Upload
esmond-curtis
View
222
Download
0
Tags:
Embed Size (px)
Citation preview
Insp
ire.
Lead.
Eng
age.
Professionalism 11/09/09 YLawlor
Professionalismin Nursing Education
NERUSeptember 11, 2009
Yvonne Lawlor, Assistant Professor, School of Nursing, McMaster University
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
Societal expectations
QuickTime™ and a decompressor
are needed to see this picture.
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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)
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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?
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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
Insp
ire.
Lead.
Eng
age.
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.
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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
Professionalism 11/09/09 YLawlor
Insp
ire.
Lead.
Eng
age.
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