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Validating international CanMEDS-based standards defining education and safe practice of nurse anesthetists

C. Herion1 RN, NA, PhD, MME Unibe , L. Egger2 RN, NA, MME Unibe, R. Greif3 MD, MME Unibe & C. Violato4,5 PhD 1 Medical Educator, Department of Anesthesiology, Kantonsspital Aarau, Aarau, Switzerland 2 Scientific Assistant and Educator Medi, Centre for Medical Education, Bern, Switzerland 3 Professor, Department of Anesthesiology and Pain Therapy, Bern University Hospital, Bern, Switzerland, 4 Professor, Department of Medical Education, University Ambrosiana, Free University of Milan, Milan, Italy, 5 Professor, Department of Internal Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA

HERION C., EGGER L., GREIF R. & VIOLATO C. (2019) Validating international CanMEDS-based

standards defining education and safe practice of nurse anesthetists. International Nursing Review 66,

404–415

Aim: To investigate whether the CanMEDS-based International Federation of Nurse Anesthetists’ Standards

could adequately define the scope of practice and reliably be used to train and evaluate Swiss nurse

anesthetists (NAs).

Background: Although nurse anesthetists represent a majority of the global workforce in anesthesia, policies

that define the scope of practice are frequently non-existent. In low- and middle-income countries, the lack

of anesthesia providers with adequate training is a major challenge.

Introduction: Despite stringent training requirements, the scope of practice of Swiss nurse anesthetists is

actually not defined. Therefore, we surveyed and assessed whether nurse anesthetists felt that the

professional competencies outlined in this framework were aligned with their clinical practice.

Methods: A cross-sectional survey investigated Swiss nurse anesthetists’ relevance ratings of 76 competencies

of the International Federation of Nurse Anesthetists according to their professional practice. Cronbach’s

alpha coefficients were used to determine the internal consistency of the competencies, as well as factor

analyses to assess construct validity of these competencies integrated into the CanMEDS roles model.

Results: Participants rated the Standards overall as very relevant with high reliability. Factor analyses

provided evidence of construct validity of these.

Discussion: The International Federation of Nurse Anesthetists’ Standards of Practice provide a highly

relevant framework and a valuable set of competencies for the scope of practice of Swiss nurse anesthetists,

which enabled translation from global guides to local national standards.

Conclusion and implication for nursing and health policy: Adopted by low- and middle-income

countries or countries where national standards are non-existent, this survey could introduce national and

Correspondence address: Dr Christian Herion, Department of Anesthesiology, Kantonsspital Aarau, Tellstr., Aarau, Switzerland; Tel: +41-62-838-6505; Fax: +41 (0)62 838

67 22; E-mail: [email protected].

Funding

This study was funded by a research foundation of the International Federation of Nurse Anesthetists (IFNA), www.ifna.site and by the Research Council

Kantonsspital Aarau, Switzerland.

Conflict of interest

During the study CH and LE were members of the IFNA Education and Practice Committee, RG and CV: None.

404© 2019 The Authors International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

Original Article

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local policies at minimally acceptable standards of care for nurse anesthetists worldwide. The above

standards have the potential to align education, outcomes and assessment of nurse anesthetists with the

needs of national healthcare systems.

Keywords: Anesthesia, Anesthesia Providers, CanMEDS, Competency-Based Medical Education, Interna-

tional Federation of Nurse Anesthetists Standards, Non-Physician, Nurse Anesthetists, Scope of Practice,

Switzerland

Introduction Non-physician anesthesia providers (NPAPs) represent the

majority of the anesthesia workforce worldwide. NPAPs work

independently, or under the supervision of anesthesiologists

or other physicians. In low and middle-income countries

(LMICs), where anesthesiologists are scarce, NPAPs provide

medical, interventional, and surgical procedures under general

anesthesia, as well as sedation and loco-regional anesthesia

(Hodges et al. 2007). Worldwide, the educational systems,

scope of practice and continuing professional development

(CPD) activities of NPAPs is adapted to national and regional

needs and legislations. We use the term NPAP to describe the

entire non-physician anesthesia workforce; nurse anesthetists

(NAs) are the predominant NPAPs worldwide.

Background Nurse anesthetists provide induction, maintenance and emer-

gence of anesthesia. In 40 LMICs, they work without physi-

cian supervision (Kempthorne et al. 2017). These differences

influence the quality and safety of anesthesia care worldwide.

NPAPs from 96 World Health Organization (WHO) member

countries reported in a rare global survey no hospital policies

in 26%, no governmental regulations in 41%, and no oppor-

tunities for continuing education were available in 50% of

countries (Henry & McAuliffe 1999).

According to the WHO (World Health Organization 2016)

and the Organisation for Economic Co-operation and Devel-

opment (OECD 2016), the workforce crisis, including global

migration of healthcare workers, further aggravates the

problem. In 77 countries from WHO regions, the density of

anesthesia providers is <5 per 100 000 habitants (Kempthorne et al. 2017). This results in a crisis of patient safety during

anesthesia for the poorest of the poor.

Fundamental components to foster the quality of health

systems are defined by the WHO (World Health Organization

2013, 2017, 2018) and the International Council of Nursing

(ICN; Catton 2017). In order to address this safety issue, NA

training and scope of practice should be regulated in LMICs

where physician anesthesiologists are not sufficiently available

(Lipnick et al. 2017). Identifying a set of international

standards that is relevant to the scope of practice for NAs

and using those standards as a framework to train and evalu-

ate NAs in LMICs can achieve this.

One possible set of standards that could be used come

from the International Federation of Nurse Anesthetists

(IFNA), a global organization representing over 40 member

countries. The IFNA, an affiliate of ICN, provides interna-

tional guidelines and recommendations addressing the quality

of the care, education, safe practice and professional values of

NAs (Meeusen et al. 2016). In 2016, the IFNA’s Standards

(Code of Ethics, Standards of Practice, Monitoring, and Edu-

cation; IFNA 2016) were thoroughly revised on a compe-

tency-based approach by adopting the Canadian Medical

Education Directions for Specialists (CanMEDS) Framework

(Frank et al. 2015; Fig. 1). The CanMEDS consists of seven

roles (Manager, Communicator, Professional, Scholar, Expert,

Health Advocate, Collaborator) and have been widely used as

a framework to describe physician competencies. The IFNA’s

Standards of Practice include 76 graduate competencies that

Fig. 1 Adapted by IFNA from the CanMEDS Physician Competency

Diagram with permission of the Royal College of Physicians and Sur-

International standards nurse anesthetists 405

are categorized within the seven CanMEDS functional roles

and 23 anesthesia-related domains (Table 1).

In Switzerland, NAs are the sole recognized and regulated

NPAPs, and there is a 50-year-long tradition of close collabo-

ration between physicians and NAs. Currently, the Swiss NA

workforce includes approximately 2000 registered certified

professionals. A recognized nurse diploma is mandatory to

apply to a 2-year nurse anesthesia program, which includes at

least 900 h of additional didactic training (OdASant�e 2012).

Despite these stringent training requirements, the scope of

practice of Swiss NAs is actually not defined. In order to

accomplish this, we surveyed NAs in Switzerland to assess

whether they felt that the 76 professional competencies out-

lined in this framework were aligned with their clinical

practice. We felt that an evaluation of the IFNA’s Standards of

Practice by Swiss NAs would provide a dependable analysis of

that framework since the Swiss association of nurse anesthetists

(SIGA/FSIA) planed to adopt the IFNA’s Standards of Practice

into the national NA curriculum revision in 2018.

If our study can demonstrate that the IFNA’s Standards of

Practice are representative of the scope of practice of NAs, then

it stands to reason that LMICs or countries where national

standards for NAs do not yet exist could adopt IFNA’s Stan-

dards of Practice. This would introduce practice consistency at

the minimally accepted standard of care for NAs worldwide.

Aims

The primary goal of our study was to investigate whether the

CanMEDS Framework and the IFNA’s Standards of Practice

show coherence and consistency with the scope of practice of

NAs. To establish and pilot a sound study design, the study

focused on a well regulated, and for research purposes well

controllable, professional community of NAs within one

country (Switzerland). The findings can serve as a basis for

further multinational research in high-, low- and middle-

income countries.

Methods

Design and setting

In 2015, possible study participants for the cross-sectional

online survey were contacted via the database of the Swiss

association of nurse anesthetists (SIGA/FSIA; Appendix S1

English and Appendix S2 German survey).

Research population

Overall 734 NAs from all Swiss cantons were invited. Partici-

pants were excluded, if they had no basic medical education

(e.g. nursing degree).

Data collection

Data were collected over a period of 32 weeks between 18

April and 27 November 2015.

Ethics

The Ethics Committee Northwest/Central-Switzerland (EKNZ

UBE-15/19, 02/17/2015) declared the study as ‘uncritical

according to ethical aspects’ and therefore granted a waiver of

informed consent according to the Swiss Human Research Act.

Data analysis

Data were analyzed by SPSS 24.0 (IBM, Armonk, USA) and

EQS 6.1 (Multivariate Software, Temple City, USA) and

Table 1 CanMEDS roles, domains and number of graduate competen-

cies within IFNA’s Standards of Practice

CanMEDS roles and domains Number of graduate

competencies

CanMEDS Role ‘Nurse Anesthetist Expert’

1. Preanesthetic patient assessment 5

2. Anesthetic management 5

3. Risk management 4

4. Monitoring 1

5. Advanced life support 4

6. Equipment 1

7. Termination of anesthesia 2

8. Postoperative care and pain management 4

9. Infection control 3

10. Documentation 2

CanMEDS Role ‘Communicator’

1. Communication and situation awareness 4

CanMEDS Role ‘Collaborator’

1. Collaboration and teamwork 7

CanMEDS Role ‘Manager’

1. Task management 5

2. Quality management 2

CanMEDS Role ‘Health Advocate’

1. Patient information 1

2. Patient education 3

3. Patient advocacy 1

CanMEDS Role ‘Scholar’

1. Continuous professional development 5

2. Research 4

3. Education 4

CanMEDS Role ‘Professional’

1. Professionalism 4

2. Advancement of anesthesia care 2

3. Accountability 3

Overall number of graduate competencies 76

406 C. Herion et al.

presented as mean, SD or percentage. A P-value < 0.05 was considered statistically significant. Differences between the

study participants’ demographic variables (level of anesthesia

education, age, gender, work experience in years and special

job function) were analyzed using a multivariate analysis of

variance (MANOVA). The demographic variables were set as

the independent variables, with the ratings of the seven Can-

MEDS roles as the dependent variables. Cronbach’s alpha

coefficients were used to determine the internal consistency

of graduate competencies within the seven CanMEDS roles.

Construct validity of IFNA’s graduate competencies for NAs

integrated into the CanMEDS roles model was assessed by

exploratory factor analyses and confirmatory factor analyses.

Accordingly, we divided the data randomly into two cohorts.

With cohort 1 (n = 225), we performed an exploratory fac- tor analysis (EFA) employing varimax rotation with Kaiser

normalization to investigate the factors structures underlying

the instrument. This allowed us to identify and extract the

significant factors from the 76 competencies, which influ-

enced NAs’ responses on the graduate competencies. Factor

loadings >0.4 indicated acceptable strength and direction and the influence of a factor on the graduate competencies.

EFA was performed with a resulting seven-factor solution.

We hypothesized that these seven factors would correspond

with the seven CanMEDS roles (Manager, Communicator,

Professional, Scholar, Expert, Health Advocate and Collabo-

rator). To determine the best-fitting model of graduate com-

petencies within the CanMEDS roles that had been derived

from cohort 1, we subsequently performed a confirmatory

factor analysis (CFA) with cohort 2 (n = 224). A maximum likelihood estimation with a comparative fit index >0.9 was accepted as good fit. Construct validity of the optimized

model would be underlined by investigating correlations

between CanMEDS roles and graduate competencies. Factor

correlation coefficients (r) were calculated and accepted to

interpret loadings if >0.4. (For details on EFA and CFA see Appendices S3 and S4).

Results Out of 734 NAs invited, 449 completed the online survey (re-

sponse rate 61%, from 23 out of 26 Swiss cantons). Respon-

dents ranged in age from 24 to 68 years [mean (m) = 44, standard deviation (SD) = 9]; 290 were female (65%). Of these, 430 (96%) had a nursing diploma from a Swiss-recog-

nized institution as basic health education. A small number

(n = 13, 3%) had a paramedic diploma and six (1%) had graduated from an accredited healthcare program in another

European country (e.g. Germany, Austria). Overall, 381

respondents (85%) were Swiss NA diploma holders, 36 were

NA students (8%), 26 had a German diploma (6%), two

from Austria (0.4%), one from the Netherlands (0.2%) and

one from Sweden (0.2%). Two participants (0.4%) had no

NA diploma.

Asked for their most accurate job function, the majority of

respondents (n = 217, 48%) indicated they were predomi- nantly in clinical practice. Nearly, a quarter (n = 104, 23%) worked primarily in education, 91 (20%) were primarily in

management/leadership and 36 (8%) were primarily students

in an anesthesia care training program.

Relevance ratings of NAs’ competencies and CanMEDS roles

Overall, 62 of the 76 (82%) graduate competencies were rated

relevant or very relevant (m = 4.45, SD = 0.71) in relation to the Swiss NAs’ scope of practice. Fourteen graduate compe-

tencies were rated as moderately relevant or relevant

(m = 3.2, SD = 1.05; Table 2). In the aggregate, all seven of the CanMEDS roles (Table 2)

were rated as relevant or very relevant (m = 4.22, SD = 0.42). On their own, five roles attained relevant or very relevant

VAS-ratings: NA-Expert (m = 4.58, SD = 0.28), Communica- tor (m = 4.58, SD = 0.10), Collaborator (m = 4.35, SD = 0.16), Scholar (m = 4.07, SD = 0.39) and Professional (m = 4.25, SD = 0.32), while the remaining two roles, Manager (m = 3.81, SD = 0.29) and Health Advocate (m = 3.89, SD = 0.25), scored moderately relevant.

Reliability of CanMEDS roles

The overall internal consistency was very high for the overall

CanMEDS roles (Cronbach’s a = 0.97), as well as for NA- Expert (a = 0.91) and Scholar (a = 0.91). The internal con- sistency was high for Collaborator (a = 0.88), Manager (a = 0.88), Health Advocate (a = 0.86) and Professional (a = 0.86); for Communicator (a = 0.78) it was acceptable (Table 2).

Relevance ratings of CanMEDS roles and differences between

survey respondents’ characteristics

The analysis of study participants’ differences revealed that

the overall CanMEDS Framework was rated as more relevant

by paramedics (n = 13, m = 4.35, SD = 0.52) than by nurses (n = 430, m = 4.21, SD = 0.52), followed by NAs with other basic education (n = 6, m = 4.18, SD = 0.51, P < 0.05). Par- ticipants with no NA education rated the CanMEDS Frame-

work the most relevant (n = 2, m = 4.70, SD = 0.35, P < 0.01). Ratings of the CanMEDS Framework differed between women (n = 290, m = 4.22, SD = 0.49) and men (n = 159, m = 4.20, SD = 0.57, P < 0.01). These differences were due to higher scores by women for only two CanMEDS

International standards nurse anesthetists 407

Table 2 Descriptive statistics and reliability (Cronbach’s a) of competencies and CanMEDS roles

CanMEDS Role ‘Nurse Anesthetist Expert’ (Cronbach’s a = 0.91) Mean SD

Graduated Competencies of Nurse Anesthetist Expert 4.58 0.28

1. Preanesthetic patient assessment

Nurse anesthetists

A. Perform and/or participate in the performance of preanesthetic interviews by eliciting comprehensive histories and

performing physical examinations based on patient’s presenting symptoms

3.88 1.24

B. Assess and evaluate multiple variables (drugs taken, preexisting diseases, allergies, previous anesthetic experiences) that may

affect the course of anesthesia. Identify potential risks to patient safety

4.45 0.85

C. Formulate an anesthetic care plan based on current knowledge, concepts, available evidence, and nursing principle 4.2 0.94

D. Provide accurate and understandable information to assist patients in giving informed consent 4.26 1.07

E. Integrate evidence to explain possible anesthetic and/or postanesthetic risks 4.18 0.92

2. Anesthetic management

Nurse anesthetists

A. Are continuously present during anesthetic management 4.54 0.73

B. Administer and/or participate in the administration of general and regional anesthesia to all patients for all surgical and

medically related procedures

4.68 0.58

C. Prepare, administer, and adapt anesthetic medications, anesthetic procedures, and other interventions according to preexisting

disease and surgical procedure, demonstrating advanced knowledge of human sciences, pharmacology, surgical and anesthesia

procedures

4.57 0.67

D. Provide psychological support to help patients through the perioperative experience by using advanced communication skills

to improve patient outcomes and design strategies to meet the patient’s needs

4.53 0.79

E. Use a broad variety of techniques, anesthesia agents, adjunctive and accessory drugs, and equipment when providing

anesthesia care and pain management. Exhibit a comprehensive knowledge of pharmacology and pharmacokinetics related to

anesthesia practice. Select, administer, and prescribe appropriate medication based on accurate knowledge of patient

characteristics, anesthesia technique, and surgical procedure

4.47 0.78

3. Risk management

Nurse anesthetists

A. Take appropriate safety precautions including documentation to ensure the safe administration of anesthesia care 4.85 0.31

B. Prepare anesthetic plans, equipment, and drugs according to standard operating procedures and globally recommended

checklists

4.82 0.37

C. Recognize and take appropriate actions during anesthesia management by rapidly assessing a patient’s situation through

synthesis and prioritization of historical and available data. Advanced knowledge and experience are demonstrated at all times.

Nurse anesthetists demonstrate confidence in their own abilities to identify normal and abnormal states in anesthesia

4.85 0.32

D. Engage in the development of guidelines, standard operating procedures, and checklists for equipment and drug use 4.36 0.8

4. Monitoring

Nurse anesthetists

A. Monitor, analyze and utilize data obtained from the use of current invasive and noninvasive monitoring modalities using

critical thinking and clinical judgment. Identify priorities quickly using context-specific knowledge and accurately identify

parameters for the safety of patients to ensure decisions are justified in the specific context. Respond constructively to

unexpected or rapidly changing situations and develop flexible and creative approaches to manage challenging clinical situations

4.81 0.33

5. Advanced Life Support

Nurse anesthetists

A. Take corrective action to maintain or stabilize the patient’s condition and provide advanced life support care 4.86 0.32

B. Assess and provide adequate advanced life support. Use advanced communication skills to inform the interdisciplinary team,

organize and collaborate with appropriate experts, and use adequate medications and equipment

4.83 0.31

C. Provide regular education in basic life support and advanced resuscitation procedures to health professionals, as needed 4.22 1.03

D. Adhere to the latest international guidelines and accept responsibility for their own regular certified training in advanced life

support

4.59 0.63

6. Equipment

Nurse anesthetists

A. Select, prepare, use and clean the appropriate equipment in routine and critical incident situations 4.62 0.65

408 C. Herion et al.

Table 2 Continued

CanMEDS Role ‘Nurse Anesthetist Expert’ (Cronbach’s a = 0.91) Mean SD

7. Termination of anesthesia

Nurse anesthetists

A. Assess, analyze and evaluate adequacy of the patient’s condition before transferring care. Evaluate patient responses for

readiness to move to next level of care by identifying patient situation, and take appropriate action in the immediate post-

operative period

4.78 0.35

B. Report all essential data regarding the perioperative period comprehensively and completely to the personnel in charge of the

next level of care

4.83 0.34

8. Postoperative care and pain management

Nurse anesthetists

A. Serve as a resource person in pain management and adequate postoperative care 4.2 0.94

B. Demonstrate advanced knowledge in pharmacology and pharmacokinetics of analgesic drugs in assessing and providing pain

management

4.36 0.8

C. Assess and manage common postoperative complications such as respiratory, hemodynamic, neurological dysfunctions, and

postoperative nausea and vomiting

4.21 1

D. Develop or participate in developing and revising standard operating procedures for all personnel covering postoperative care 3.91 1.1

9. Infection control

Nurse anesthetists

A. Apply practices such as proper hand hygiene and cleaning or sterilization of equipment 4.65 0.5

B. Maintain knowledge of and adhere to national and/or institutional standards of infection control to protect the patient and

healthcare workers from infectious diseases

4.61 0.58

C. Adapt or participate in adaptation and revision of infection control standards for all anesthesia procedures, and adhere to

national standards for storing, handling, prescribing and administering drugs

4.25 0.91

10. Documentation

Nurse anesthetists

A. Provide prompt, complete and accurate recording of pertinent information and action of care on the patient’s record 4.8 0.4

B. Facilitate, through accurate recording, comprehensive patient care. Provide information for retrospective review and research

data, and establish a medical-legal record

4.69 0.57

CanMEDS Role ‘Communicator’ (Cronbach’s a = 0.78) Mean SD

Graduate Competencies of Communicator 4.58 0.10

1. Communication and situation awareness

Nurse anesthetists

A. Communicate in a calm, confident, and effective approach that brings comfort and emotional support to patients and

their family, and create a climate that supports mutual engagement and establishes partnerships with patients

4.68 0.53

B. Engage in effective interpersonal and intraprofessional communication using advanced communication skills suitable

for the interdisciplinary domain of the workplace

4.67 0.46

C. Create awareness of specific and overlapping functions and the potential for interdisciplinary tensions and demonstrate

strategies of conflict management, if necessary

4.44 0.68

D. Display crisis intervention skills when required and assure patient understanding, respect, empathy and trust by

maintaining confidentiality and discretion

4.54 0.65

CanMEDS Role ‘Collaborator’ (Cronbach’s a = 0.88) Mean SD

Graduate Competencies of Collaborator 4.35 0.16

1. Collaboration and teamwork

Nurse anesthetists

A. Collaborate with others to identify innovative solutions to clinical and system problems. Advance patient care standards by

partnering with interdisciplinary healthcare team members in research and educational activities

4.09 0.93

B. Implement new technologies that enhance patient care and promote patient safety goals 4.18 0.86

International standards nurse anesthetists 409

Table 2 Continued

CanMEDS Role ‘Collaborator’ (Cronbach’s a = 0.88) Mean SD

C. Establish effective, collegial relationships with other health professionals that reflect confidence in the contribution that nurse

anesthetists make to the system

4.3 0.75

D. Encourage cooperative relationships between nurse anesthetists, physician anesthetists, and other members of the medical

profession, the nursing profession, hospitals and agencies representing a community of interest in nurse anesthesia

4.42 0.66

E. Respect roles and competencies of other team members and demonstrate joint decision-making skills to achieve the best

possible patient outcome

4.6 0.58

F. Provide feedback and constructively discuss team strengths and weaknesses, listen to others, and ensure consistent information

flow to patients and colleagues

4.41 0.78

G. Demonstrate effective solutions to problems concerning team issues 4.42 0.7

CanMEDS Role ‘Manager’ (Cronbach’s a = 0.88) Mean SD

Graduate Competencies of Manager 3.81 0.29

1. Task management

Nurse anesthetists

A. Anticipate and make decisions in advance for challenges by allocating appropriate time frames, organizing appropriate

staffing, and preparing equipment and materials

4.21 0.94

B. Use existing resources effectively and efficiently by designing or participating in designing evidence-based strategies to meet

the multifaceted needs of patients

4.24 0.78

C. Consider fiscal and budgetary implications in decision-making regarding practice and system modifications 3.67 1.14

D. Organize and plan for the correct ecological handling of wastes such as gases, drugs, sharps, and infectious materials 4.12 0.98

E. Evaluate and optimize the use and impact of products, services, and technologies on high quality patient care 4.02 0.97

2. Quality management

Nurse anesthetists

A. Measure or participate in measuring patient satisfaction, cost, clinical outcomes, nurse satisfaction and retention by

applying methods of quality assurance and improvement

3.45 1.28

B. Foster an interdisciplinary approach to quality improvement, evidence-based practice, research and transition of research

into practice

3.67 1.17

CanMEDS Role ‘Health Advocate’ (Cronbach’s a = 0.86) Mean SD

Graduate Competencies of Health Advocate 3.89 0.25

1. Patient information

Nurse anesthetists

A. Consider and evaluate various influences on patients’ health status. Detect health related and anesthetic risk factors

through anesthetic assessment, and promote individual health by addressing behavioral change

3.8 1.15

2. Patient education

Nurse anesthetists

A. Participate in the education of patients, other members of the health team and members of the community before, during,

and after the operative period

3.34 1.26

B. Design or select health information and patient education appropriate to developmental level, health, literacy level, learning

needs, readiness to learn, preferred learning style, and cultural values and beliefs

3.13 1.29

C. Facilitate patient and family understanding of the risks, benefits, and outcomes of proposed anesthesia regimen to

promote informed decision-making

3.33 1.29

3. Patient advocacy

Nurse anesthetists

A. Support and preserve the rights of patients for privacy by protecting information of a confidential nature from those who

do not need such information for patient care. Support the rights of patients for independence of expression, decision and

action

4.59 0.69

410 C. Herion et al.

Table 2 Continued

CanMEDS Role ‘Health Advocate’ (Cronbach’s a = 0.86) Mean SD

Graduate Competencies of Scholar 4.07 0.39

1. Continuous professional development

Nurse anesthetists

A. Commit to continuous professional development 4.6 0.6

B. Accept responsibility and accountability for practice and engage in lifelong professional educational activities 4.46 0.65

C. Engage in a formal self-evaluation process, seeking feedback regarding their own practice from patients, peers, professional

colleagues, and others. Develop and implement strategies for lifelong learning

4.15 0.92

D. Are aware of and address individual needs for clinical inquiry through continuous professional development activities 4.04 0.93

E. Demonstrate knowledge of and adherence to the national legal regulations, accepting the respective responsibility and

accountability of nurse anesthesia and others

4.36 0.74

2. Research

Nurse anesthetists

A. Incorporate evidence-based techniques and knowledge, as well as international guidelines and standards in clinical

performance

4.14 0.91

B. Design or assist in designing and implementing studies, data collection, and analysis, as well as public dissemination and

discussion of results. Use measurement instruments that are critiqued for validity, reliability and clinical applicability

3.32 1.22

C. Incorporate research into practice and assist the nursing staff and the institution in evaluating and rating evidence,

applying evidence to practice, designing innovations, critiquing research studies and analyzing sources of evidence-based

guidelines

3.46 1.21

D. Protect the rights of patients or animals involved in research projects and conduct the projects according to ethical

research and reporting standards

3.55 1.32

3. Education

Nurse anesthetists

A. Facilitate and teach based on national and international standards of education and practice 4.42 0.81

B. Contribute to learning experiences for all professionals and students within their spheres of influence, and interact with

colleagues at the local, national, governmental and regulatory levels to enhance professional practice

4.36 0.76

C. Assist healthcare professionals in identifying their educational needs related to anesthesia and acute care needs 4.01 1.04

D. Provide peers, colleagues, students and staff with constructive feedback regarding practice with the goal of facilitating

improved outcomes and professional development

4.3 0.8

CanMEDS Role ‘Professional’ (Cronbach’s a = 0.86) Mean SD

Graduate Competencies of Professional 4.25 0.32

1. Professionalism

Nurse anesthetists

A. Provide safe and patient-centred care based on available evidence. The nurse anesthetist recognizes the responsibility of

professional practice and maintains a high level of quality in knowledge, judgment, technological skills, and professional

values prerequisite to deliver patient-centred care

4.57 0.58

B. Accept responsibilities and correctly delegate responsibilities to other team members or healthcare professionals 4.56 0.6

C. Demonstrate self-appraisal activity 4.14 0.89

D. Identify opportunities for generating and using research and/or continuous professional development activities 3.8 1.07

2. Advancement of anesthesia care

Nurse anesthetists

A. Demonstrate leadership by disseminating outcomes of nurse anesthesia practice through presentations and publications

and participation in local and national nurse anesthesia organizations. Promote and facilitate the awareness of public and

professional policy issues that affect nurse anesthesia practice. Serve as a role model for nurse anesthesia practice and

encourage and support staff in professional achievements

3.81 1.1

B. Use quality, satisfaction, and cost data to modify patient care, nurse anesthesia practice and systems. Accept

accountability for own errors. Identify and handle critical incidents by entering them into critical incident reporting systems

4.1 1

International standards nurse anesthetists 411

roles: Communicator (P < 0.02) and Professional (P < 0.01; MANOVA).

Subgroup analyses of job functions found that the CanMEDS

Framework was most relevant for NAs who identified that their

primary job function was in education (n = 104, m = 4.34, SD = 0.49), followed by students in NA educational programs (n = 37, m = 4.22, SD = 0.49), then by NAs primarily in man- agement positions (n = 91, m = 4.17, SD = 0.54) or those pre- dominantly in clinical practice (n = 217, m = 4.17, SD = 0.52; P < 0.05, overall). Differences in the relevance of the overall CanMEDS Framework and the roles of Collaborator

(P < 0.001), Scholar (P < 0.001) and Professional (P < 0.001) were rated more relevant by NAs involved in education than by

NAs operating in practice (P < 0.001).

Exploratory factor analysis

The EFA of cohort 1 revealed seven theoretically meaningful

and cohesive factors. The seven factors accounted for 72% of

the variance and reflected the seven existing CanMEDS roles

of IFNA’s Standards of Practice. Several factors correlated,

ranging from 0.4 to 0.84 (P < 0.01; the optimum seven-factor solution is summarized in Appendix S3).

Confirmatory factor analysis

Based on the EFA of cohort 1 and the CanMEDS Framework,

the seven-factor model was tested using a CFA on cohort 2.

Twenty-six graduate competencies (loadings > 0.4) were selected to test the fit of the model with maximum likelihood

estimation (Appendix S4).

As indicated by a large comparative fit index (CFI) of

0.952, small root mean square error approximation (RMSEA)

of 0.037 and a 90% CI 0.024–0.046, the graduate competen- cies and the modified seven-factor model (namely the Can-

MEDS roles) of the EFA were well-fitting.

Overall, the CFA results showed that a strong relationship

of the 26 graduate competencies as observed variables and the

seven CanMEDS roles as underlying latent construct of

IFNA’s Standards of Practice exists. There were also strong

relationships between several CanMEDS roles (r = 0.41–0.75). The CFA provided the construct validity of the seven Can-

MEDS roles by empirical investigation of relationships

between the seven factors and graduate competencies of the

IFNA’s Standards of Practice.

Discussion

Limitations

One limitation of our study is that we focused on one single

high developed country. Furthermore, the study was con-

ducted with German and English only (not French and Ital-

ian) and might not capture all the language and cultural

regions in Switzerland with the same rigidity due to language

limitations.

To date, we are not aware of published studies investigating

whether NAs or NPAPs consider the IFNA’s Standards of

Practice to accurately reflect their scope of practice. Our

approach provided specific information and evidence about

how the IFNA’s Standards of Practice can be assessed follow-

ing the CanMEDS Framework as a baseline.

This study demonstrates that the roles of Swiss NAs are

identified by seven factors that correspond closely to the

seven CanMEDS roles – Manager, Communicator, Profes- sional, Scholar, Expert, Health Advocate and Collaborator.

Furthermore, (a) all factors, except Communicator, show high

internal consistency based on Cronbach’s alpha; (b) the indi-

vidual CanMEDS roles, except Manager and Health Advocate,

were all rated relevant or very relevant; (c) the primary job

function of respondents, especially educators, impacted on

their rating of the relevance of the overall CanMEDS roles;

(d) the EFA provides evidence of convergent and discrimi-

nant validity by identifying the seven factors corresponding to

the CanMEDS roles; (e) the CFA demonstrates an optimal

model for NAs’ competency framework with evidence of

Table 2 Continued

CanMEDS Role ‘Professional’ (Cronbach’s a = 0.86) Mean SD

3. Accountability

Nurse anesthetists

A. Maintain credentials in nurse anesthesia, as mandated by national legislation or regulation 4.32 0.85

B. Respect the confidentiality of information about patients learned in clinical relationships, demonstrate overall respect, and

maintain the basic rights of patients, showing concern for personal dignity and human relationships

4.69 0.52

C. Are aware of individual, ethnic, cultural, and religious differences, and provide appropriate care to deliver the best possible

patient outcomes

4.58 0.62

Overall ratings of CanMEDS Roles (Cronbach’s a = 0.97) 4.22 0.42

412 C. Herion et al.

construct validity for CanMEDS roles and graduate

competencies of the IFNA’s Standards of Practice.

Content validity of the graduate competencies

Eighty-two per cent (n = 62) of the graduate competencies were rated as relevant or very relevant with respect to Swiss

NAs’ scope of practice, which confirms the CanMEDS roles

of the IFNA’s Standards of Practice provide evidence for con-

tent validity.

Only 14 of the 76 graduate competencies (18%), mainly

from the Manager’s and Health Advocate’s roles, were rated

moderately relevant. We submit the following four possible

reasons why these 14 competencies are not in Swiss NAs’

scope of practice and therefore received lower ratings: (a)

‘anesthesiologists’ area of accountability’ may have been inter-

preted as the legal responsibility for obtaining informed con-

sent by physician anesthesiologists; (b) ‘accountability for

management, leadership and education’ may have been seen

by general NAs as the responsibility of managers or leaders in

the field; (c) ‘health advocate’ roles related to patient infor-

mation and patient education might reflect the limited partic-

ipation of NAs in pre-anesthetic patient management within

Swiss NAs’ scope of practice; and (d) ‘scholarship’ focusing

on study design, implementation of research into daily prac-

tice, and protecting patient or animal rights appears sec-

ondary for clinically practicing NAs as does dissemination,

presentations and publication of research.

Construct validity of CanMEDS roles and graduate

competencies

The results of the EFA identified seven roles of NA competen-

cies that corresponded to the seven CanMEDS roles. As we

hypothesized, the EFA from cohort 1 identified seven factors

(CanMEDS roles), which are meaningful. The factor loadings

from the various items also supported the seven-factor solution.

While factors were correlated, they proved to be independent

and meaningful. Overall, this provides evidence of construct

validity through both convergent and divergent validity.

The CFA results from cohort 2 provide evidence of construct

validity because of good fit indices and small residual variance.

The seven-factor model was confirmed, as was the pattern of

loadings and the inter-correlations between the seven factors

(the seven CanMEDS roles). Both CFA and EFA provided evi-

dence for construct validity. The integration of the 76 graduate

competencies together with the adopted CanMEDS role model

provides a well-fitting conceptual framework for Swiss NA’s

scope of practice (represented in Appendix S4).

The relevance ratings of CanMEDS roles varied according to

study participants’ basic training. NAs engaged in education

favoured the rating of the overall framework and the

Collaborator, Scholar and Professional roles. We assume this is

because many educators are already familiar with CanMEDS

and the IFNA Standards of Practice, which have been pro-

moted nationally. For the implementation of new policies,

educators most likely cover an important role as change

agents.

This study provides evidence that the IFNA’s Standards of

Practice are a valuable international framework to define

national standards of practice for NAs. Our findings examine

the validity of the IFNA’s Standards of Practice by demon-

strating its relevance to the scope of practice for Swiss NAs.

As a result of this study the graduate competencies of IFNA’s

Standards of Practice were implemented into the national

framework curriculum for Swiss nurse anesthetists during a

revision in 2018.

A standardized competency framework for anesthesia pro-

viders might have the ability to increase patient safety and

with the aim to improve quality of anesthesia care worldwide.

This can be achieved by identifying a set of international

standards that is relevant to NAs’ scope of practice and using

those standards as a framework to train and evaluate NAs in

LMICs (Lipnick et al. 2017). Our survey therefore serves as

an instrument to identify the local needs of NAs and helps to

advance regulatory standards that aim to improve education

and safe anesthesia practice, especially in LMICs.

Conclusion To our knowledge, the present study is the first of its kind

showing rigorous psychometric approaches applying factor

analyses to provide evidence of construct validity of the

CanMEDS roles and IFNA’s Standards of Practice for NAs.

The good fit of the CanMEDS model provides evidence of

construct validity. The validation and successful implementa-

tion of the IFNA’s Standards of Practice presented with this

study can be applied worldwide to compare international

standards to national and local standards. The study there-

fore is an example for and provides a sound approach to

identify national demands of the healthcare systems and

clinical needs for anesthesia care. The approach to the sur-

vey and the resulting study design could be expanded

among other countries, and as a result it might expose dif-

ferences in scopes of practice among NAs, which in turn

could support the ultimate goal of improving anesthesia care

quality, education and patient safety. For LMICs, where

health policies or governmental regulations for NAs are

missing, the IFNA’s Standards of Practice could be a stan-

dardized and evidence-based starting point for defining a

consistent scope of practice.

International standards nurse anesthetists 413

Implications for nursing and policy By adopting the IFNA’s international Standards of Practice

into national and local policies and regulations, there is the

potential to align initiatives of WHO (World Health Organi-

zation 2013, 2017, 2018) and ICN (Catton 2017) with educa-

tion, outcomes and assessment of NAs and the needs of

national healthcare systems. In addition, the use of the

IFNA’s Standards of Practice could make it feasible to com-

pare differing healthcare systems worldwide. The regulations

for continuing professional development (CPD) strategies, as

well as the attempts for international recognition and certifi-

cation of programs for NAs is recommended (Meeusen et al.

2016). As an approach, our validation has the potential that

the IFNA’s Standards of Practice might be suitable to support

lifelong learning. Our national validation of the IFNA’s Stan-

dards of Practice has underlined the role of NAs in daily

anesthesia practice. This validation process of these graduate

competencies can be used to develop competency-based

teaching and assessment programs for NAs. In the event of

workforce shortages and global migration of healthcare work-

ers, WHO initiatives for international recruitment of health

personnel and consistency of national policies (Campbell

et al. 2016) might be supported by the application of the

worldwide-approved IFNA’s Standards of Practice to compare

and equalize different NA-education programs.

Acknowledgements Thanks to Sabine Schaedelin, MSc and Michael Scharfe, PhD,

Clinical Trial Unit (CTU) University Hospital Basel, for

statistics and data management. For the kindly support and

editing of the manuscript we’d like to thank Liz Phillips,

Medical Writer.

Author contributions Study design: CH, LE, RG, CV

Data collection: CH, LE, RG, CV

Data analysis: CH, LE, RG, CV

Study supervision: CH, LE, RG, CV

Manuscript writing: CH, LE, RG, CV

Critical revisions for important intellectual content: CH, LE,

RG, CV

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Supporting information

Additional Supporting Information may be found in the

online version of this article:

Appendix S1 Study Survey English

Appendix S2 Study Survey German

Appendix S3 Exploratory factor analysis: principal compo-

nent extraction with varimax rotation to the Kaiser normal-

ization criterion (n = 225) with factor loadings >0.4

Appendix S4 Confirmatory factor analysis with best-fitting

model of seven factors and graduate competencies of IFNA’s

Standards of practice for nurse anesthetists

International standards nurse anesthetists 415