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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
Perceptions of Nurse Anesthesia Students Regarding Professionalism and Professional
Attributes and Behaviors
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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Running head: PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA 1
Perceptions of Nurse Anesthesia Students Regarding Professionalism and Professional
Attributes and Behaviors
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.
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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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
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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.
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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
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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
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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,
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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
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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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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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
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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
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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
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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,
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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
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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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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-
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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-
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.”
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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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
“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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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:
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
“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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
“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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
“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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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.”
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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 &
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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,
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
“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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
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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
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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;
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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.
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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
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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
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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].
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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.
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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: ____________
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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.
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Appendix F–IRB Approval
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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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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
PERCEPTIONS OF PROFESSIONALISM IN NURSE ANESTHESIA
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