inspire. lead. engage. professionalism 11/09/09 ylawlor professionalism in nursing education neru...

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Professionalism 11/09/09 YLawlor

Professionalismin Nursing Education

NERUSeptember 11, 2009

Yvonne Lawlor, Assistant Professor, School of Nursing, McMaster University


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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?


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Professionalism


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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?


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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)


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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)


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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)


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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)


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Professionalism

Increased interest since early ‘90’s Medicine has done considerable work in

this field Other disciplines, including nursing also

interested Incivility, patient safety


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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


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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


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CNO Entry Level Competencies

CNO,2008


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RNAO Professionalism in Nursing

Knowledge Spirit of Inquiry Accountability Autonomy Advocacy Innovation and Visionary Collegiality and Collaboration Ethics and Values (RNAO, 2007)


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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)


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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


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Societal expectations

QuickTime™ and a decompressor

are needed to see this picture.


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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)


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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)


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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


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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


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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?


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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”


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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


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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


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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


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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


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Assessment of Professionalism

Program of longitudinal assessments including multiple assessment approaches

Frequently throughout the program Give feedback Multiple assessors, multiple settings,

multiple opportunities


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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)


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Cruess, Cruess & Steinert, 2009


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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)


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Assessment of Professional competence


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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


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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.


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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


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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


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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.


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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)


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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


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Role Modeling with Reflection

1. Explicitly call attention to what you are role modeling

2. Explain what you have done and why3. Treat learners with the respect with which you

expect them to treat patients.4. Ask learners to reflect on their observations and

experiences. “How did that go for you?” “What did you learn?”

5. Articulate and teach values. For example, tell learners that you value caring for the patient and showing respect and compassion and why.

6. Provide perspective. Place learners’ observations/experiences in the broader context of patient care. (Rider, 2007)


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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?


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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)


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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)


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Unprofessional BehaviourDuff, 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?


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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.


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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)


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Remediation


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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 :)


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Moving Forward

Faculty of Health Sciences Interprofessional Professional working group

School of Nursing Professionalism Task Force

Common definition of professionalism Process for addressing breaches


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Quote

"Professionalism is knowing what to do, how to do it, when to do it, and doing it.” Author unknown


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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


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References Cruess, R.L, Cruess, S. R., & Steinert, Y. (2009). Teaching

Medical Professionalism. New York: Cambridge University Press

Cruess, R.L., & Cruess, S. R. (2006). Teaching professionalism: General principles.

Medical Teacher, 28(3), 205-208. Cruess, S. R., Johnston, S., & Cruess, R. L. (2004). “Profession”:

A working definition for medical educators. Teaching and Learning in Medicine, 16:1, 74-76

Cruess, S. R. & Cruess, R. L. (2008).Professionalism and medicine’s social contract with society. Perspectives in Biology & Medicine. 51(4), 579-98

Cruess, R. L., Cruess, S. R., & Johnston, S. E. (2000). Professionals: An ideal to be

sustained. The Lancet, 356, 156-158. Cruess,S.R., & Cruess, R.L.(1997) Teaching medicine as a profession in the service of

healing. Academic Medicine. 72(11), 941-52 Epstein, R.M., & Hundert, E.M.(2002) Defining and assessing professional competence.

JAMA. 287(2):226-235 Kirk, L.M.(2007). Professionalism in Medicine:definitions & considerations for teaching.

Baylor University Medical Center Proceedings. 20(1), 13-16.


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References Kolb, D. (1983). Experiential learning. Paramus, NJ.: Financial Times/Prentice Hall Lindquist, I.,Engardt, M., Garnham,L., Poland, F., & Richardson, B. (2006).

Physiotherapy students’ professional identity on the edge of working life. Medical Teacher. 28 (3), 270-76

Lynch,D.C, Surdy, P.M., Eisner, A. R. (2004). Assessing Professionalism: A review of the literature. Medical Teacher. 26, (4), 366-373

Papadakis, M.A., Osborn, E.H. S., Cooke, M., Healy, K., & th University of California,

San Francisco School of Medicine Clinical Clerkships Operation Committee. (1999). A Strategy for the Detection and Evaluation of Unprofessional Behavior in Medical Students. Academic Medicine. 74, (9), 980-990

Rider, E.A., Nawotniak, R. H., & Smith, G.(2007). A Practical Guide to Teaching and Assessing the ACGME Core Competencies. Marblehead, MA: HCPro, Inc.

Registered Nurses of Ontario. (2007). Professionalism in Nursing. Toronto, ON: Author

Silberman, M. (2007). The Handbook of Experiential Learning. San Francisco, CA: Pfeiffer


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References Teherani, A., Hodgson, C.S., Banach, M., & Papadakis, M.A.(2005).

Domains of Unprofessional Behavior During Medical School Associated with Future Disciplinary Action by a State Medical Board. Academic Medicine. 80, (10), Supplement S17-S20

Vezeau, T.M. (2006). Teaching professional values in a BSN program. International Journal of Nursing Scholarship. 3(1)

Weis, D., & Schank, M.J. (2002). Professional values: Key to professional development. Journal of Professional Nursing, 18(5), 271-275

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