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Professionalism in Nursing Education

Professionalism in Nursing Education. NERU September 11, 2009 Yvonne Lawlor, Assistant Professor, School of Nursing, McMaster University. Objectives. What is professionalism? What values or behaviours are associated with professionalism? How can professionalism be assessed?

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Professionalism in Nursing Education

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  1. Professionalismin Nursing Education NERU September 11, 2009 Yvonne Lawlor, Assistant Professor, School of Nursing, McMaster University Professionalism 11/09/09 YLawlor

  2. Objectives • What is professionalism? • What values or behaviours are associated with professionalism? • How can professionalism be assessed? • How can professionalism be taught? • How can lapses or breaches in professionalism be addressed? Professionalism 11/09/09 YLawlor

  3. Professionalism Professionalism 11/09/09 YLawlor

  4. Professionalism • Can you think of person who exemplified professionalism? ie. The most professional person you have ever known • Can you think of the person who was the most unprofessional? Professionalism 11/09/09 YLawlor

  5. What is Professionalism? • “Conduct, aims or qualities that characterize or mark a profession or a professional person” (Merriam-Webster, 2009) • “Qualities or typical features of a profession or professional. A collection of attitudes and actions; it suggests knowledge and technical skill.” (RNAO, 2007) Professionalism 11/09/09 YLawlor

  6. Definition of Profession • “An occupation whose core element is work based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning or the practice of an art founded upon it is used in the service of others. Its members possess a commitment to competence, integrity, morality, altruism and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession the right to autonomy to practice and the privilege of self-regulation. Professions and their members are accountable to those serviced and to society.” (Cruess & Cruess, 2004, RNAO, 2007) Professionalism 11/09/09 YLawlor

  7. Professional Competence • …“the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning,emotions, values and reflection in daily practice for the benefit of the individual and community being served.” (Epstein & Hundert, 2002) Professionalism 11/09/09 YLawlor

  8. Professional Presence • “As a reflective practitioner, the registered nurse demonstrates confidence, integrity, optimism, passion, and empathy, in accordance with professional standards, guidelines and codes of ethics. This includes the registered nurses’ verbal and nonverbal communications and the ability to articulate a positive role and professional image, including the use of name and title (CNO, 2008) Professionalism 11/09/09 YLawlor

  9. Professionalism • Increased interest since early ‘90’s • Medicine has done considerable work in this field • Other disciplines, including nursing also interested • Incivility, patient safety Professionalism 11/09/09 YLawlor

  10. Professionalism • Many disciplines consider themselves professions eg.law, medicine, clergy, physiotherapy, nurses, midwives, social workers • Difficult to define • Even more challenging to assess and measure • Wide variety of definitions depending on discipline • Most definitions describe behaviours/traits associated with societal role • Behaviours can be observed/ assessed Professionalism 11/09/09 YLawlor

  11. Principles of Professionalism • Altruistic concern for patient welfare • Individuals bound together by commitment • Specialized body of knowledge • Self-regulation, accountability, integrity, honesty • Social contract with society, service to the public • Ethics, ethical behaviour, patient autonomy, dignity, • Social justice Professionalism 11/09/09 YLawlor

  12. CNO Entry Level Competencies CNO,2008 Professionalism 11/09/09 YLawlor

  13. RNAO Professionalism in Nursing • Knowledge • Spirit of Inquiry • Accountability • Autonomy • Advocacy • Innovation and Visionary • Collegiality and Collaboration • Ethics and Values (RNAO, 2007) Professionalism 11/09/09 YLawlor

  14. Self-Regulation, Accountability • 21 Regulatory Health Colleges in Ontario • RHPA, 1991, all colleges must: • Profession decides education and qualifications necessary to be a member • Establish standards of practice with which members must comply • Administer QA programs, members are required to participate to help maintain competence • Provide complaint and investigation process (CNO, 2008) Professionalism 11/09/09 YLawlor

  15. Service to Public/Social Contract • Implicit and explicit, legislation determines nursing role within society • Contract between the nursing profession and the community, moral and legal obligations • Written and unwritten-legislation, codes of ethics, policies • Nursing offers safe, competent & ethical care as a service • Community allow nursing to function autonomously • Societal expectations change Professionalism 11/09/09 YLawlor

  16. Societal expectations Professionalism 11/09/09 YLawlor

  17. Professional Values • CNA, Code of Ethics, Seven Primary Values • Providing safe, compassionate, competent and ethical care • Promoting health and well-being • Promoting and respecting informed decision making • Preserving dignity • Maintaining privacy and confidentiality • Promoting justice • Being accountable • (Canadian Nurses Association, 2008) Professionalism 11/09/09 YLawlor

  18. Professional Values • Need to acquire and internalize values espoused by profession • Provide a common framework on which expectations and standards can be developed • Ethics instruction increases moral reasoning and judgment. • “For full embodiment of professional values to occur, education, service and the profession must deliberately participate in the process.” (p. 274, Weis & Schank, 2002) Professionalism 11/09/09 YLawlor

  19. Social Justice and professionalism • Upholding legal and moral humanistic principles • Ensure equal treatment and access to health care through impartiality and non discriminatory care, supporting universal access to care and legislation that promotes improvement of health care. (Vezeau, 2006) • Responsible use of limited resources Professionalism 11/09/09 YLawlor

  20. Why is Professionalism Important? • Ensures quality of patient care • Use of best evidence in practice • Competence and safety in a changing world • Collegial working relationships with other disciplines • Sharing limited resources Professionalism 11/09/09 YLawlor

  21. Can it be learned? • Only by its absence can we identify what it is--when unprofessional behaviour is observed • Is it inborn or can it be learned? (Ainsworth & Szauter, 2006). • Taught or caught? Professionalism 11/09/09 YLawlor

  22. Can it be learned? • Recognize and value importance of professionalism to patient care • Clear definition of professionalism expectations and requirements • Support from systems ie. health care and educational • Positive learning environment, recognition of the “hidden curriculum” Professionalism 11/09/09 YLawlor

  23. Why Teach Professionalism? • Students have diverse backgrounds and experiences, enter programs without knowledge of professional values and behaviours • Lack of professionalism in undergraduate programs can indicate problems later in career • Lapses may occur, students need to be aware of process of assessment, receive feedback in order to develop professional attitudes and behaviours Professionalism 11/09/09 YLawlor

  24. Teaching Professionalism • Concepts & principles--explicit information in a variety of sources/formats ie. lecture, course objectives, learning goals • Concepts need to be applied in practice, internalized as attitudes and expressed as professional behaviours • Values clarification and development-guided discussion, reflection • Applying knowledge through experience ie. Learning by doing, reflection and role modelling • Classroom, practice setting, other circumstances • Summative and formative assessment Professionalism 11/09/09 YLawlor

  25. Teaching Professionalism • Institutional support • Allocation of responsibility • Environment-supportive of learning professionalism • Cognitive theoretical knowledge can be taught/tested • Experiential/Self-learning component/moral endeavour-must be based in practice ie- commitment, communication, collaboration, service • Role modelling, feedback r/t performance • Faculty development • Continuity-multiple opportunities • Evaluation-both summative and formative Cruess & Cruess, 2009 Professionalism 11/09/09 YLawlor

  26. Assessment of Professionalism • Multi-faceted, many variables to consider • Purpose of assessment ie. evaluation for competence or identification of learning needs? • Behaviour and attitudes cannot be separated, behaviour can be observed attitude more difficult • Clear definition of what is being assessed • Needs to be formative and summative to be effective • Context affects professional behaviour and assessment Professionalism 11/09/09 YLawlor

  27. Assessment of Professionalism • Program of longitudinal assessments including multiple assessment approaches • Frequently throughout the program • Give feedback • Multiple assessors, multiple settings, multiple opportunities Professionalism 11/09/09 YLawlor

  28. Assessing Professionalism • Assessments can be organized into content areas to be addressed(eg. Ethics, personal characteristics) and type of outcome (eg. Affective, behavioural, cognitive) • Medical students-longitudinal approach, performance based method and behavioural simulations with post encounter probes • For residents-360 assessment and cognitive assessment • For practicing physician-patient questionnaires and cognitive assessment • (Lynch, Surdyk,& Eiser, 2004) Professionalism 11/09/09 YLawlor

  29. Cruess, Cruess & Steinert, 2009 Professionalism 11/09/09 YLawlor

  30. Professionalism mini-evaluation exercise • Listened actively to pt. • Showed interest in patient as a person • Recognized and met patient needs • Extended him/herself to meet patient needs • Ensured Continuity of patient care • Advocated on behalf of a patient • Demonstrates awareness of own limitations • Admitted errors/omissions • Solicited feedback • Accepted feedback • Maintained appropriate boundaries • Maintained composure in a difficult situation • Maintained appropriate appearance • Was on time • Completed tasks in a reliable fashion • Addressed own gaps in knowledge and/or skills • Was available to colleagues • Avoided derogatory language • Maintained patient confidentiality • Used health resources appropriately • (Cruess,Cruess, Steinert, McGill University and S. Ginsburg, Herold-McIlroy, J, University of Toronto) Professionalism 11/09/09 YLawlor

  31. Assessment of Professional competence Professionalism 11/09/09 YLawlor

  32. Challenges to Assessment • Focus on behaviours vs. qualities is it a competency or virtue based? • Professional behaviour + unprofessional attitude= satisfactory • Unprofessional behaviour + professional attitude = unsatisfactory • Sociocognitive psychology-there is a mismatch between behaviour & attitude need to use observation + conversations governed by models • Need to focus on moral reasoning to explore professional dilemmas Professionalism 11/09/09 YLawlor

  33. Assessing Professionalism • You notice your colleague Monica reading a chart of a patient who is a personal friend of hers. Monica has not been involved in her friend’s care. You know that the chart has some sensitive personal information in it. • Identify the elements, characteristics, or attributes of professionalism raised by each of the following cases. You may then discuss solutions to the problem. Professionalism 11/09/09 YLawlor

  34. Experiential Learning Essential • “Learning is the process whereby knowledge is created through the transformation of experience.” (Kolb, 1983) • “Experience may underpin all learning but it does not always result in learning. We have to engage with the experience and reflect on what happened, how it happened and why.” (Beard & Wilson, 2002) • First acquisition of knowledge- • Then application through meaningful activities Professionalism 11/09/09 YLawlor

  35. Learning by Doing • Practice-simulation, interprofessional experiences • Role modelling of others, tutor, staff, other professionals • Self-reflection, guided by specific questions (LEARN etc.) • Need feedback to reflect on and therefore change behaviour Professionalism 11/09/09 YLawlor

  36. Professionalism through self-reflection • Cognitive and affective domain of learning • Focus on development of professional values • Reflect on own values first then develop professional values • Reflection encourages practitioners to challenge the way they think, feel and believe. Professionalism 11/09/09 YLawlor

  37. Self-Reflection • How might my prior experiences affect my actions with this patient/ • What am I assuming about this patient that might not be true? • What surprised me about this patient? How did I respond? • What interfered with my ability to observe, be attentive, or be respectful with this patient? • Were there any points at which I wanted to end the visit prematurely? • If there were relevant data that I ignored, what might they be? • What would a trusted peer say about the way I managed this situation? • Were there any points at which I felt judgmental about the patient-in a positive or negative way? • Is there an ethical issue embedded in this situation? • (Epstein, 2006) Professionalism 11/09/09 YLawlor

  38. Professionalism through role modelling • Very important to transmit “the art” of nursing • Positive impact on the profession • Destructive effects equally strong • Faculty development important • Faculty need to have knowledge and skills to teach/role model professionalism • Role must be explicit to role model and student Professionalism 11/09/09 YLawlor

  39. Role Modeling with Reflection • Explicitly call attention to what you are role modeling • Explain what you have done and why • Treat learners with the respect with which you expect them to treat patients. • Ask learners to reflect on their observations and experiences. “How did that go for you?” “What did you learn?” • Articulate and teach values. For example, tell learners that you value caring for the patient and showing respect and compassion and why. • Provide perspective. Place learners’ observations/experiences in the broader context of patient care. (Rider, 2007) Professionalism 11/09/09 YLawlor

  40. Breaches in Professionalism • Have you observed breaches/lapses in professionalism? • What types of behaviours are considered unprofessional? • What is the process for dealing with breaches in your program? Professionalism 11/09/09 YLawlor

  41. Breaches in Professional behaviour • Increased frequency observed (anecdotal) • Concerns identified by health care professions eg. Medicine, Rehab science, Dentistry, Nursing • Many pt. complaints about physicians involve unprofessional behaviour • Strongest association was in those described as irresponsible or as having diminished ability to improve their behaviour • (Papadakis et. al, 1999, Ainsworth & Szauter, 2006) Professionalism 11/09/09 YLawlor

  42. Predicting Breaches • A) Poor reliability and responsibility • B) Lack of self-improvement and adaptability • C) Poor initiative and motivation • More recently, completion of immunizations, program requirements • 100% prediction not likely • (Teherani, et al. 2005) Professionalism 11/09/09 YLawlor

  43. Unprofessional Behaviour Duff, 2004 Examples include: • Intellectual or personal dishonesty • Arrogance and Disrespect • Abrasive interactions with patients and coworkers • Lack of accountability for errors • Fiscal irresponsibility • Lack of commitment to self-learning • Lack of due diligence • Substance abuse/high-risk behaviour • Sexual misconduct • Others? Professionalism 11/09/09 YLawlor

  44. Breaches in Professionalism • Early identification critical to change behaviour • Investigate and characterize lapse • Cause of lapse can assist with remediation • Important to characterize severity as it affects extent of intervention required • Due process mandatory when implementing remediation 1) Early notification of concern/lapse 2) Opportunity for individual to respond 3) Transparent definition of competency based on professional standards. Professionalism 11/09/09 YLawlor

  45. Breaches in Professionalism • Specific strategies to address these breaches, Extended concern notes, ECN • Emphasizes importance of professionalism within a program • Tracking of unprofessional behaviours • Plan for addressing “professionalism deficiencies” (Ainsworth and Szauter, 2006) Professionalism 11/09/09 YLawlor

  46. Remediation Professionalism 11/09/09 YLawlor

  47. Role of the Tutor • Understand professionalism and professional values • Explain/describe professionalism expectations to students clearly, continuously • Teach theoretical concepts ie. what is accountability? Why is it important? • Role model professionalism, be explicit to students • Encourage self-reflection, provide guidance and support • Assess, evaluate, provide feedback • Reward positive behaviour • In cases of lapses, plan for on-going student development • Keep a sense of humour :) Professionalism 11/09/09 YLawlor

  48. Moving Forward • Faculty of Health Sciences Interprofessional Professional working group • School of Nursing Professionalism Task Force • Common definition of professionalism • Process for addressing breaches Professionalism 11/09/09 YLawlor

  49. Quote • "Professionalism is knowing what to do, how to do it, when to do it, and doing it.” Author unknown Professionalism 11/09/09 YLawlor

  50. References • Ainsworth, M. A., & Szauter, K. M. (2006). Medical student professionalism:Are we measuring the right behaviours? A comparison of professional lapses by students and physicians. Medical Teacher,28(3), 205- 208. • Beard, C., & Wilson, J. (2002). The power of experiential learning. London: Kogan Page • Canadian Medical Association. (2004). CMA Code of Ethics. Ottawa, ON: Author • Canadian Nurses Association. (2008). Code of Ethics. Ottawa, ON: Author • Canadian Nurses Association. (2007). Framework for the Practice of Registered Nurses in Canada. Ottawa, ON: Author • Canadian Physiotherapy Association. (ND). Code of Ethics and Rules of Conduct. Ottawa, ON: Author • College of Nurses of Ontario. (2008). What is CNO? Self-Regulation. Toronto, ON:Author • College of Nurses of Ontario. (2008). National Competencies. Toronto, ON: Author Professionalism 11/09/09 YLawlor

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