Nursing

384 AANA Journal October 2021 Vol. 89, No. 5 www.aana.com/aanajournalonline

This study examined the level of perceived cultural competence of student registered nurse anesthetists (SRNAs) in Illinois and made educational recommen- dations. A descriptive, cross-sectional study was com- pleted using the Clinical Cultural Competency Question- naire (CCCQ) to evaluate the perceived level of cultural competence among SRNAs in Illinois. Four domains of clinical cultural competency—knowledge, skills, atti- tudes (awareness), and encounters—were evaluated and reported. The survey response rate was 16.7% (N=57). A significant positive correlation was observed between cultural knowledge and age (P=.03). There was a significant difference in cultural knowledge between students attending a nurse anesthesia program in suburban Northeastern Illinois and students attending

a large, urban university in the city of Chicago, with CCCQ knowledge mean rank scores of 38.44 and 13.77, respectively. The overall level of perceived clinical cul- tural competence of SRNAs was low: mean (SD)=3.13 (0.54); range=2.17 to 4.89. The authors concluded that SRNAs need additional cultural education and training in their program of study to enhance their perceived level of cultural competence and to deliver culturally competent anesthesia care. The desire to become culturally competent coupled with deficient levels of cultural knowledge among SRNAs merits further work.

Keywords: Anesthesiology, cultural competence, cul- tural competence education, student registered nurse anesthetist.

Cultural Competence of Student Registered

Nurse Anesthetists in Illinois

Lisa M. Brown, DNP, CRNA

S. Saad Iqbal, DNP, CRNA

Susan Krawczyk, DNP, CRNA, APRN

Joseph D. Tariman, PhD, RN, ANP-BC, FAAN

C ultural competence is of paramount impor- tance in the United States. The US Citizenship and Immigration Services reports that each year more than 700,000 immigrants from countries around the world are naturalized

as US citizens.1 Today, half of the American population is forecast to belong to a group other than non-Hispanic whites by 2044.2 By 2060, the number of Asians and His- panics will increase from 5.4% and 17.4% to 9.3% and 28.3% of the total US population.2,3 Additionally, 1 in 4 patients accessing healthcare may not share the same cul- tural background as their providers by 2020.4

In 2018, the American Association of Nurse Anesthetists (AANA) published data on race and eth- nicity of its active members, showing an overwhelming majority (89%) of its members were whites, and there were only 3% Hispanics, 3% Asian or Pacific Islanders, 1% African Americans, 1% Native Americans, and 4% others (mixed races). To gain more perspectives on where the anesthesia provider workforce stands in terms of diversity, the report also provided data from other professional organizations of anesthesia. The Association of American Medical Colleges reported that most health- care providers are white despite the diversifying patient population.5 Furthermore, underrepresented minorities comprise 8.6% of the anesthesia workforce yet account for 32% of the US population.6 This disparity speaks

to the importance and relevance of integrating cultural competence into the nursing anesthesia education and training to help prepare all future nurse anesthetists to provide culturally and linguistically appropriate anesthe- sia care to a growing diverse patient population.

Cultural competence is realized when providers display personal awareness and culturally specific skills in delivering care to a multicultural patient population.7 Culturally competent care empowers patients and puts them at ease with medical treatments.8 Lack of culturally competent care negatively affects patients. They may not seek treatment for fear of being misunderstood, resulting in potential neglect and harm.4 Moreover, a deficiency in cultural competence among healthcare providers can be detrimental, as details about a patient’s traditional prac- tices must be considered to prevent interactions between herbal supplements, anesthetics, medications, and proce- dures. In the field of anesthesia, any miscommunication or lack of thoroughness can lead to errors and have an impact on patient safety.4

Culture encompasses an individual’s religion, race, attitudes, life experiences, and subscribed social norms; each human exhibits a unique cultural identity that influ- ences personal interactions.3 Cultural competence is a dynamic and continual process requiring individuals to demonstrate cultural awareness, knowledge, skills, and comfort when interacting with people of cultural back-

www.aana.com/aanajournalonline AANA Journal October 2021 Vol. 89, No. 5 385

grounds different from their own. The diverse US patient population requires anesthesia providers to be culturally competent to enhance patient safety and outcomes, yet there is little information available concerning the current level of cultural competence among anesthesia provid- ers. The Council on Accreditation of Nurse Anesthesia Educational Programs, the accrediting body for nurse anesthesia programs in the country, also provided a definition of cultural competence and described it as “ef- fectively utilizing various approaches in assessing, plan- ning, implementing and administering anesthesia care for patients based on culturally relevant information.”9

The current level of perceived clinical cultural com- petence has not been previously examined in student registered nurse anesthetists (SRNAs), to our knowledge. Hence, this study was conducted with 2 goals: (1) to assess the current level of clinical cultural competence among SRNAs in the state of Illinois using a reliable and validated questionnaire and (2) to identify educational gaps in their program of study. Based on study results, a robust discussion on opportunities and strategies to enhance the cultural competence among SRNAs in clini- cal practice is included in this article.

The Process of Cultural Competence in the Delivery of Healthcare Services Model guided the development and conduct of this study.10,11 This model defines cultural competence as a process wherein a healthcare provider never assumes his or her own proficiency and continu- ally and willingly endeavors to function within a client’s cultural milieu.10,11 Cultural awareness is defined as “the self-examination and in-depth exploration of one’s own cultural and professional background,” whereas cultural knowledge is defined as “the process of seeking and ob- taining a sound educational foundation about diverse cultural and ethnic groups.”10,11 Cultural skill refers to the gathering and processing of culturally specific information and performing thorough, patient-specific assessments.10,11 The construct of cultural encounters encompasses active and meaningful cross-cultural inter- actions, and the construct of cultural desire involves the aspiration to partake in the lifelong journey of becoming culturally competent.10,11

Materials and Methods • Design. A descriptive, cross-sectional, online survey study design was employed in this study. The Clinical Cultural Competency Questionnaire (CCCQ) was used to evaluate the perceived level of overall cultural com- petence among SRNAs enrolled in nurse anesthesia programs in Illinois. Four domains of clinical cultural competency—knowledge, skills, attitudes (awareness), and encounters—were evaluated and reported.

• Sample. The sample consisted of SRNAs enrolled in a nurse anesthesia program in the state of Illinois. Individuals enrolled in these programs have, at minimum,

1 year of critical care experience as a registered nurse and a bachelor of science in nursing degree.9 There are 5 nurse anesthesia programs in Illinois: NorthShore University HealthSystem School of Nurse Anesthesia (NSUHS), Evanston; Rosalind Franklin University of Medicine and Science (RFUMS) Nurse Anesthesia Program, North Chicago; Rush University Medical Center (RUMC) College of Nurse Anesthesia, Chicago; Southern Illinois University Edwardsville (SIUE) School of Nurse Anesthesia, Edwardsville; and Millikin University and Decatur Memorial Hospital (DMH) Nurse Anesthesia Program, Decatur. Program durations average approxi- mately 38 months; the range was 36 to 40 months. The average graduating class size is between 20 and 25 students, and an average of 68 students were enrolled at each school at the time of the survey; thus, there were approximately 340 SRNAs in the state of Illinois at that time.12 Each school helps students with the registration of their students for membership with the AANA and the Illinois Association of Nurse Anesthetists.

In this study, the exclusion criteria included age less than 18 years, Certified Registered Nurse Anesthetists, anesthesiologists, attendance at a nurse anesthesia program not in the state of Illinois, and completion of less than 75% of the survey.

• Setting and Instrument. This study used the Qualtrics Online Survey Research Platform. This platform allowed participants to complete the online survey using any elec- tronic device with internet access.

The Clinical Cultural Competency Questionnaire (CCCQ) is a validated and reliable survey that quanti- tatively measures cultural knowledge, skill, awareness, and encounters using a series of questions on a 5-point Likert-type scale.13 The tool operationally measures cul- tural knowledge with 10 questions; cultural skill with 15 questions; cultural encounters with 12 questions; cul- tural attitudes, a reflection of cultural awareness, with 21 questions.13 In keeping with the conceptual model used to guide the conduct of this study, the level of clinical cultural competence is determined by adding the totals of each subscale; higher scores indicate greater levels of cultural competence and lower scores indicate lower levels of cultural competence.10,11 The CCCQ instrument was adapted by researchers with permission from the primary author of the instrument and administered in conjunction with a 6-item demographic survey to study participants. For example, the word nurses was replaced with SRNAs to fit the context of this study.

• Recruitment and Data Collection. After obtaining approval from the institutional review board (IRB) of DePaul University, the electronically prepared study ma- terials (CCCQ survey, recruitment email, study informa- tion sheet) were electronically distributed to study partic- ipants by the executive director of the Illinois Association of Nurse Anesthetists. The researchers adhered to all

386 AANA Journal October 2021 Vol. 89, No. 5 www.aana.com/aanajournalonline

rights of study participants. All correspondence and data collection procedures did not gather internet protocol (IP) addresses or other personal identifiers to ensure the anonymity of participants. A reminder email containing the same information as the initial recruitment email was sent 2 weeks after the original communication.

The initial recruitment efforts did not result in the desired sample size, and an amendment was submitted to the IRB for additional recruitment approaches. After IRB approval of the amendment, the program directors of all nurse anesthesia programs in the state of Illinois were contacted and asked to forward the survey link to the SRNAs. As done previously, all correspondence and data collection procedures did not store any personal identifi- ers to secure the anonymity of the study participants. The survey was closed on January 10, 2019, after the desired sample size of at least 25 in each gender-based group was met. The sample size is based on the recommended sample size for a robust t-test analysis in the mean scores in CCCQ between male and female participants.14

• Data Analysis. The anonymous dataset was ex- ported from Qualtrics experience management software (Qualtrics) into a Statistical Package for the Social Sciences (SPSS) data file for statistical analyses. The data collected from the online survey were analyzed using the IBM SPSS software version 25.15 A total of 57 surveys met the inclusion criteria. The demographic characteristics of the sample were summarized using frequencies and percentages. The Cronbach coefficient value was cal- culated for each subscale of the CCCQ. Next, the mean scores for each subscale were calculated, added, and then averaged to determine the total level of cultural compe- tence among all participants. The Likert-type questions in the CCCQ inherently resulted in skewed data distri- butions and required the employment of nonparametric inferential statistics for the accurate determination of significant differences in the CCCQ scores between groups (Mann-Whitney U test and Spearman correla- tional test) and among 3 or more independent categorical groups (Kruskal-Wallis H test).

Results The sample was composed of 40 women and 17 men. Approximately 78.9% of participants were white, and 42.1% spoke at least one language other than English. The average age of participants was 30 years old. There were participants from each of the 5 nurse anesthesia programs in Illinois. Of the total sample, participants from NSUHS comprised 54.4%, RFUMS participants comprised 15.8%, SIUE participants comprised 14%, RUMC participants comprised 12.3%, and DMH par- ticipants comprised 3.5%. The breakdown of participants based on their year in anesthesia school was as follows: 31.6% were first year, 24.6% were second year, and 43.9% were third year (Table 1).

The CCCQ showed excellent validity and reliability. The overall calculated Cronbach coefficient for the survey was 0.961. The calculated Cronbach coefficients for all 4 subscales were all greater than 0.8 (Table 2).

The Likert-type questions were designed with 5 re- sponses: 1=not at all, 2=a little, 3=somewhat, 4=quite a bit, and 5=very. In keeping with the score analysis reported in a similar study, responses of 1 or 2 indicated very low levels of cultural competence, responses of 3 indicated fairly low levels of cultural competence, and responses of 4 or 5 indicated moderate to high levels of cultural competence.16 Participants reported a low level of cultural competence, with an overall mean score (SD) of 3.1 (0.54) and a range of 2.17 to 4.89). The reported overall mean scores for knowledge, skill, encounters, and attitudes (the measure of awareness) were 2.69, 2.86, 2.91, and 3.93, respectively. A Spearman rank correlation test revealed a significant positive correlation between the mean scores for cultural knowledge and age (P=.03; Figure). A Kruskal-Wallis H test revealed a sig- nificant difference in the mean ranks of cultural knowl- edge between participants attending RFUSM and RUMC. The RFUMS students scored significantly higher than did RUMC students in this subscale (P=.02). This finding in- dicates RFUMS students perceive they have significantly higher levels of cultural knowledge than RUMC students only, and no significant difference in cultural knowledge exists among SRNAs in RFUMS and the SRNAs in 3 other nurse anesthesia schools in Illinois.

More than half of the study participants (N=30; 52.6%) reported some form of cultural education in their program of study. Of these 30 responses, 20 (66.6%) received a course, 3 (10%) attended a seminar, 2 (6.6%) partook in student presentations, 1 (3.3%) participated in short class discussions, 1 (3.3%) reported culturally relevant life experiences, and 1 (3.3%) expressed involve- ment in all of the above. This self-report of previous cultural education can be problematic due to memory recall issues. Students may have taken topics relating to cultural education as part of their curriculum but simply forgot about it at the time of the survey. Moreover, there was no significant difference in the overall mean scores on CCCQ between those who reported receiving educa- tion on culture and those who did not receive educa- tion (P=.384; 2-sided Mann-Whitney U). Furthermore, nonparametric tests showed no significant correlation between the overall mean scores on CCCQ and age (using Spearman ). There also was no significant dif- ference in the distribution of the overall mean scores on CCCQ between the male and female groups (using Mann-Whitney U) and no significant differences in the overall mean ranks on CCCQ among 3 or more inde- pendent groups according to ethnicity, nurse anesthesia school attended, and year in the anesthesia program (all P values were above the significance level of .05).

www.aana.com/aanajournalonline AANA Journal October 2021 Vol. 89, No. 5 387

Discussion The results of this study found that SRNAs in the state of Illinois have moderate to high levels of cultural aware- ness but low levels of cultural knowledge. This finding aligns with the report by Hart and Mareno16 of moderate to high levels of cultural awareness and low levels of cultural knowledge in undergraduate and graduate pre- pared nurses across the United States. These results are also supported by Repo and colleagues,17 who discovered that 74% of graduating nursing students in Southern Finland demonstrate cultural awareness but lack full cul- tural competence. However, the findings contradict the assertion by Shepherd and colleagues18 that healthcare providers exhibit practical cultural knowledge but lack cultural awareness. Shepherd and colleagues18 claimed that anesthesia providers (eg, anesthesiologists or nurse anesthetists) are unaware of their cultural prejudice and

how this prejudice affects patient care. Potential negative clinical outcomes from clinical prejudice included lack of trust for the provider, poor communication or lack of communication leading to errors in providing patient care, and patient dissatisfaction with the health provider and the entire healthcare delivery enterprise.18 Smith19 asserts that this lack of cultural awareness is a pitfall among many providers, educators, and students and is remedied with self-assessment and reflection. However, the results of this study show that SRNAs exhibit cultural awareness and a strong desire for cultural knowledge. This finding indicates a need for a dedicated course concerning cultural competence and clinical immersion experiences with multicultural patient encounters rather than self-assessment and reflection (see detailed discus- sion later on immersion to Hispanic or Black communi- ties). The American Association of Colleges of Nursing

Table 1. Demographic Characteristics of Study Participants (N=57)a aSome percentages do not total to 100 because of rounding.

Characteristic Number (%)

Gender

Male 17 (29.8)

Female 40 (70.2)

Self-identified race-ethnicity

African American/Black 1 (1.8)

Asian American 7 (12.3)

Latino/Hispanic 1 (1.8)

Native Hawaiian/ Pacific Islander 1 (1.8)

White 45 (78.9)

Mixed race 2 (3.5)

Spoken languages other than English

Yes 24 (42.1)

No 33 (57.9)

Nurse anesthesia program in Illinois

Millikin University and Decatur Memorial Hospital Nurse Anesthesia Program 2 (3.5)

NorthShore University HealthSystem School of Nurse Anesthesia/DePaul University 31 (54.4)

Rush University College of Nursing Nurse Anesthesia Program 7 (12.3)

Rosalind Franklin University of Medicine and Science 9 (15.8)

Southern Illinois University Edwardsville School of Nursing/Anesthesia Nursing Specialization 8 (14.0)

Year in program

First 18 (31.6)

Second 14 (24.6)

Third 25 (43.9)

Education/seminar/course on culture

Yes 30 (52.6)

No 27 (47.4)

Types of education/seminar/course

Seminar/lecture 17

Class/course 8

Other experience 1

No education reported 4

388 AANA Journal October 2021 Vol. 89, No. 5 www.aana.com/aanajournalonline

(AACN) doctoral essentials for nursing education has included culture, ethics, and policy as among the core doctoral courses that all DNP graduates must complete to earn the DNP degree.20

This study found a significant correlation between cultural knowledge and age, with older participants ( 30 years old) reporting higher levels of cultural knowledge. Sargent and colleagues21 also report a positive correlation between age and cultural knowledge in the level of per- ceived cultural competence among occupational thera- pists. Suarez-Balcazar and colleagues22 report cultural knowledge increases as years of experience increases, although this correlation is not attributed to age; instead, it is a result of increased exposure to cultural encounters in the workplace.

This study found no relationship between ethnicity and cultural competence. This finding should be inter- preted within the context that 78% of the participants in this current study identified themselves as white, whereas only 22% were nonwhite. Conversely, Repo and colleagues17 report a positive correlation between ethnicity and one’s overall level of cultural competence.

Repo and colleagues17 also report individuals who par- ticipate in exchange programs demonstrate higher levels of cultural competence. This finding has been corrobo- rated in several other studies, as integrative (didactic on culture, followed by a 3-month immersion in Black- or Hispanic-serving clinics or neighborhoods) and immer- sive cultural experiences significantly increase cultural competence.23-27

• Immersion. Immersion of nurses in Hispanic- or Black-serving community clinics is a recommended strat- egy to improve cultural competence. Immersive educa- tion is one of the best ways to learn other people’s culture through firsthand experience, wherein students receive both formal classroom cultural education and an immer- sive cultural experience in a foreign country, results in higher levels of cultural competence than formal class- room education alone.26,27 A study abroad program or Surgical Brigades community outreach program such as the Honduras Surgical Brigades led by Bernadette Roche, EdD, CRNA (an NSUHS nurse anesthetist who has par- ticipated in the Honduras Surgical Brigade every year for the past 10 years) can provide an impactful cultural and

Figure. Plot Graph Showing Relationship Between Participant Age and Mean Cultural Knowledge Scoresa aSignificant positive correlation (Spearman rank correlation test) exists between participant age and mean scores for cultural knowledge (P=.03).

Table 2. Reliability of Individual Subscales Abbreviation: CCCQ, Clinical Cultural Competency Questionnaire.

Cronbach coefficient CCCQ subscale Number of items value for subscales

Knowledge 16 .877

Skills 15 .956

Encounters 12 .917

Attitudes 20 .942

Overall CCCQ 63 .961

www.aana.com/aanajournalonline AANA Journal October 2021 Vol. 89, No. 5 389

language experience for SRNAs. Teaching strategies that employ international service-learning immersion projects contribute to students’ cultural encounters, knowledge, skills, awareness, sensitivity, self-efficacy, and under- standing of cultural barriers.26,27 The addition of debrief- ing and reflective learning after these service-learning experiences enhances these educational benefits.26,27 This form of immersive training increases the frequency of cross-cultural encounters, which positively correlates with increased levels of cultural competence.17,21-27

Another educational strategy to improve cultural com- petence among SRNAs involves presentations. Lectures and presentations created and disseminated to students by minority groups (eg, Blacks, Hispanics, and Asians) increase cultural attitudes and knowledge.28 This strat- egy relies on the direct involvement of minorities and requires educators to realize their limitations when teaching curricula about cultures other than their own. If direct minority involvement is not feasible, Upvall and colleagues29 recommend student mentors. For example, some students have more knowledge, experience, and comfort when interacting with individuals of certain cul- tural groups. Pairing these students with individuals with limited cultural encounters facilitates meaningful learn- ing and enhances cultural competence in both parties.29

The desire to become culturally competent coupled with very low levels of cultural knowledge among SRNAs merits further work. Additional educational needs as- sessments should be performed on state and national levels. The AANA asserts cultural awareness and cultural competence are essential for the delivery of high-quality, patient-centered care, as these provider characteristics have been shown to improve patients’ health, engage- ment, and satisfaction.30 The results of this study add to the current body of knowledge and should be included in future analyses to identify specific areas for improve- ment. Educational programs should be created and implemented based on identified areas of weakness.

Research to determine the most effective means to in- crease cultural competence in SRNAs is necessary. Based on the results of this study, the authors strongly feel the inclusion of a dedicated course on multiculturalism and clinical cultural competence in the DNP program cur- riculum is essential as outlined by the AACN’s doctoral essentials for nursing education.20 The authors recom- mend that these programs employ cultural immersion techniques, peer mentoring, and minority guest speakers to increase efficacy. Future studies in this area should be individualized by the institution using systematic, rigorous research design. The authors suggest a longitudinal pretest (first year in the program) and posttest (fourth year in the program) with randomization into intervention (with im- mersion) vs nonintervention (without immersion).

• Study Limitations and Strength. The participants of this study included SRNAs enrolled in a nurse anesthe-

sia program in the state of Illinois. The results from this study may not be reflective of the cultural competency of SRNAs on a national level. Another limitation of this study stems from study recruitment. Despite the email being sent to all SRNAs in Illinois, it was difficult to recruit an equal number of participants from each school. Therefore, the sample size from each school varied con- siderably. Participation was voluntary, and the sample size may not be representative of all the SRNAs in Illinois. The results must be interpreted with caution given that they were self-reported and could be perceived as being subjective in nature. Self-reported data can lead to recall bias and social desirability bias, as the questions in this survey cover sensitive topics.31 Despite these limitations, this study has a major strength as the first study exam- ining the cultural competence of SRNAs in the United States. The data gathered in this study can be used for programmatic quality improvement initiatives to enhance the cultural competency of SRNAs during their training.

Conclusion Student registered nurse anesthetists need additional cul- tural education and training in their program of study to enhance their perceived level of cultural competence and to deliver culturally competent anesthesia care. The desire to become culturally competent coupled with deficient levels of cultural knowledge among SRNAs merits further work in this area. Program directors should evaluate their curriculum and proactively integrate clinical cultural education and training to build the cultural competency of the SRNAs. Such efforts will help meet the emerging market need for culturally competent CRNAs as stated in the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS).32

REFERENCES

390 AANA Journal October 2021 Vol. 89, No. 5 www.aana.com/aanajournalonline

AUTHORS Lisa M. Brown, DNP, CRNA, was a student registered nurse anesthetist attending NorthShore University HealthSystem School of Nurse Anesthe- sia and DePaul University in Chicago, Illinois, at the time this article was prepared for dissertation. She now is a CRNA at Loyola University Medical Center in Maywood, Illinois. Email: [email protected].

S. Saad Iqbal, DNP, CRNA, was a student registered nurse anesthetist attending NorthShore University HealthSystem School of Nurse Anesthe- sia and DePaul University. Dr Iqbal is now a CRNA at the University of Chicago Department of Anesthesia and Critical Care, Chicago, Illinois.

Susan Krawczyk, DNP, CRNA, APRN, is a faculty member at the NorthShore University HealthSystem/DePaul University School of Nurse Anesthesia and a clinical CRNA at Loyola University Medical Center.

Joseph D. Tariman, PhD, RN, ANP-BC, FAAN, is a faculty member and codirector for the DNP program at DePaul University in Chicago, Illinois. Email: [email protected].

DISCLOSURES Name: Lisa M. Brown, DNP, CRNA Contribution: This author made significant contributions to the concep- tion, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: S. Saad Iqbal, DNP, CRNA Contribution: This author made significant contributions to the concep- tion, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Susan Krawczyk, DNP, CRNA, APRN Contribution: This author made significant contributions to the concep- tion, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. Name: Joseph D. Tariman, PhD, RN, ANP-BC, FAAN Contribution: This author made significant contributions to the concep- tion, synthesis, writing, and final editing and approval of the manuscript to justify inclusion as an author. Disclosures: None. The authors did not discuss off-label use within the article. Disclosure statements are available for viewing upon request.

ACKNOWLEDGMENTS The survey used has been adapted with permission obtained via email from the Clinical Cultural Competency Questionnaire (CCCQ) developed by Robert C. Like, MD, MS, professor and director of the Center for Healthy Families and Cultural Diversity, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. The CCCQ was used in a project titled, “Assessing the Impact of Cultural Competency Training Using Participatory Quality Improvement Methods,” funded by the Aetna Foundation. Any results obtained in future projects making use of the CCCQ are solely the respon- sibility of the project investigators and do not necessarily represent the official views of the Aetna Foundation or its affiliates.

Copyright of AANA Journal is the property of American Association of Nurse Anesthetists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.