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Literature Review of the Working Environment of Certified Registered Nurse Anesthetists’ and its Relationship with Patient Safety, Quality of Care, and Job Satisfaction.

By Soo Jung Ha

Senior Honors Thesis

University of North Carolina Chapel Hill School of Nursing

April 11, 2020

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Mary Lynn PhD, Thesis Advisor

Foreword

I became interested in the work environment of Certified Registered Nurse Anesthetists (CRNA) during a summer externship where I interacted with a CRNA at Duke University Hospital. He allowed me to observe the anesthesia working station and what he does in his daily role. During our time, he explained the basics of hemodynamic monitoring and indications for certain anesthesia medications (ex: propofol, nitrous oxide, ephedrine, and fentanyl). When I asked him to explain what working in the operating room (OR) was like, he responded that the operating room was a unique care area because physicians, residents, and nurses had to

continuously collaborate. Through my interactions with him, I became interested in knowing more about the work environment of CRNAs and what, if any, relationship it had with patient safety, quality of care, and job satisfaction.

Abstract

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on working conditions of CRNAs and, to the extent possible, examine how they influence patient safety, quality of care, and work satisfaction.

Primary sources used for the literature review were CINAHL and PubMed. By utilizing combinations of Mesh Terms related to different aspects of CRNA work environment

(communication, decision making, collaboration, and patient safety), fourteen articles were selected for analysis. The review of literatures revealed two overarching themes: (1) there were discrepancies in attitudes toward collaboration between CRNAs and anesthesiologists, and (2) CRNAs work in an intense environment that can lead to decreased job satisfaction and decreased patient safety. It must be noted that there was a limited research related to CRNA-physician collaboration, which limited clear ways to look into such aspect of the OR work environment. Future research should focus on utilizing strategies such as OR debriefings to mitigate the discrepancies in teamwork perceptions, implementing standardized hand-off process to improve patient safety, and instituting interventions such as zero tolerance policies and workshops to minimize incivility in the OR environment.

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Introduction

According to the study by Boyd and Poghosyan, the demand for anesthesia services is increasing as individuals live longer, experience more acute and chronic conditions and require diagnostic, procedural, and surgical interventions (Boyd & Poghosyan, 2017). Currently, the 42,000 CRNAs in the United States cover about 65% of all anesthesia cases per year (Boyd & Phogsyan, 2017). However, despite the projected 25% increase in the CRNA workforce by 2022, the supply of CRNAs may still be inadequate, potentially thwarting the ability of hospitals to provide sufficient anesthesia care. The work environment of the CRNA is fast-paced and unique in that techs, nurses, residents and physicians collaborate in real time to care for patients. The uniqueness of this environment suggests a need to examine to see if there are any aspects that influence CRNAs themselves (e.g., satisfaction) and the overall quality of patient care.

According to the American Association of Critical-Care Nurses (AACN), a healthy work environment enables nurses to provide highest standards of patient care (AACN, 2015). A healthy work environment is especially important in operating room where CRNAs, surgeons, and nurses constantly collaborate with each other to care for the patient during surgery. The six essential components of a healthy work environment are communication, collaboration, decision making, appropriate staffing, meaningful recognition, and leadership.

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defined as working together to ensure supportive environment to promote patient care. Effective decision-making is defined as empowering healthcare professionals to design protocols that benefit team members and patients. Similarly, appropriate staffing refers to effective match between patient needs and nurse competencies to provide quality care and increased patient outcomes. Meaningful recognition refers to recognizing team members for values they bring to the organization, and authentic leadership is defined as leaders who create culture of

compassionate care and equip nurses with skills to grow in their practice.

However, despite the promotion of healthy work environment by the AACN, many healthcare workers suffer workplace violence and aggression. For example, the National Institute for Occupational Safety and Health reports that over 1 million workers are assaulted each year in hospitals, nursing, and residential care services (Sakellaropoulos, Pires, Estes, & Jasinki, 2011). As workplace aggression continues to increase, it creates problems related to job stress, morale, working relationships, and patient safety (Sakellaropoulos et al, 2011).

Although numerous studies exist on working conditions of registered nurses, very little literature exists regarding the working conditions of CRNAs. Therefore, the focus of this literature review was, using the elements of a healthy work environment (AACN, 2015), to examine how the work environment of the CRNA can impact patient safety, quality of care, and job satisfaction.

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According to the AACN, a healthy work environment leads to decreased burnout, low turn-over rate, and better patient care (AACN, 2015). Creating such an environment enables nurses to provide the highest standards of patient care while having satisfaction and contentment with their work. What follows is a literature review of the work environment of CRNAs. As noted above, the focus of this literature review was to use the six aspects of healthy work environment (AACN, 2015) to examine the work environment of CRNAs and how they influence patient safety, quality of care, and job satisfaction.

Methods

The primary sources used for literature review were CINAHL and PubMed. The initial search was performed using search terms “Certified Registered Nurse Anesthetists” and “Work Environment,” which yielded 355 results. To refine the search, Mesh Terms were established by combining following terms: Certified Registered Nurse Anesthetists, work environment,

communication, decision making, and collaboration. Incorporating the six aspects of a healthy work environment (AACN, 2015), the following search terms were used in study.

 Collaboration or teamwork or interdisciplinary AND CRNA or certified registered nurse anesthetist or nurse anesthetist

 Work environment or working condition or workplace AND CRNA or certified registered nurse anesthetist or nurse anesthetist

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 Communication or communicating or communicate AND CRNA or certified registered nurse anesthetist or nurse anesthetist

 Effective decision making or leadership AND CRNA or certified registered nurse anesthetist or nurse anesthetist

 Patient safety or patient outcomes or quality of care AN D CRNA or certified registered nurse anesthetist or nurse anesthetist

Inclusion criteria consisted of articles relevant to the work environment of CRNAs that were published in English since 2005. The literature yielded 344 articles, of which 62 were potentially relevant based on the title or description. After reviewing the abstracts, 37 articles that did not include patient safety as related to the OR environment were excluded. Twenty-five articles were then retrieved for more detailed evaluation, with 11 articles being excluded based on published dates. A total of 14 articles were then included in this systematic review.

Results

After examining the literature, it was found that only three of the AACN concepts could be applied --- collaboration, communication, and decision making. Because there were studies that could not be classified using the AACN framework, two additional concepts were added (patient safety and work environment), bringing the framework of categories for the analysis to five. Each of the 14 articles selected for the literature review were examined for specific

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concepts identified above (collaboration, communication, and decision making, patient safety and work environment), each article was then put into its most relevant category in Table 1. Studies in each category will be noted below.

Collaboration

Although CRNAs and anesthesiologists need to work in a collaborative team for optimal patient safety, there were differences in attitudes toward collaboration by CRNAs and

anesthesiologists (Jones & Fitzpatrick, 2009). For example, although CRNA’s attitude towards collaboration was more positive, only few CRNAs perceived their practice as being collaborative with anesthesiologists. Taylor (2009) also noted that CRNAs’ had a significantly more positive attitudes toward collaboration than did anesthesiologists. Furthermore, the attitude towards collaboration between CRNAs and anesthesiologists was less positive when the practice time increased. Barriers to collaboration that may have led to such findings include: perceived limited interpersonal skills for both CRNAs and physicians, mutual need for teamwork/respect, and differences in educational trainings (Jones & Fitzpatrick, 2009).

In a descriptive survey conducted by Alve (2005), CRNAs were found to use

compromise or an avoidance approach rather than seeking ways to resolve conflict. Although it was not clear why CRNAs preferred to avoid conflict, it nonetheless was a barrier to

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positively correlated with collaboration between CRNAs and anesthesiologists. However, because not much is known about how scope of practice is positively correlated to collaboration in CRNAs, more research is needed addressing the relationship between scope of practice and collaboration among CRNAs.

Using the Safety Attitudes Questionnaire, Makary et al. (2006) studied teamwork in the OR setting. The questionnaire revealed that physicians were rated the lowest and nurses were rated the highest in teamwork. However, physicians rated that everyone in the OR was doing well in terms of teamwork. These differences in ratings suggest a discrepancy in the perceptions of teamwork among OR members.

Communication

The Practices in the Operating Room (PRIOR) survey was used to analyze aspects of communications used by CRNAs, anesthesiologists, and surgeons to look at what contributes to the culture of operative communication behavior (Kirschbaum & McAuliffe, 2018). It was found that CRNAs scored highest on independence, reflecting the need for independent decision making. Additional findings included that CRNAs used combination of integration and

avoidance as conflict management styles, which suggest that CRNAs take either a diplomatic or distancing approach to resolve conflicts, which supports the earlier-reported work of Alve (2005).

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postoperative staff members’ perception of safety. The intervention involved team education addressing the standardized handoff procedures using the Team STEPPS model. The hand-off process revealed four communication barriers --- quality of information, engagement of CRNAs receiving report, format of hand-off, and the length of hand-off. Prior to the intervention, none of the CRNAs were satisfied with the handoff process, but after the intervention, half of them “strongly agreed with being satisfied with handoffs” (p.141). One CRNA stated that “Sometimes, the [receiving] CRNA doesn’t want to listen to all of it” (p. 142). Nonetheless, the quality of transfer of information, perception of patient safety, and healthcare worker satisfaction improved with implementation of standardized handoff procedure.

The problem with engagement during hand-off process was also addressed by Lowe (2017), who found that non-interactive communication (i.e., disengagement) was the greatest (negative) component of handoffs. For example, when handoff scores were low, the handoffs were non-interactive in nature; when handoff scores were high, the handoffs were always interactive (Lowe, 2017). Another communication barrier that was revealed during the hand-off process was incomplete or omitted information. During hand-offs, airway techniques were communicated in only 53% of cases, and vital signs were communicated in only 29% of cases.

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was that not every anesthesia provider complied unless the process was made to be a standard of care (Wright, 2013).

Decision Making

In a study by Cahana et al. (2008), a survey was given to anesthesiologists, CRNAs, surgeons, and nurses to assess their decisions in a situation posing moral dilemma, and how to their reasoning differed. It was found that when an ethical decision had to be made on patient’s behalf, anesthesiologists and CRNAs used beneficence (doing good) and non-maleficence (not inflicting harm) in decision making. Surgeons and nurses used only one principle to guide their decision making --- surgeons used non-maleficence and nurses used beneficence. There was no relationship between decision making and gender, age, and professional experience. This study supported the notion that each profession (nurses, CRNAs, anesthesiologists and surgeons) entered practice with their own ethical ideas about what decisions are good or bad and right or wrong.

Patient Safety

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self-efficacy, confidence, expert mentoring/guidance, supportive work environment, and peer support. Major factors that impeded CRNA role development included: practice limitations, hostile work environment, decreased case complexity and decreased workload (Tracy, 2017). Both Tracy (2017) and Wong and Li (2011) emphasize that characteristics of CRNAs that may promote or hinder patient safety can be influenced by the OR work environment.

Work Environment

Sakellaropoulos et al. (2011) identified three key aggressive behaviors in the OR arena ---verbal, active, and direct aggression. These behaviors were seen in surgeons and

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Discussion

The purpose of this literature review was to integrate existing evidence on working conditions of CRNAs and project how they might influence patient safety, quality of care, and work satisfaction.

Regarding collaboration in the CRNA working environment, there was consistent differences in actual “team-ness” with physicians being less of a team player, which may decrease quality of care and patient safety. This proposition is supported by the found need for mutual respect/teamwork and limited interpersonal skills among OR professionals, which leads to barriers to adequate collaboration in the CRNA work environment. Therefore, more research is needed to explore strategies that promote effective interpersonal communication skills to build an environment of mutual respect needed for collaborative interaction.

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The basis for decision making in the CRNA work environment differed among

professions (nurses, CRNAs, anesthesiologists, and surgeons). For example, each professions had their own principles of what was good vs bad, or right vs wrong. Such differences in

dynamics make it challenging to discern whether choices made by certain professions are better for patients or not. Nonetheless, healthcare providers should seek to respect and collaborate different decision making traits among team members.

When looking at patient safety, it was revealed that there were characteristics of CRNAs that promoted or impeded patient safety. However, the studies did not specifically address the impact of factors that negatively influenced patient safety. For example, in what ways and to what extent does hostile work environment influence patient safety? Further studies are needed to make such correlations and determinations.

Finally, the work environment of CRNA was found to be a stressful and aggressive environment that can lead to decreased job satisfaction, and decreased patient safety. Boyd and Poghosyan (2017) noted that almost all CRNAs experienced active aggression, verbal

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There were two limitations noted while completing this literature review. First, only one article could be found that focused on decision making aspect of CRNA work environment, which limited the conclusions that could be reached here. Second, because the search included only the mesh terms noted above and articles published within the last 15 years, additional studies that may have been useful for this review may have been missed. Despite these

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References

Alves SL. (2005). A study of occupational stress, scope of practice, and collaboration in nurse anesthetists practicing in anesthesia care team settings. AANA Journal, 73(6), 443–452. American Association of Critical-Care Nurses (2015). Healthy work environments. Retrieved

February 11, 2020, from https://www.aacn.org/nursing-excellence/healthy-work-environments.

Boyd, D. (2017). Certified registered nurse anesthetist working conditions and outcomes: a review of the literature. AANA Journal, 85(4), 261–269.

Cahana A, Weibel H, & Hurst SA. (2008). Ethical decision-making: do anesthesiologists, surgeons, nurse anesthetists, and surgical nurses reason similarly? Pain Medicine, 9(6), 728–736.

Canale, M. L. (2018). Implementation of a standardized handoff of anesthetized patients. AANA Journal, 86(2), 137–145.

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.

Jones TS, & Fitzpatrick JJ. (2009). CRNA-physician collaboration in anesthesia. AANA Journal,

77(6), 431–436.

Kirschbaum, K., & McAuliffe, M. S. (2018). Team communication in the operating room: a measure of latent factors from a national sample of nurse anesthetists. AANA

Journal, 86(1), 11–18.

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impact on anesthesia care-related handoff outcomes. AANA Journal, 85(4), 250–255.

Makary, Martin & Sexton, John & Freischlag, Julie & Holzmueller, Christine & Millman, E &

Rowen, Lisa & Pronovost, Peter. (2006). Operating room teamwork among physicians

and nurses. Journal of the American College of Surgeons, 202. 746-752.

Doi:10.1016/j.jamcollsurg.2006.01.017

Sakellaropoulos, A., Pires, J., Estes, D., & Jasinski, D. (2011). Workplace aggression:

assessment of prevalence in the field of nurse anesthesia. AANA Journal, 79(4), S51-7. Taylor CL. (2009). Attitudes toward physician-nurse collaboration in anesthesia. AANA

Journal, 77, 343–348.

Tracy, A. (2017). Perceptions of certified registered nurse anesthetists on factors affecting their transition from student. AANA Journal, 85(6), 438–444.

Wong, E., & Li, Q. (2011). Faculty discernment of student registered nurse anesthetist’s personality characteristics that contribute to safe and unsafe nurse anesthesia practice: metrics of excellence. AANA Journal, 79(3), 227–235.

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Table 1: Integrative Literature Review Matrix

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Collaboration

A Study of

Occupational Stress, Scope of Practice, and Collaboration in Nurse Anesthetists Practicing in Anesthesia Team Settings

Alves SL. (2005). A study of occupational stress, scope of practice, and collaboration in nurse anesthetists practicing in anesthesia care team settings. AANA Journal, 73(6), 443–452. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A Purpose

 To examine occupational stress in nurse anesthetists practicing in Anthologists in anesthesia care team (ACT) settings in relation to CRNA scope of practice (SOP) and collaboration Sample

 347 CRNAs

 Descriptive correlation survey was used to address relationship between CRNA SOP and collaboration

 SOP tool included 41 item Likert scale derived from AANA statement on CRNAs and

anesthesiologists.  Occupational stress was

measured by scales that measured: role overload, role insufficiency, role ambiguity, role boundary, responsibility and physical environment.

 Psychological strain questions consisted of vocational, psychological, interpersonal, and physical strain.

 Coping resources were measured by scales that constituted PRQ:

recreation, self-care, social support, and

 Higher scores on SOP were seen with hospital employed CRNAs than CRNAs

employed by anesthesiology group with more restrictions to practice

 Only few CRNAs perceived their practice as collaborating with anesthesiologists. The compromise mode was used most frequently with

avoidance mode as the next. This indicated that CRNAs were more apt to use

compromising or avoidance approach to resolve conflict as opposed to collaboration.  CRNAs with broader SOP

experienced increased stress with role overload and responsibility.

 Tendency towards higher scores on role insufficiency with lower SOP suggested that CRNAs who scored lower in performing skills and procedures tended to have

 Both CRNAs and

anesthesiologists perform functions that are more similar than different, and each brings expertise that is essential to provide high-quality anesthesia services.  CRNAs and

anesthesiologists must continue to value their individual worth to the provision of anesthesia care.  Although CRNAs with

broader SOP experienced increased stress in terms of role overload and

responsibility, stress related to increased responsibility may be a positive

expression of how an individual feels about being responsible for his/her own performance and welfare of others on the job.

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice N=106395961&site=eh

ost-live&scope=site rational/cognitive coping. higher role insufficiency in ACT settings. and anesthesiologists in ACTs, emphasizing clearly defined roles and optimizing productivity.

Collaboration

CRNA-Physician Collaboration in Anesthesia

Jones TS, & Fitzpatrick JJ. (2009). CRNA-physician collaboration in anesthesia. AANA Journal, 77(6), 431– 436. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=105273672&site=eh ost-live&scope=site Purpose

 To compare attitudes toward collaboration of CRNAs with those of anesthesiologists Sample  62 anesthesiologists and 208 nurse anesthetists.

 Descriptive study that measured physician’s and nurse’s attitude

towards authority, autonomy, responsibility for patient monitoring, and collaborative decision.  Adaptation of

Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration was used.

 Questionnaire consisted of 15 items with answers on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree)  Higher scores indicated

more positive attitude toward physician-nurse collaboration

 Mean for total scores on attitudes toward collaboration was 44.4 for anesthesiologists and 51.8 for CRNAs.

 Anesthesiologist’s comment on education indicated a strong bias toward medical education over nursing education

 Comments on teamwork referred to limited

interpersonal skills between CRNAs and anesthesiologists  Comments on nurses’

autonomy referred to lack of autonomy for nurse

anesthetists related to job satisfaction and scope of practice.

 Comments regarding physician authority were primarily about physician being the leader of the team, along with the need to value input of those being given orders.

 Collaboration between CRNAs and

anesthesiologists plays an important role in patient safety.

 However, results indicated that there were differences in attitude toward

collaboration between CRNAs and

anesthesiologists.

 Research that digs deeper into issues that contribute to CRNAs and physician’s dissatisfaction should be implemented.

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Collaboration

Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder

Makary, Martin & Sexton, John & Freischlag, Julie & Holzmueller, Christine & Millman, E & Rowen, Lisa & Pronovost, Peter. (2006). Operating Room Teamwork among Physicians and Nurses. Journal of the American College of Surgeons. 202. 746-52.

10.1016/j.jamcollsurg.2 006.01.017.

Purpose

 To measure teamwork in the surgical setting among surgeons, anesthesiologists, CRNAs, and OR nurses.

Sample

 2,135 responses from surgeons, anesthesiologists, CRNAs, and OR nurses

 Safety Attitudes Questionnaire (OR Version) was used  OR caregivers included

surgeons, anesthesiologists, CRNAs, and OR nurses  Surveys were administered

during pre-existing departmental and staff meetings with a pencil and return sealable envelope to maintain confidentiality.  Individuals not captured in

pre-existing meetings were hand-delivered a survey, pencil, and return

envelope.  Using ANOVA,

differences in ratings of communication and collaboration were tested among OR caregivers.

 Teamwork ratings for each OR caregiver differed significantly by caregiver type. This may due to the differences in expectations among physicians and nurses, including status, authority, gender, and patient care responsibilities.

 Physicians had the lowest overall ratings of teamwork and OR nurses were given the highest ratings of teamwork

 Substantial discrepancies in perceptions of teamwork exist in the OR, with physicians rating the teamwork of others as good, and nurses perceive teamwork as poor.

 Surgeons and

anesthesiologists were more satisfied with physician/nurse collaboration than nurses. Nurses did not reciprocate the high ratings of teamwork given by physicians.

 Surgeons perceived everyone in the OR was doing a good

 Strategy such as OR briefings and debriefings can be used to minimize discrepancies in teamwork perceptions as well as to improve performance and safety.

 Brief discussion at the time of surgical “time-out” can also be helpful. OR

caregivers can use this time to review names, roles of team members, operative plan and potential issues for the case, and a debriefing to learn lessons from the case for future patients.

 In 2007, the Joint Commission proposed hospitals to measure culture, indicating that culture was crucial in hospital system.  The SAQ is a valid and

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice job in terms of teamwork.

However, the different ratings that were each OR caregiver types received indicate disconnection in teamwork.

improving teamwork in the OR setting.

Collaboration

Attitudes Toward Physician-Nurse Collaboration in Anesthesia

Taylor CL. (2009). Attitudes toward physician-nurse collaboration in anesthesia. AANA Journal, 77(5), 343– 348. Retrieved from http://search.ebscohost.c om/login.aspx?

direct=true&db=rzh&A

Purpose

 To compare the attitudes of anesthesiologists and CRNAs toward collaboration with each other Sample

 501 CRNAs, 353

anesthesiologi sts

 Descriptive, comparative study was used, and data were obtained from each group via mailed survey  Differences in attitudes

toward collaboration between CRNAs and anesthesiologists was measured by Jefferson Scale of Attitude Toward Physician-Nurse

Collaboration.  The Jefferson scale

consisted of 15 items on a 4-point Likert-type scale. Higher scores indicated more positive attitudes.

 Anesthesiologists and CRNAs were asked what percentage of their practices involved them working together. Responses covered the entire range of 0% to 100%.

 The attitudes of the nurse anesthetists were significantly more positive than those of the anesthesiologists.  The correlation between

attitude toward collaboration (total Jefferson score) and percentage of practice

arrangement in which CRNAs and anesthesiologists work together was not significant in anesthesiologists. However, the correlation was significant for CRNAs

 Years of anesthesia

experience were associated

 Although the influence of gender has been suggested as a source for difference, the influence of gender is difficult to examine due to disproportionate gender distribution between

medicine and nursing. More studies are needed to test for influence of gender on physician-CRNA collaboration.

 Scope of practice was positively correlated to collaboration in

CRNAs. Therefore, research into interactions of

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice N=105330780&site=eh

ost-live&scope=site

with more positive attitudes toward collaboration in anesthesiologists and less positive in nurse anesthetists.  Among the CRNAs in this

study, attitude towards collaboration decreased as percentage of practice with anesthesiologists increased.

can benefit understanding of CRNA-anesthesiologist collaboration.

 Continued inquiry into collaboration and meaningful dialogue between anesthesiologists and CRNAs can help build the environment of mutual respect essential for collaborative interaction.

Communication

Implementation of a Standardized Handoff of Anesthetized Patients

Canale, M. L. (2018). Implementation of a Standardized Handoff of Anesthetized

Patients. AANA

Purpose

 To implement a standardized handoff to improve the quality and continuity of transfer of information, perceptions of patient safety, and healthcare worker satisfaction.

 Project Design: EBP quality improvement project that used

pre-test/post-test quality improvement design.  The pre-intervention and

post-intervention survey consisted of questions related to continuity and quality of transfer of information, perioperative staff satisfaction, and perioperative staff perception of safety.

T test indicated statistically significant improvement when pre-intervention handoff was compared with

post-intervention handoff in following areas: number of standardized handoffs performed, satisfaction and appropriateness of hand-off, whether the handoff lend itself to mistakes, whether the handoff was comprehensive, and whether the handoff provided effective transfer of important information.

 17 barriers to pre-intervention

 Only few studies measured actual improvement in patient safety. This may be due to culture of under-reporting mistakes. Future research should focus on more rigorous study designs and include transfer of care between anesthesia

providers.

 As recommended by AORN, The Joint

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Journal, 86(2), 137– 145. Retrieved from http://search.ebscohost.c om/login.aspx? direct=true&db=rzh&A N=128916549&site=eh ost-live&scope=site Sample

 20 CRNAs involved in transfer of care of anesthetized patients in medical center in West Central Florida.

 The intervention consisted of education of team, followed by modification, adoption, and

implementation of a standardized handoff procedure using the Teams EPPS model

 Data obtained through Likert-type questions from preintervention and

postintervention surveys were analyzed using a paired t test.

 Free-text responses to open-ended questions were analyzed to identify emerging themes.

handoff process were: 8 related to quality, 6 related to engagement, 2 related to format, and 1 related to length.

 When asked about suggestions to improve handoff process, 50% (N=3) participants reported barriers related to engagement by the receiving CRNA, remarking that “Sometimes the

[receiving] CRNA doesn’t want to listen to all of it.”

improve patient safety medical errors due to communication breakdown.

 This project revealed that the quality of transfer of information, perceptions of patient safety, and

healthcare worker

satisfaction improved with implementation of

standardized handoff procedure. Based on these results, it is recommended that all anesthesia providers implement a standardized procedure for the handoff of anesthetized patients.

Communication

Team Communication in the Operating Room: A Measure of Latent Factors from a National Sample of Nurse

Anesthetist

Kirschbaum, K., & McAuliffe, M. S.

Purpose  To better

understand communication variables used by CRNAs that contribute to culture of operative communication behavior.

 PRIOR (Practices in the Operating Room) survey included 56 Likert-scale items. Among 56 items, 15 items measured self-construal and preference for independence or interdependence. 12 items measured face-concern, and 23 items measured conflict management style.

Additional 6 items were added to collect data on

 CRNAs scored highest on independence, reflecting their need for independent decision making.

 The second highest score for CRNAs was conflict

management style of integration. This reflected preference for collaboration to find a solution.

 EFA data indicated that CRNAs had combination of integration and avoidance as conflict management styles.

 The 3 emergent factors provide important insight for future research. The role of peacemaker, the question of perceived status inequity, and the use of assertive conflict styles are interesting components of

communication behaviors.  There may be emergent

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice (2018). Team

Communication in the Operating Room: A Measure of Latent Factors from a National Sample of Nurse

Anesthetists. AANA Journal, 86(1), 11–18. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=130496831&site=eh ost-live&scope=site

 To understand how communication is negotiated among physicians and CRNAs Sample  664 nurse

anesthetists

communication patterns CRNAs experience with surgeons and

anesthesiologists.

 Exploratory factor analysis (EFA) was used to

discover how CRNA data were similar and different from those of

anesthesiologists and surgeons.

EFA data also indicated that CRNAs had dominance and avoidance as conflict management styles.

 Combination of dominance and avoidance suggests that CRNAs may take diplomatic approach to voice dissenting opinion. Individuals who use assertive conflict management have been found to enhance role clarity in the workplace

 The presence of dominance and avoidance suggests that CRNAs seek to clarify

positions in the OR and strive for mutually beneficial communication among team members.

 Future communication training programs can be designed to encourage behaviors that support interdisciplinary team members and to help medical professionals to collectively problem-solve through eliminating

avoidance that often results in silenced team members.  Attention to manifestations

of hierarchy and associated communication practices can improve communication among complex operative providers, which may positively influence patient outcomes.

Communication

A High-Fidelity Simulation Study of

Purpose

 To identify latent conditions that are present during intraoperative handoffs

 Video-recorded

simulations were examined for latent conditions and handoff content

 The simulated scenarios took place during

anesthesia crisis resource management training at the

 Most common latent condition was distraction followed by production pressure

 70% of handoffs (n = 40) were judged to be either good, rated as 6 to 8, or excellent, rated

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Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Intraoperative Latent Hazards and Their Impact on Anesthesia Care-Related Handoff Outcomes

Lowe, J. S. (2017). A High-Fidelity

Simulation Study of Intraoperative Latent Hazards and Their Impact on Anesthesia Care-Related Handoff Outcomes. AANA Journal, 85(4), 250– 255. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=124667332&site=eh ost-live&scope=site

 To identify nature of intraoperative handoff failures  To correlate

identified latent conditions to handoff failures

Sample

 58 stimulated anesthesia patient handoffs

university

 Participants in the recorded simulations included anesthesiologists, CRNAs, and student registered anesthetist.

 Each archived video scenario was evaluated for following latent conditions: distractions, production pressure, non-interactive (1 way) communication and handoffs that occurred at

inappropriate times  Handoff was

evaluated for 10 criteria, including: patient identification, procedure

identification, patient allergies, review of systems,

medications, vital signs, anesthesia technique, airway technique, intake and output, and pertinent events

as 9 to 10.

 Most hand-off items were frequently communicated.

Exceptions were airway technique

(communicated in 53% of cases), vital signs (29% of cases), and I&O output (21% of cases).  The lowest handoff

scores (0, 1, or 2) were associated with 3 or more latent conditions.  The presence of latent

condition non-interactive

communication was the most consistent

predictor of poor handoff scores. When handoff scores were low, the handoffs were frequently

characterized as non-interactive

communication. When handoff scores were high, the handoffs were always interactive

concealed system issues become part of the culture, and what is thought to be a safe system is occultly unsafe. Discovering and neutralizing latent conditions will have a much greater effect on system safety than efforts to minimize active errors.

 Clinicians must acknowledge that handoffs are a high- risk event that can cause patient harm. The complexity of healthcare mandates competent

communication to ensure safe patient care.

(27)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Communication

Examining Transfer of Care Processes in Nurse Anesthesia Practice: Introducing the PATIENT protocol

Wright, S. M. (2013). Examining Transfer of Care Processes in Nurse Anesthesia Practice: Introducing the PATIENT Protocol. AANA Journal, 81(3), 225– 232. Retrieved from http://search.ebscohost.c om/login.aspx? direct=true&db=rzh&A N=107948904&site=eh ost-live&scope=site Purpose

 To examine current transfer of care practices of CRNAs during intraoperative period

 To develop, implement, and evaluate

communication checklist tool to improve situation awareness.

Sample

 1,000 CRNAs

 2 phase study was utilized for this study

 Phase 1 study involved questionnaire about transfer of care. It contained 10 items that captured demographic data and current transfer of care processes.

 Additional items asked to identify and rank the most important factors to: 1) communicate when transferring care of anesthetized patient from one anesthesia provider to another, 2) characteristics of transfer process that most likely lead to adopt change in practice, and 3) barriers that most likely prevented them from adopting a systematic transfer of care process.  Phase 2 study involved a

transfer of care checklist based on phase 1 survey. A laminated card containing checklist was posted on the anesthesia machine in each operating room, and a pocket-sized paper

 When asked about systematic process for communicating vital information during transfer of care. most subjects (n = 220, 72.8%) indicated that there was no systematic process in place.

 Subjects were then asked if they liked the idea of adopting a standardized transfer of care process. Of the 30

respondents, 87% either agreed or strongly agreed with the use of a standardized tool.  When asked to describe

current process for

transferring care during the intraoperative period, 82 (27.2%) offered explanations of process they use during the transfer of care. Most

responses included,

procedure, and allergies as descriptors. SBAR was cited by 11% of those responding to item 4 (n = 9) as a method of transferring care.

 The most frequently reported barrier to adopting a

systematic transfer of care

 The discipline of anesthesiology is well- recognized to advance patient safety throughout the perioperative period.

 However, despite this success, transfer of care events are not well

understood and associated with preventable accidents in anesthesia.

 Effective communication strategies characterized as clear, brief, accurate, and reliable are theorized to contribute to situation awareness in complex and dynamic environments, such as the operating room.  With an accurate mental

model of current situation through a questionnaire and transfer of care checklist, the incoming anesthetist may be able to make decisions based on fact rather than assumption, to detect and solve problems efficiently, and to initiate tasks with greater

(28)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice illustrating the checklist

were given to all subjects. process was that not every anesthesia provider complied unless the process was made to be a standard of care.

Decision Making

Ethical Decision-Making: Do Anesthesiologists, Surgeons, Nurse Anesthetists, and Surgical Nurses Reason Similarly?

Cahana A, Weibel H, & Hurst SA. (2008). Ethical decision-making: do anesthesiologists, surgeons, nurse anesthetists, and surgical nurses reason similarly? Pain Medicine, 9(6), 728– 736. Retrieved from http://search.ebscohost.c

Purpose

 To explore responses given by

anesthesiologists, surgeons, nurses, and CRNAs to a specific moral dilemma, how they reason in facing this moral dilemma, and to assess differences between them.

Sample  29

anesthesiologists, 41 surgeons, 21 surgical nurses, 33 CRNAs

 Anonymous survey was given before and after 1 hour-tutorial about principle-based theory.  The tutorial included:

introduction on

ethics/bioethics, principles of biomedical ethics, practical exercise on how to analyze a case, and question time

 Questionnaire on ethical decision-making was used to collect following data: demographic, participation in previous course in bioethics, and interest of having a course in bioethics using visual analog scale

 Clinical presentation was presented, and participants were asked to answer questions related to presentation

 The response to the ethical question, the choice of ethical principle, and the

 Anesthesiologists and CRNAs who would transfuse against patients will use the principles of Beneficence and

Nonmaleficence for decision

 Surgeons use nonmaleficence and surgical nurses use beneficence.

 Most people who would not transfuse applied the principle of respect for autonomy.

 There was no correlation between gender, age, and professional experience with choice of principle

 Anesthesiologists were more likely than others to report that they would transfuse a Jehovah’s Witness in a life-threatening situation despite clear refusal of patient. Two among 11 of them did not specify why they would do so.

 42% of surgeons reported

 Physicians and nurses enter practice with their own ethical ideas about what conduct is good/bad or right/wrong.

 To answer ethically challenging situations and subsequently perform “good” choices, a

theoretical and systematic understanding of our moral life is necessary. However, choosing an ethical theory to apply and applying it appropriately can be difficult.

(29)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=105704740&site=eh ost-live&scope=site

satisfaction score were compared before and after the tutorial

they would transfuse the patient, while nurses cited B and nurse anesthetists cited B and NM as the rationale behind their findings.

 Even though this theory is subject to revision, the principles of respect for autonomy; nonmaleficence; beneficence; and distributive justice are regarded as the basis of bioethics and serve as coherent guidelines for universal judgment in moral medical dilemmas

Patient Safety

Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting Their

Transition from Student

Tracy, A. (2017). Perceptions of Certified Registered Nurse

Purpose

 To examine and describe factors impacting CRNAs during their role transition Sample

500 CRNAs from the AANA membership

 Qualitative, descriptive, phenomenographic design using online recruitment and interviewing was used  Data on recently graduated

CRNAs were collected in semi-structured online interviews using the Internet communication software audio-video conferencing (Skype, Microsoft Corp) and recording software (Evaer Technology)

 Pilot study was performed to test logistics and expose any deficiencies before the full study was performed.

 Five major factors promoting role transition included: (1) mastery of self-efficacy and confidence, (2) expert mentoring and guidance, (3) supportive work environment, (4) peer support, and(5) previous experiences as a SRNA

 In each participant’s interview, an overarching theme was found regarding the importance of mastery of self-efficacy and confidence.  Four major factors impeding

role transition included: (1)

 The results of this study can have implications for CRNA practice and employers.

(30)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice Anesthetists on Factors

Affecting Their Transition from Student. AANA Journal, 85(6), 438– 444. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=126503416&site=eh ost-live&scope=site

practice limitations, (2) lack of orientation and preceptor, (3) hostile work environment, and (4) decreased case

complexity and workload.  Practice limitations were

perceived as impeding role transition, and most

participants felt frustrated with not being able to use and master skills they learned during their education.

 Previous research identified that CRNAs with limited scope of practice reported increased work stress and role insufficiency.

 The compassion and empathy shared by participants through their stories and perceptions culminated into rich descriptions of first few years of CRNA practice and identified factors that promote and impede CRNA role transition.

 Further quantitative

research is needed to verify study’s findings and to address the feasibility of possible intervention in a larger population of recently graduated CRNAs.

Patient Safety

Faculty Discernment of Student Registered Nurse Anesthetist’s Personality

Characteristics That Contribute to Safe and Unsafe Nurse

Anesthesia Practice: Metrics of Excellence

Wong, E., & Li, Q.

Purpose

 To allow Nurse Anesthesia Educational Program (NAEP) academic faculty and expert CRNA clinical faculty to discern which of the 63

intrapersonal and

 63 intrapersonal and 15 interpersonal personality characteristics that comprise the survey tool was used

 10 CRNA clinical faculty members (group A) were asked to discern if each personality characteristic indicated safe or unsafe anesthesia practice. In addition, group A was asked to discern whether

 Although academic profile, GPA, MCAT scores, and interview scores are analyzed to admit the applicant, the admission ranking, and the interview process did not predict clinical performance.

 Safe characteristics denoted by group A and group B were vigilant, responsible, ethical, good critical thinking skills, honest, good judgement, careful, integrity, able to learn

 Although negative

personality characteristics can harm patients, no studies address which personality contribute to harm of the patient.

 The present study attempts to determine which

personality characteristics contribute to safe or unsafe practice as it pertains to nurse anesthesia.

(31)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice (2011). Faculty

Discernment of Student Registered Nurse Anesthetist’s Personality

Characteristics That Contribute to Safe and Unsafe Nurse

Anesthesia Practice: Metrics of

Excellence. AANA Journal, 79(3), 227– 235. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=104713731&site=eh ost-live&scope=site 15 interpersonal characteristics that student registered nurse anesthetists (SRNAs)

contribute to safe or unsafe nurse anesthesia practice

Sample

 10 CRNA clinical faculty members  25 NAEP

academic faculties

each characteristic was relevant or not relevant to the purpose of study.  The NAEP academic

faculties (Group B) were also asked to discern if the personality characteristic contributed to safe or unsafe nurse anesthesia practice.

 2 open-ended questions at the end requested both groups to write

characteristics they believed were important for safe/unsafe anesthesia practice

 Last open-ended question requested additional information participants wanted to share.

from mistakes, etc.

 Unsafe characteristics denoted by group A and group B were easily distracted, refusal to accept responsibility of actions, poor critical thinking skills, does not recognize limitations, does not pay attention to details, unable to learn from mistakes, etc.

personality is an area that deserves attention. The literature is replete with articles that examine effect of elements on personality that may contribute to safe or unsafe nurse anesthesia practice. Further studies would need to be conducted to make those correlations and determinations.

 CRNAs make life and death decisions for patients. Therefore, the intrapersonal and interpersonal

characteristics that

contributes to safe and nurse anesthesia practice is important.

Work

Environment

Certified Registered Nurse Anesthetist Working Conditions and

Purpose  Investigate existing evidence regarding working conditions of CRNAs and their

 Comprehensive literature search was conducted through: Ovid/MEDLINE, PubMed, Elsevier, and Cumulative Index to Nursing and Allied Health Literature (EBSCO). Google Scholar was used

I. Collaboration

 CRNA attitudes toward collaboration were more positive

II. Professional Autonomy  Conflict between CRNAs and

anesthesiologists may stem from overlap in clinical

 Administrations should take steps to decrease conflict between anesthesiologists and CRNAs by promoting professional identities of both providers.

(32)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice Outcomes: A Review of

the Literature

Boyd, D., & Poghosyan (2017). Certified

Registered Nurse Anesthetist Working Conditions and

Outcomes: A Review of the Literature. AANA Journal, 85(4), 261– 269. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=124667334&site=eh ost-live&scope=site relationships with CRNA outcomes. Sample

 Total of 13 studies for in-depth review were used

to search for additional articles

 Keywords such as: nurse anesthetists, job satisfaction, physician-nurse relations, interpersonal relations, organizational culture, professional anatomy, practice environment, professional practice, care environment, work

environment, and stress were used.

responsibilities.

 In some practice settings, 23% of CRNAs were required to accept clinical decisions by anesthesiologist.

III. Work Relations of CRNA  Few CRNAs perceived their

practice with anesthesiologists as collaborative.

 CRNAs with less restrictive SOP experienced more occupational stress and role overload than CRNAs with more restrictive SOP. IV. CRNA Outcomes

 92% of CRNAs experienced active aggression, 90% experienced verbal aggression, and 83% experienced physical aggression. Study showed a positive correlation of workplace aggression with negative impact on patient safety.

collaborative practice is ACT. Literature showed that CRNA SOP restrictions were most evident in preoperative and postoperative periods. Therefore, instituting less restrictive SOP in these areas may be an option in maximizing CRNA care.  Care must be taken by

administration to utilize CRNAs to full capacity while providing

opportunities that prevent role overload, promote productivity, and increase job satisfaction.

 Positive organizational influences such as work satisfaction and personal support can reduce burnout. More research in this area can help organizations to understand how to mitigate negative provider outcome.

Work

Purpose

 Survey included questions

(33)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

Environment

Workplace Incivility Affecting CRNAs: A Study of Prevalence, Severity, and

Consequences with Proposed Interventions

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. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=103918137&site=eh ost-live&scope=site

 To examine the prevalence of incivility and the influence of workplace

incivility on burn-out among CRNAs

Sample

 385 CRNAs

Scale, Burnout Inventory, and 3 open-ended

questions about

recommendations CRNAs had to prevent and manage incivility

 CRNAs were asked to report incivility experienced from 3 sources: 1. Interactions with general employee or nonemployees

(patients/visitors), doctors, nurses, or other hospital personnel 2. Interactions with other CRNAs 3. Interactions with CRNA supervisors

levels of incivility from employee, nonemployee, and physician sources; moderate levels of incivility from CRNA colleagues, and low levels of incivility from CRNA supervisors

 Mean burnout composite score was 43.3 (moderate)

 Linear relationship between incivility and burnout. As respondents experienced higher levels of workplace incivility, burnouts increased (P<.0001)

 In replies to open-ended questions, the most notable suggestion was the use of zero tolerance policy for practice regardless of title or role as well as following a similar policy to students in anesthesia programs.

 Other comments included: prevention, coping, and detection for management

anesthesia care. However, CRNAs work in a

potentially stressful and, at times, uncivil work

environment that can lead to professional burnout.  It is key to curb incivility in

healthcare facilities by instituting interventions found in study, such as: zero tolerance policies,

workshops on quality communication

skills/behaviors, increased management visibility in the clinical areas, and

individual/ group in-services on how to handle workplace incivility once identified.

(34)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice

supervisors, and physicians.

Work

Environment

Workplace Aggression: Assessment of

Prevalence in the Field of Nurse Anesthesia

Sakellaropoulos, A., Pires, J., Estes, D., & Jasinski, D. (2011). Workplace Aggression: Assessment of

Prevalence in the Field of Nurse Anesthesia.

AANA Journal, 79(4), S51-7. Retrieved from http://search.ebscohost.c om.libproxy.lib.unc.edu/ login.aspx? direct=true&db=rzh&A N=104680988&site=eh ost-live&scope=site Purpose  To assess

prevalence of workplace aggression in the field of

anesthesia  To assess

negative impact of aggressive behavior and how it impacts work environment of CRNAs

Sample

 205 CRNA Respondents

 Workplace Aggression Research Questionnaire was used to measure workplace aggression in the field of nurse

anesthesia and its impact on CRNAs

 Likert scale was used to ask respondents how often (never to daily) they experienced aggressive behavior in the workplace and who was responsible for the behavior

 Respondents were asked which factors they thought contributed to aggressive experiences

 The second section of the tool, part II (questions 87-98), was composed of demographic-type questions

 2 significant issues were found: (1) The OR arena is highly volatile and does not function under the same protocols found in other hospital work settings. (2) Young female CRNAs may be vulnerable targets trying to cope within the volatile OR environment.

 3 key aggressive behavior themes emerged: verbal, active, and direct aggression. These behaviors between surgeons and other team members was frequent, overt and may be a major factor to compromised patient safety.  75% of respondents witnessed

disruptive behavior on a weekly basis with most disruptive behavior by

surgeons or anesthesiologists  Disruptive behavior included

"yelling, abusive language, berating others, and physical abuse."'

 Encourage staff to fill out incident reports for

disruptive behavior. Reports should

not be used as retaliatory, but as an opportunity to document the problem and shift the focus to a solution.  Avoid negative behaviors,

such as blaming others. Instead, act as a team to solve problem

 When aggression occurs, consider the context of the situation and approach the situation accordingly  Confront physicians whose

behaviors are degrading by speaking to them in

private. State the behavior and its effect. Ask manager for support if needed.  Take the time to thank and

acknowledge physicians with who have good working relationship.  Act as a liaison – bring

(35)

Concept, Title &

Citation Purpose and Sample Methodology Major Findings

Implications for Nursing Practice  CRNAs experienced active

aggression regardless of age. The largest % of aggression was against females from 20-39 years of age

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