’re obtaining an advanced degree?

How do you think professionalism should be learned?

What are some of the challenges to professional behavior in nurse anesthesia?

How do you think we can model professional behaviors for other nurse anesthetist students?

Tell me about someone you know whose behavior really exemplifies professionalism.

69


Appendix F–IRB Approval

70


References

American Association of Nurse Anesthetists (2005). Code of Ethics for the Certified Registered

Nurse Anesthetist. Park Ridge, IL: Author

American Nurses Association (2015). Code of Ethics for Nurses with Interpretive Statements.

Silver Springs, MD: Author

71


Anselmi, K. K., Smith Glascow, M. E., & Gambescia, S. F. (2014). Using a nursing student

conduct committee to foster professionalism among nursing students. Journal of

Professional Nursing, 36(4), 481-485.

Bahaziq, W. & Crosby, E. (2011). Physician professional behaviour affects outcomes: A

framework for teaching professionalism during anesthesia residency. Canadian Journal

of Anesthesia, 58,1039-1050 doi: 10.1007/s12630-011-9579-2.

Bailey, C. (2014). Human patient simulation. In M. J. Bradshaw & A. J. Lowenstein (Eds.),

Innovative teaching strategies in nursing and related health professions (6th Ed.) (pp.

203-224). Burlington, MA: Jones & Bartlett Learning

Baumann, A. & Kolotylo, C. (2009). The Professionalism and Environmental Factors in the

Workplace Questionnaire: Development and psychometric evaluation. Journal of

Advanced Nursing, 65(10), 2216-2228. doi: 10.1111/j.1365-2648.2009.05104.x

Berk, R. (2009). Derogatory and cynical humour in clinical teaching and the workplace: The

need for professionalism. Medical Education, 43, 7-9 doi: 10.1111/j.1365-

2923.2008.03239.x

Blue, A. V., Crandall, S., Nowacek, G., Luecht, R., Chauvin, S. & Swick, H. (2009).

Assessment of matriculating medical students’ knowledge and attitudes towards

professionalism. Medical Teacher, 31, 928-932 doi: 10.3109/0142159080257.4565

Bowman, R. (2013). Understanding what it means to be a professional. The Clearing House,

86, 17-20 doi: 10.1080/00098655.2012.723641

Brennan, M. D. & Monson, V. (2014). Professionalism: Good for patients and health care

organizations. Mayo Clinical Program, 89(5), 644-652 doi:

10.1016/j.mayocp.2014.01.011

72


Brockett, R. G. (2015). Teaching Adults: A Practical Guide for New Teachers. San Francisco,

CA: Jossey-Bass

Brockopp, D., Schooler, M., Welsh, D., Cassidy, K., Ryan, P. Y., Mucogenburg, K. & Orr

Chleboey, D. (2003). Sponsored professional seminars: Enhancing professionalism

among baccalaureate nursing students. Journal of Nursing Education, 42(12), 562-564.

Burford, B., Morrow, G., Rothwell, C., Carter, M. & Illing, J. (2014). Professionalism

education should reflect reality: Findings from three health professions. Medical

Education, 48, 361-374. doi: 10.1111/medu.12368

Chisholm, M. A., Cobb, H., Duke, L., McDuffie, C., & Kennedy, W. K. (2006). Development

of an instrument to measure professionalism. American Journal of Pharmaceutical

Education, 70(4), 1-6.

Clark, C. M. (2008). Student voices on faculty incivility in nursing education: A conceptual

model. Nursing Education Perspectives, 29(5), 284-289.

Clark, C. M. & Springer, P. J. (2007). Thoughts on incivility: Student and faculty perceptions

of uncivil behavior in nursing education. Nursing Education Perspectives, 28(2), 9397.

Clickner, D. A. & Shirey, M. R. (2013). Professional comportment: The missing element in

nursing practice. Nursing Forum, 48(2), 106-113.

Connelly, L. M. (2015). Focus groups. Medsurg Nursing, 24(5), 369-370.

Cook, A. F., Sobotka, S. A., & Ross, L. F. (2013). Teaching and assessment of ethics and

professionalism: a survey of pediatric program directors. Academic Pediatrics, 13(6),

570-576

73


Council On Accreditation of Nurse Anesthesia Educational Programs. (2014). Standards for

Accreditation of Nurse Anesthesia Educational Programs. Park Ridge, IL: Council On

Accreditation of Nurse Anesthesia Educational Programs.

Doody, O., Slevin, E., & Taggart, L. (2013a). Focus group interviews in nursing research: Part

1. British Journal of Nursing, 22(1), 16-19.

Doody, O., Slevin, E., & Taggart, L. (2013b). Preparing for and conducting focus groups in

nursing research: Part 2. British Journal of Nursing, 22(3), 170-173.

Doody, O., Slevin, E., & Taggart, L. (2013c). Focus group interviews. Part 3: Analysis.

British Journal of Nursing, 22(5), 266-269.

Dubree, M., Kapu, A., Terrell, M., Pichert, J. W., Cooper, W. O., Hickson, G. B. (2017)

Nurses’ essential role in supporting professionalism: What’s your part in maintaining

high standards? American Nurse today, 12(4), 6-8.

Elmblad, R., Kodjebacheva, G., & Lebeck, L. (2014). Workplace incivility affecting CRNAs:

A study of prevalence, severity, and consequences with proposed interventions. AANA

Journal, 82(6), 437-445.

Felstead, I. (2013). Role modelling [sic] and students’ professional development. British

Journal of Nursing, 22(4), 223-227.

Finn, G., Garner, J., & Sawdon, M. (2010). ‘You’re judged all the time!’ Students’ views on

professionalism: A multicenter study. Medical Education, 44, 814-825. doi:

10.1111/j.1365-2923.2010.03743.x

Foster, S. D. & Horton, B. J. (2011). Defining work and the professional spirit. In S. D. Foster

& M. F. Callahan (Eds.), A Professional Study and Resource Guide for the CRNA (2nd

Ed.) (pp.3-23), Park Ridge, IL: American Association of Nurse Anesthetists

74


Gambescia, S. F. & Sahl, M. (2015). Exploratory study in how professionalism is explicated in

undergraduate degrees in a health sciences college. Academy of Educational Leadership

Journal, 19(3), 141-154.

Ginsburg, S., Regehr, G., Hatala, R., McNaughton, N., Frohna, A., Hodges, B…. & Stern, D.

(2000). Context, conflict, and resolution: A new conceptual framework for evaluating

professionalism. Academic Medicine, 75(10), supplement, S6-S10.

Goldie, J. (2013). Assessment of professionalism: A consolidation of current thinking.

Medical Teacher, 35(2), e952-e956 doi: 10.3109/0142159X.2012.714888

Goldie, J., Dowie, A., Cotton, P., & Morrison, J. (2007). Teaching professionalism in the early

years of a medical curriculum: a qualitative study. Medical Education, 41, 610-617 doi:

10.1111/j.1365-2923.2007.02772.x

Hammer, D. (2006). Improving student professionalism during experiential learning. American

Journal of Pharmaceutical Education, 70(3), 1-6.

Hilton, S. R. & Slotnick, H. (2005). Proto-professionalism: How professionalization occurs

across the continuum of medical education. Medical Education, 39, 58-65 doi:

10.1111/j.1365-2929-2004.02033.x

Houghton, C., Casey, D., Shaw, D., & Murphy, K. (2013). Rigour in qualitative case-study

research. Nurse Researcher, 20(4), 12-17.

Jha, V., Bekker, H. L., Duffy, S. RG., & Roberts, T. E. (2007). A systematic review of studies

assessing and facilitating attitudes towards professionalism in medicine. Medical

Education, 41, 822-829 doi: 10.1111/j.1365-2923.2007.02804.x

75


Johanson, M. A. (2005). Association of importance of the doctoral degree with students’

perceptions and anticipated activities reflecting professionalism. Physical Therapy,

85(8), 766-781.

Keeling, J. & Templeman, J. (2013). An exploratory study: Student nurses’ perceptions of

professionalism. Nurse Education in Practice, 13, 18-22 doi:

10.1016/j.nepr.2012.05.008

Kelley, K. A., Stanke, L. D., Rabi, S. M., Kuba, S. E., & Janke, K. K. (2011). Cross-validation

of an instrument for measuring professionalism behaviors. American Journal of

Pharmaceutical Education, 75(9), 179, 10 p.

Klein, E. J., Jackson, J. C., Kratz, L., Marcuse, E. K., McPhillips, H. A., Shugerman, R. P. … &

Stapleton, F. B. (2003). Teaching professionalism to residents. Academic Medicine,

78(1), 26-34.

Krueger, R. A. & Casey, M. A. (2015). Focus Groups: A Practical Guide for Applied Research

(5th Ed). Los Angeles, CA: Sage.

Lawrence, W. (2014). Lessons learned: employing focus groups as a research methodology.

Journal on Nursing. 3(4), 15-22.

LeDuc, K & Kotzer, A. M. (2009). Bridging the gap: A comparison of the professional nursing

values of students, new graduates, and seasoned professionals. Nursing Education

Perspectives, 30(5), 279-284.

Miller, B. K., Adams, D., & Beck, L. (1993). A behavioral inventory for professionalism in

nursing. Journal of Professional Nursing, 9(5), 290-295.

Montgomery, J. E. (2007). Incorporating emotional intelligence concepts into legal education:

Strengthening the professionalism of law students. U Tol. L. Rev., 39, 323-352.

76


Nagler, A., Andolsek, K., Rudd, M., Sloane, R., Musick, D. & Basnight, L. (2014). The

professionalism disconnect: Do entering residents identify yet participate in

unprofessional behaviors? BMC Medical Education, 14, 60, 12p. doi: 10.1186/1472-

6920-14-60

Noble, C., Coombes, I., Shaw, P. N., Nissen, L. M., & Clavarino, A. (2014). Becoming a

pharmacist: The role of curriculum in professional identity formation. Pharmacy

Practice, 12(1), 380-392.

Polit, D. F. & Beck, C. T. (2012). Nursing Research: Generating and Assessing Evidence for

Nursing Practice (9th Ed.). Philadelphia, PA: Wolters Kluwer Health.

Poirier, T. I. & Gupchup, G. V. (2010). Assessment of pharmacy student professionalism across

a curriculum. American Journal of Pharmaceutical Education, 74(4), 1-5.

Powell, R. A. & Single, H. M. (1996). Focus Groups. International Journal for Quality in

Health Care, 8(5), 499-504.

Rhodes, M. K., Schutt, M. S., Langham, G. W., & Bilotta, D. E. (2012). The journey to nursing

professionalism: A learner-centered approach. Nursing Education Perspectives, 33(1),

27-29.

Robinson, A. J., Tanchuk, C. J., & Sullivan, T. M. (2012). Professionalism and occupational

therapy: An exploration of faculty and students’ perspectives. Canadian Journal of

Occupational Therapy, 79(5), 275-284.

Rutter, P. M.& Duncan, G. (2010). Can professionalism be measured?: Evidence from the

pharmacy literature. Pharmacy Practice, 8(1), 18-28.

Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing

& Health, 23, 334-340.

77


Sanner-Stiehr, E. & Ward-Smith, P. (2017). Lateral violence in nursing: Implications and

strategies for nurse educators. Journal of Professional Nursing, 33(2), 113-118. doi:

10.1016/j.profnurs.2016.08.007

Santasier, A. M. & Plack, M. M. (2007). Assessing professional behaviors using qualitative

data analysis. Journal of Physical Therapy Education, 21(3), 29-39

Schafheutle, E. I., Hassell, K., Ashcroft, D. M., Hall, J., & Harrison, S. (2012). How do

pharmacy students learn professionalism? International Journal of Pharmacy Practice,

20, 118-128 doi: 10/1111/j.2042-7174.2011.00166.x

Secrest, J. A., Norwood, B. R., Keatley, V. M. (2003). “I was actually a nurse”: The meaning

of professionalism for baccalaureate nursing students. Journal of Nursing Education,

42(2), 77-82.

Shepard, L. H. (2014). It takes a village to assure nurse professionalism. Journal on Nursing,

3(4), 1-5.

Speziale, H. S. & Carpenter, D. R. (2007). Qualitative Research in Nursing: Advancing the

Humanistic Imperative (4th Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Stephenson, A. E., Adshead, L. E., & Higgs, R. H. (2006). The teaching of professional

attitudes within UK medical schools: Reported difficulties and good practice. Medical

Education, 40, 1072-1080 doi: 10.1111/j.1365-2929.2006.02607.x

Sullivan, W. & Benner, P. (2005). Challenges to professionalism: Work integrity and the call

to renew and strengthen the social contract of the professions. American Journal of

Critical Care, 14(1), 78-84

78


Tanaka, M., Yonemitsu, Y., & Kawamoto, R. (2014). Nursing professionalism: A national

survey of professionalism among Japanese nurses. International Journal of Nursing

Practice, 20, 579-587 doi: 10.1111/ijn.12201

Then, K. L., Rankin, J. A., & Ali, E. (2014). Focus group research: What is it and how can it be

used? Canadian Journal of Cardiovascular Nursing, 24(1), 16-22.

Thrush, C. R., Spollen, J. J., Tariq, S. G., Williams, K. & Shorey, J. M. II (2011). Evidence for

validity of a survey to measure the learning environment for professionalism. Medical

Teacher, 33, e683-e688 doi: 10.3109/0142159X.2011.611194

Tunajek, S. K. (2011), Standard of care in anesthesia practice. In S. D. Foster & M. F. Callahan

(Eds). A Professional Study and Resource Guide for the CRNA (2nd Ed.), (pp. 149-174).

Park Ridge, IL: American Association of Nurse Anesthetists

Van Zanten, M., Boulet, J. R., Norcini, J. J. & McKinley, D. (2005). Using a standardised

patient assessment to measure professional attributes. Medical Education, 39, 20-29 doi:

10.1111/j.1365-2929.2004.02029.x

Wagner, P., Hendrich, J., Moseley, G. & Hudson, V. (2007). Defining medical professionalism:

A qualitative study. Medical Education, 41, 288-294 doi: 10.1111/j.1365-

2929.2006.02695.x

Weis, D. & Schank, M. J. (2009). Development and psychometric evaluation of the Nurses

Professional Values Scale—Revised. Journal of Nursing Measurement, 17(3), 221-231

doi: 10.1891/1061-3749.17.3.221

Wise, H. H. & Yuen, H. K., (2013). Effect of community-based service learning on

professionalism in student physical therapists. Journal of Physical Therapy Education,

27(2), 58-64

79


Woloschuk, W., Harasym, P. H. & Temple, W. (2004). Attitude change during medical school:

A cohort study. Medical Education, 38, 522-534 doi: 10.1046/j.1365-

2929.2004.01820.x

Zafiropoulos, G. (2017). Definition of professionalism by different groups of health care

students. Educational Research and Reviews, 12(7), 380-386.

80

beatleyweb.simmons.edu€¦ · Web viewPerceptions of Nurse Anesthesia Students Regarding...

Documents

Transcript of beatleyweb.simmons.edu€¦ · Web viewPerceptions of Nurse Anesthesia Students Regarding...