Transcript Slide 1

Inspire
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Engage.
Lead.
Professionalism
in Nursing Education
NERU
September 11, 2009
Yvonne Lawlor, Assistant Professor,
School of Nursing, McMaster University
Professionalism 11/09/09 YLawlor
 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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Objectives
Professionalism 11/09/09 YLawlor
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Professionalism
Professionalism 11/09/09 YLawlor
 Can you think of person who exemplified
professionalism? ie. The most professional
person you have ever known
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Professionalism
 Can you think of the person who was the most
unprofessional?
Professionalism 11/09/09 YLawlor
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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)
Professionalism 11/09/09 YLawlor
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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)
Professionalism 11/09/09 YLawlor
 …“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
Competence
Professionalism 11/09/09 YLawlor
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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)
Professionalism 11/09/09 YLawlor
 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
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
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Principles of
Professionalism
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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
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CNO Entry Level
Competencies
Professionalism 11/09/09 YLawlor
CNO,2008
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RNAO Professionalism
in Nursing
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Knowledge
Spirit of Inquiry
Accountability
Autonomy
Advocacy
Innovation and Visionary
Collegiality and Collaboration
Ethics and Values (RNAO, 2007)
Professionalism 11/09/09 YLawlor
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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)
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
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Societal expectations
Professionalism 11/09/09 YLawlor
Qu i c k T i m e ™ a n d a
d e c o m p re s s o r
a re n e e d e d to s e e th i s p i c t u re .
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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)
Professionalism 11/09/09 YLawlor
 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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Social Justice and
professionalism
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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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Why is
Professionalism
Important?
Professionalism 11/09/09 YLawlor
 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?
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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”
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
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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
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Institutional support
Allocation of responsibility
Environment-supportive of learning professionalism
Cognitive theoretical knowledge can be taught/tested
Experiential/Self-learning component/moral endeavourmust 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
Professionalism 11/09/09 YLawlor
Cruess & Cruess, 2009
 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
Professionalism 11/09/09 YLawlor
 Program of longitudinal assessments including
multiple assessment approaches
 Frequently throughout the program
 Give feedback
 Multiple assessors, multiple settings, multiple
opportunities
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Assessment of
Professionalism
Professionalism 11/09/09 YLawlor
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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)
Professionalism 11/09/09 YLawlor
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Professionalism 11/09/09 YLawlor
Cruess, Cruess &
Steinert, 2009
Professionalism minievaluation exercise
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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
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Assessment of
Professional
competence
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
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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.
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
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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
Professionalism 11/09/09 YLawlor
• 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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Professionalism
through selfreflection
Professionalism 11/09/09 YLawlor
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Self-Reflection
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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
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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Professionalism through
role modelling
Professionalism 11/09/09 YLawlor
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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 why
3. 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?
Professionalism 11/09/09 YLawlor
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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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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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Predicting Breaches
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Unprofessional
Behaviour
Duff, 2004 Examples include:
 Intellectual or personal dishonesty
 Arrogance and Disrespect
 Abrasive interactions with patients and coworkers
 Lack of accountability for errors
 Fiscal irresponsibility
 Lack of commitment to self-learning
 Lack of due diligence
 Substance abuse/high-risk behaviour
 Sexual misconduct
 Others?
Professionalism 11/09/09 YLawlor
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Breaches in
Professionalism
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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.
Professionalism 11/09/09 YLawlor
 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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Breaches in
Professionalism
Professionalism 11/09/09 YLawlor
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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 :)
Professionalism 11/09/09 YLawlor
 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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Moving Forward
Professionalism 11/09/09 YLawlor
 "Professionalism is knowing what to do, how to
do it, when to do it, and doing it.” Author
unknown
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Quote
Professionalism 11/09/09 YLawlor
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References
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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), 205208.
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
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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
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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
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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
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 Weis, D., & Schank, M.J. (2002). Professional values: Key to
professional development. Journal of Professional Nursing, 18(5), 271275
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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)
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