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Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting their Transition Sandra TavarezFairleigh Dickinson UniversityPerceptions of Certified Registered Nurse Anesthetists on Factors Affecting their TransitionIntroduction This article titled Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting Their Transition from Students was written by Andy Tracy, a PhD and CRNA student, who was also the primary researcher. The article is referenced as Tracy, A. (2017). Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting Their Transition from Student. AANA Journal, 85 (6), 438-444. This article was chosen for the purpose of exploring ways to facilitate the transition period from student nurse into the professional role.Study PurposeThe purpose of this study is to explore the factors that certified registered nurse anesthetists perceive to affect their role in transitioning from students (Tracy, 2017). The researcher wanted to know what factors influenced the newly graduated CRNA role transition from student to successful new employee. According to the researcher, not enough research has been done on this particular topic concerning this specialty. The author argues that although research has been done concerning the role transition of RN to APN from student, the experiences of the CRNAs could be different based on their educational and clinical training. The research also aims at examining the impeding factors perceived by participants in making their role transition difficult (Tracy, 2017).The turnover rates for CRNAs are not well known for many reasons. However, according to Tracy (2017), a main reason may be due to a “lack of reporting”. (p.438). It seems as if CRNAs are not coming forward with reasons to terminate a job by being reserved. Similarly, Tracy (2017) also noted that The Retention Institute at NSI Nursing Solutions Inc. found “Eighty-three percent of hospitals do not report APN turnover rates or reasons for turnovers, and the cost to replace an APN has been estimated as high as twice the APN’s annual salary”. (p.438).The literature suggests that high turnover rates can be quite expensive for hospitals. “The complexity of the CRNA’s transition requires substantial and consistent support to ensure success, satisfaction, and retention”. ( Tracy,2017,p.438).The significance of the study is that in finding out the reasons why newly graduated CRNA are leaving the job, employers can receive feedback and find out ways to provide support during the transition period (Tracy, 2017). If employers gain further input into turnover rates, they can formulate programs involving mentorships that can potentially lead to increased employee satisfaction. Higher employee satisfaction increases retention and lowers cost of hiring and orienting new staff. Literature Review Although, the author cited 36 references, only one was highly relevant to the study. “Only one study, by Schreiber and MacDonald, was found that examined the factors CRNAs viewed as influencing the CRNA role transition. Schreiber and MacDonald stated that further research was needed to identify other factors influencing the CRNA transition.”(Tracy, 2017, p.438). The author claims to have reviewed other references examining successful role transition, but those studies have come from points of view other than the CRNA experiencing the transition. There is a gap in knowledge identified by the lack of studies done from the CRNA view point, furthermore other factors influencing their role transition from students need to be explored (Tracy,2017). The author pointed out the strengths and weaknesses of the literature review by pointing out its relevance to his study. His oldest reference dates back to 38 years ago and is titled “Job satisfaction of nurse anesthetists” by Thompson L., 1981. Whether this old study is ground breaking or not is not known, furthermore one cannot assume the perception of a job’s satisfaction will be the same almost 40 years later.Study DesignThis qualitative study has a descriptive and phenomenographic design used to describe the perception or personal experiences on role transition of CRNA from students (target population) (Tracy, 2017). The approach is appropriate to answer the research questions and meet the objectives. The researcher noted that the gap in knowledge from previous research was identified in the lack of research made with a phenomenographical design where the CRNAs themselves describe their own personal experiences on role transition. The researcher is familiar with the challenges faced in role transition from student because he is a certified registered anesthetist himself. Only a CRNA knows what is like being a newly graduated CRNA.The researcher formulated two main questions to guide his research through the interview. “Two guiding research questions were developed to guide the qualitative interview process. The first research question asked which factors CRNAs perceived as facilitating their transition into their new role as a CRNA. The second research question asked which factors CRNAs perceived as impending their role transition.”(Tracy, 2017, p.439).The answers to those questions need to be elicited from this particular population in order to avoid bias that would otherwise occur by using a different study design. Qualitative MethodsThe participants were recruited by email and interviewed online through video conference. They were recruited through the American Association of Nurse Anesthetists (AANA) nationwide. Transitions theory provided the background to analyze previous factors inhibiting or promoting transitioning (Tracy, 2017).SamplingOut of the 500 randomly selected CRNAs from the AANA membership 15 met the criteria for the final sample. The criteria was based on graduating within the last 4 years, residing in the United States and being employed full time as a CRNA. “Purposeful sampling was chosen to select participants who would best be able to provide data about the phenomenon”. (Essentials of Nursing Research, as cited in Tracy, 2017, p. 439). These participants were relevant to meet the objective set by the questions due to their recent graduation time period. On the other hand, 80% of the final 15 participants were women and their experiences can be different from men. Also the age range was from 27 to 35 years of age, which does not shed light into what the experience could have been for someone older. There was more variety in the areas in which they practice: Two in the Department for Veteran Affairs, one in the military, ten in care team settings, the rest in mixed settings. Sampling was done until saturation or redundancy in data was reached. It is noted that “Data saturation is achieved when the recruitment of new participants does not yield additional or new data and redundancy occurs”. (Essentials of Nursing Research, as cited in Tracy, 2017, p.439). Informed consent was emailed to the participants along with IRB approval and information on the study being done. All 15 participants, including individuals from the pilot study participated in the study where anonymity and confidentiality was ensured. Data CollectionThe participants were interviewed through Skype and the meeting time was arranged by mutual accordance. The interviews were recorded and transcribed word by word. The participants were USA citizens that have become CRNAs within the last 4 years and were employed on a full time basis. They are all AANA members. Their average age were 30 years, 80% are women, and they work in various settings. The main researcher was Andy Tracy, a doctoral student. He worked along two more experienced researchers, one of them was an expert on qualitative studies and another CRNA experienced researcher. The role of the researcher is to conduct the study while ensuring the participants right of confidentiality and anonymity. Although the researcher is a CRNA himself, his relationship with the participants was not clearly described. “One of the important difference between quantitative and qualitative research lies in the degree of involvement of the researcher with the participants of the study. This involvement, considered to be a source of bias in quantitative research, is thought by qualitative researchers to be critical element of the research process. The nature of the researcher-participant relationship has an impact on the collection and interpretation of data”. (Maxwell, as cited in Grove et al., 2015, p.82). The relationship of researcher and participants is one of mutual respect, honesty and transparency in regards to responding questions. The interviews were conducted online on an individual basis. A face to face interview can lead the researcher to be more involved and can make the experience more personable. On the other hand, hiding behind a computer screen can give those who are anxious a sense of safety. “Focus groups were designed to obtain the participants’ perceptions of a specific topic in a permissive and nonthreatening setting. One of the assumptions underlying the use of focus groups is that group dynamics can help people express and clarify their views in ways that are less likely to occur in a one-to-one interview.” (Grove, Gray, &Burns, 2015, p. 85). Likewise, focus groups can help participants become less anxious about the interview process because it offers them a sense of support through the process of sharing similar experiences collectively as a group of individuals.Procedural RigorThe author did not mention the length of the interview. Adequate amount of time is of essence when it comes to revoke personal memories and events. The researcher mentioned that all interviews came to an end when all questions asked were answered, but does not mention allowing time for any extra thoughts. Instead, the participants were invited for a follow up interview a week after. In order to ensure rigor, the primary researcher conducted a pilot study with 3 participants to test the data collection process. The data was reviewed in a periodic basis and supervised by other experts on the subject. The process of triangulation is when different methods of data collection are used or data is reviewed by more than one expert to assure validity (Grove et al., 2015).Data AnalysisThe context of data analysis had an audit trail of decision making or rule of analyzing data. Data was analyzed by following 8 steps of inductive content analysis. Tracy (2017) reported the 8 steps : “(1) reading the entire text to obtain a sense of the whole, (2) making memos of initial impressions of the text, (3) detailed and word by word readings, (4) highlighting important statements that appeared to capture key concepts in the interviews, (5) analyzing statements across interviews for labels that appeared in several interviews, (6) examining labels across interviews and transforming labels into themes, (7) developing descriptions of each theme, and (8) identifying quotations that represented the themes”.(p.440).Although the process of transforming data into themes was described above, it is not done in a step by step manner as in the rule of analyzing data. Transferability is the process of describing experimental procedures step by step in order to replicate the study by others (Grove et al., 2015). Transferability contributes to the trustworthiness of the study (rigor).Theoretical Connections Tracy (2017) revealed 5 major themes or factors contributing to the promotion of role transition: “(1) Mastery of self-efficacy and confidence. (2) Expert mentoring and guidance. (3) Supportive work environment. (4) Peer support, and (5) previous experience as a SRNA. Previous research supports the idea of expert mentoring or preceptorship as beneficial in role transitioning”. (p. 440). Earlier study findings by Thompson connect supportive work environment with CRNA increased job satisfaction (Tracy, 2017).Factors impeding role transition according to Tracy (2017) were: “(1) practice limitations, (2) lack of preceptors, (3) hostile work environment and (4) decreased case complexity and workload.”(p. 442). The second and third impeding factors are exactly the opposite of the second and third factors promoting role transition. Further studies conducted by Daugherty et al., supported that hostile work environments are not conducive to learning or transitioning to a new role (as cited in Tracy, 2017, p. 442). On this study, Tracy connected old theories with his findings.TrustworthinessDependability, credibility, and transferability were used to evaluate this research study. According to Lincoln, those are factors used to evaluate the trustworthiness of the study (Tracy, 2017). To ensure dependability, the data was analyzed by other experts in the field besides the primary researcher, thus reducing bias in terms of interpretation. The credibility of the data collected was confirmed by the participants during the follow up interview. Only the participants can identify the veracity of their words. In terms of transferability “Experience researchers reviewed each step to ensure a detailed data trail”. (Tracy, 2017, p. 440).ConclusionsDespite its limitations the study conducted demonstrated to have rigor. The literature review revealed the significance of the study by identifying a gap in knowledge. The gap in knowledge is that no previous research has been done on the subject of identifying the factors affecting role transition of CRNAs from students (Tracy, 2017). The study design of a phenomenographic approach was the most appropriate one to meet the study objectives of describing a personal experience at first hand. The interviews were carried out on a one to one basis through online, although a face to face group focus could also be considered as a way of ensuring more validity and credibility. Although the participants were purposely selected, the author also agrees that the ratio of women participants of (80%) was not representative of the actual number scale. Also all the participants were members of the AANA and employed on a full time basis, therefore it did not apply to non-members or part time employees. Even though, the study was ethically sound because informed consent was obtained, it did not mention that they were free to leave the study if they wish to. The researchers were qualified to do the study which facilitated the development of an audit trail to ensure transferability and dependability. Also more than one researcher confirmed data analysis through triangulation. The results culminated into the conclusion of what employers can do to ease the process of transitioning. “Employers may find that implementing a mentorship program for recently graduated CRNAs by experienced CRNAs is a way to promote CRNA role transition and increase CRNA retention and satisfaction.” (Tracy, 2017, p.443). This research can be rated 4.5 out of 5 because it could have used another methodology of data collection to support further validity. The methodology of collecting data through a face to face group support can also implicate additional costs, as the interviewees were located across the nation and needed to be accommodated to meet in unison. Scientific research is not meant to be perfect, but its methodology needs to have a sound scientific approach like the ones listed above (validity, triangulation, transferability, dependability, credibility, and obtaining informed consent). This article deserves to be rated as having high scientific merit. The researchers were pioneers on the subject that laid the foundation for further studies in the future.Personal Growth & DevelopmentThe factors affecting role transition from students to professionals among the healthcare workforce (RNs to NPs, SRNAs to CRNAs, and medical students to physicians) can share some similarities. Research into a specific role transition (SRNAs to CRNAs) help us determine how those factors differed by their unique perceptions. Those perceptions are best captured by performing phenomenographic research studies. The implication of the study suggests that by knowing the factors promoting role transition of CRNAs from students, employers can be better prepared to assist the transition process. The nurse manager can plan and implement orientation programs with the idea that mentorship promotes a successful role transition, thus reducing cost of turnover caused by dissatisfaction. References1) Tracy, A. (2017). Perceptions of Certified Registered Nurse Anesthetists on Factors Affecting Their Transition from Student. AANA Journal, 85 (6), 438-444.2) Grove, S. K., Gray, J. R., & Burns, N. (2015). Understanding nursing research: Building an Evidence-based practice (6thed.). St. Louis, MO: Elsevier Saunders.