Welcome to the course, Didactic and Clinical Instruction. The presenting author of this course is Dr. Michael Kramer, professor and director of the Nurse Anesthesia Program at Rush University College of Nursing. He is also the co-director of the Center for Clinical Skills and Simulation, Rush University Medical Center. This series of education courses was developed by Rebecca Gamcotto and Betty Horton. Upon completion of this course, you will be able to describe current evidence-based practices for clinical and didactic instruction in nurse anesthesia educational programs. In the behaviorist paradigm, learning consists of changes in behavior. In this context, it's believed that learning is a function of environmental elements and not actions of the learner. The behaviorist focus is on external, observable behavior. Examples of behaviorism include Thorndike's Stimulus-Response Theory and Skinner's Operant-Conditioning Theory. The application to teaching is that it's the role of the instructor to provide appropriate learning reinforcement so that the desired behavior occurs. The cognitive approach reflects internal mental processes, including information processing, storage, and retrieval in the mind of the learner. Central to this theory is the belief that people interpret sensations and provide meaning to events that are experienced. Cognitivists integrate and analyze data until problems are solved. Social learning theory is related to the social setting where learning occurs. In this framework, if it is believed that people learn from observing others or that learning is a function of interactions between people, the environment, and behavior. Theories of modeling and mentoring fall into this category. The human perspective posits that learning involves more than cognitive processes and behavior. Humanists believe that learning is a function of motivation involving choice and responsibility. The focus of the humanist is on human nature, human potential, human emotions, and affect. Humanist theory encompasses Maslow's hierarchy of needs and Noll's theory of andragogy. Andragogy is often used as a synonym for teaching, but is defined as the art and science of teaching children. In the pedagogical framework, the teacher is responsible for all decisions about what is to be learned, when learning will occur, and how content will be assimilated. Andragogy is the process of helping adults learn. Andragogy is focused to a greater extent on the process of teaching and to a lesser degree on the content being taught. Andragogy is learner-focused. Active learning, students take control of their own learning. Discussing the content or solving problems in small groups leads to better long-term retention and the ability to use the material in new situations in the future. When students articulate their ideas to their peers, hear what others have to say about these ideas, and collaborate on an instructional task, their conceptual learning improves. Tasks and tasks in higher education are complex, involving different component skills, cognitive processes, and many different facts. To help students learn, instructors need to break down these complex concepts into tasks or their component parts, provide students opportunities to perform these skills or cognitive processes separately, and then allow them to practice the integrated tasks before assessing them. When students engage in authentic learning, defined as solving real-world problems, they become more motivated to learn deeply and with intention. Students may work collaboratively and use technology to carry out these tasks. Authentic learning promotes the development of critical thinking and the ability to organize and use information creatively. Contemporary view of learning is defined as knowledge construction. The most effective learning occurs when students build their own associations between new information and their previous knowledge base, not when they memorize how others have framed it. Prior knowledge about a topic influences what and how is learned, may include appropriate and inappropriate conceptions. Effective teachers find out if their students have incorrect prior knowledge, such as misconceptions or stereotypes, by assessing students and challenging misconceptions directly. Best learning occurs when a course is perceived as challenging with achievable objectives, like basic science of anesthesia principles content. If a course is too easy, students won't put forth effort. If the course is perceived as too hard, students are not motivated to try, since they doubt they'll be successful. The extent to which students are motivated or engaged with their educational program influences their learning experience. Adults want to learn regardless of their age. The capacity to learn doesn't diminish with age. The rate and speed of learning may vary depending on physiology changes. Student nurse anesthetists are no different. They're enrolled in a nurse anesthesia program for one reason, to become nurse anesthetists. It's unlikely that students are forced to attend an anesthesia program against their will. Adults are ready to learn what they need to know to cope effectively with real-life situations. The road to becoming a CRNA is long and demanding. The magnitude of information that must be learned can seem overwhelming. Despite this potential barrier, the student learns that mastery of this content is necessary to realize the goal of becoming a CRNA. So most students are motivated to engage in the learning process. Adult learning is an active process. Adults appear to be better motivated when they're actively engaged in the learning process because adults want to have some control over their lives. Many students perceive themselves to be independent and self-reliant. They enjoy making decisions and are freely offering their opinions. This is especially true for student nurse anesthetists who are experienced critical care nurses whose decision-making was valued and encouraged. Many student nurse anesthetists have filled leadership roles prior to returning to school. As faculty members, we need to remember that one of the goals in clinical and didactic education is to foster independent decision-making capabilities in our students. Adult learning is goal-directed. Students learn best when they have clear, obtainable goals. Before learning, adults need to know what they're going to learn and why the information is important. CRNA faculty members need to emphasize key associations in content areas. Example, content in anesthesia principles is related to the AANA scope and standards of CRNA practice and is reflected on the national certification examination. Adults don't want to be sidetracked by what may be perceived as unnecessary information, but the faculty member is a better arbiter of what must be learned to become a CRNA. Learned material is retained longer if there is an opportunity for application, such as clinical practicum, to apply material learned in class. The subject matter should be presented in a logical sequence. Learning is facilitated when there's logic to the subject matter and the logic makes sense in the context of the adult learner's experiences. The CRNA didactic and clinical instructors need to present new material in a logical, progressive sequence. When teaching new clinical skills, the instructor should first break the skill into its individual components so each build on the other, resulting in successful performance of the desired skill. Adults need to be aware of their progress. Learning is facilitated and reinforced when learners know their progress. A clinical instructor can't expect students to change or improve their performance if the students don't know what they're doing is right or wrong. Student learning can be facilitated and reinforced by the use of constructive feedback, that is feedback that is not belittling or degrading. All instructors should focus on the desired performance, behavior, or outcome. There should be no focus or attack on the individual as a person. When a technique is performed incorrectly, first note that the student is doing what the student is doing correctly and then address areas needing improvement. Adult learners often reach learning plateaus. The existence of periodic plateaus in the rate of learning requires changes in the nature of learning to ensure continuous progress. Some students seem to grasp concepts faster than others. Adult learners may encounter temporary learning plateaus or obstacles that inhibit learning progression. Students may acknowledge that they are having trouble understanding a concept or procedure, but such disclosures may be limited due to the desire of the student to avoid being perceived as weak. Adults possess a large amount of prior knowledge and experience. Learning new material is facilitated when it's related to what students may already know. Adults accumulate copious knowledge and experience throughout their lives. Adult learning is facilitated when the instructor presents new concepts by building on information that the learner has already mastered. But past experiences can also hinder learning. Life experiences may form undesirable behavior patterns that require unlearning before new learning can occur. Adults have a strong sense of self-esteem. Adults want to be treated as adults. Self-esteem can be defined as pride in oneself and the quality of being worthy of respect. A student's self-esteem and ego are on the line whenever he or she is asked to risk trying a new behavior in front of peers. When an adult's self-esteem, self-image, or psychological well-being is attacked, the adult often moves into survival mode. When adult students are belittled, humiliated, embarrassed, or criticized in front of others, their primary focus switches from learning to self-preservation and survival. This does not mean that students should not be corrected. Feedback should be constructive and not destructive. Take a moment to familiarize yourself with Bloom's Taxonomy if it's new to you, moving from the competencies associated with knowledge to those related to evaluation. During the last half of the 20th century, educators developed objectives using Benjamin Bloom's Taxonomy to describe learning experiences. This taxonomy reflects the behaviorist psychological theories of learning that were accepted in the 1950s and 1960s and identified a hierarchy of cognitive learning levels from recall to evaluate. Objectives could also be in the psychomotor or affective domain. Courses often had such a long list of behavioral objectives that faculty became frustrated and limited their teaching innovations. With the move toward more accountability and the focus on learning as opposed to teaching, educators are now using learning outcomes. There are other learning taxonomies to investigate when developing learning outcomes. Bloom's Taxonomy has been modified to be more consistent with current learning theories and considers a hierarchy of types of cognitive processes, similar to the verbs used in Bloom's Taxonomy, required to learn four non-hierarchical types of knowledge, factual, conceptual, procedural, and metacognitive. For example, metacognition is defined as awareness of one's own learning or thinking process and includes the elements of motivation with attribution of self-efficacy, monitoring or demonstration of reflection and self-assessment, and study strategies. Fink identified six types of learning, fundamental knowledge, application, integration, human dimension, caring, and learning how to learn. Choose the learning taxonomy that best suits your learning goals. Research findings demonstrate that there are relationships between the emotions of teaching and learning relative to the ages of teachers and students. To the extent possible, it's helpful for instructors to tailor their instructional style and methods based on generational factors in the areas of preferred learning culture, learning materials, including likes and dislikes, instruction, and feedback. Lecturing may be the most commonly used teaching method, but hasn't been proven to be the most effective teaching method. Lecturing may be effective when carefully planned and supplemented with other teaching methods. McKeachie and Svanicki believe that lecturing is best used for providing up-to-date material that can't be found in one source. Memorizing material found in a variety of courses, adapting material to the interest of a particular group, and initially helping students discover key concepts, principles of ideas, and model expert thinking. Lecture is appropriate for large audiences, but even then should be supplemented with other teaching techniques. Disadvantages of lecture are that cognitive function, even at lowest levels such as recalling and remembering, rely on the learner's mental activity. In order to understand, analyze, apply, and commit information to long-term memory, the learner must actively engage with the material. Lecture has been shown to be passive. Students need to be compelled to mentally manipulate information. Essential considerations for a lecture include enthusiasm, both for the subject and the ability of students to learn it. Expert thinking. Learners look to the teacher for both content, the facts, as well as an expert's way to think about the content. Students need illustrations for the clinical applicability of material. Telling isn't learning. Teachers teach thinking and are not dispensers of facts. Thinking takes time. Realize that students need time to think about the material and adjust the pace of teaching accordingly. Rapid coverage of material results in rapid note-taking from students and little time to process the information. Most students will only memorize and not try to understand large volumes of material that are covered quickly. Learning needs to be learned. Students need additional time to process and need more structure early in the academic term. As a course progresses, instructors can shift to activities that ask students to perform higher-level cognitive function. Students must be engaged in order to retain and understand material. Lecture for no more than 20 minutes before utilizing an activity, that is, have them summarize what was just said without notes. Provide a lecture outline only, rather than a complete set of your notes. Note-taking helps to reinforce content. Cool isn't always cool. Resist the urge to do anything just for its cool factor. Any technique, audio-visual, and or technology must be used because it fits the goals and objectives of the course, not just because it's cool. The introduction of a good lecture should include a call for questions from previous material, an overview of today's class, and how today's class fits into the bigger scheme of the course. It could also briefly summarize the previous class. The purpose of the body is to improve student understanding of a few points, not to cover material in great depth. Students can gain understanding by reading. Concentrate on the objectives for today's class, summarize the main points of those objectives, and provide students with examples of the main points. If purpose of the lecture is to cover large amounts of material, don't expect the students to understand the material. You need to provide students some activity that promotes engagement, example, homework, online discussions, or written assignments. Check for their understanding. Remember to leave time for student questions. Using classroom assessment techniques helps to improve student and faculty understanding of what the students know. The conclusion signals a clear ending to class activities. It should provide a summary of the day's activities, major points, how the class fits into the course objectives, and previews upcoming activities. Consider having the students provide a list of major points as part of your wrap-up activity and check for their understanding. Lecture notes should serve as an outline, not a script to be read verbatim. Resist the temptation to use PowerPoint as your narrative. Don't place all the information on your slides and then proceed to read from your slides. Your slides should only contain a few bullet points to remind you of the activity or topic and provide your students with an outline. Highlight in color the main points of your lecture so that you can quickly recognize this content. Write cues to yourself in the margin. Remind yourself to slow down here, have the students take a stretch break, or have the students work in pairs here. Another lecture suggestion is to vary your speech pattern, including the tone of your voice and speed, as well as gestures. Start the lecture with a problem or controversy to spark interest in your topic. Refer to this problem or controversy during the lecture as you make your main points. Use the problem or controversy as your wrap-up. Ensure that your audience can see and hear your AV. Give the students a pre-planner. Write the topic of today's class on the board and go through it as part of your introduction. Stress important points several times and make them the most important part of your lecture. Team teaching. The pro is that students hear more than one perspective and are exposed to different instructional styles. The con is that instructors may have divergent views on instructional priorities. Close communication is necessary for team teaching to work. Students need to know they will get the similar information from the course faculty members. Sole instructor. there is greater inter-rater reliability, but can be a monotheistic view of the content being taught. Guest Speakers – the pro is that students hear more than one perspective and are exposed to different instructional styles. The con is that the content may not be organized or presented consistently with how primary course faculty teach. Logistics and timing can also be challenging. As noted earlier, lectures may be useful when much factual content needs to be covered in a limited amount of time, as is sometimes the case in nurse anesthesia education. The downside to lectures is expressed in this quote from Albert Camus, The danger of lectures is that they create the illusion of teaching for teachers and the illusion of learning for learners. Conrad suggested that the needs of 21st century learners are not well served by lecture. For example, ICT literacy refers to information, communication, and technology literacy, using technology as a tool to research, organize, evaluate, and communicate information. The knowledge, skills, and abilities required of CRNA practitioners, teachers, and researchers in the 21st century requires commitment to innovative instructional modalities that reflect ongoing changes in knowledge acquisition and dissemination. Let's discuss online education. Synchronous learning is an exchange of ideas and information with one or more participants during the same time frame. This could be online, real-time, live teacher instruction and feedback, Skype conversations, chat rooms, or virtual classrooms. Asynchronous learning can involve emails, blogs, wikis, web applications that allow participants to add or change content, discussion boards, web-supported textbooks, hypertext documents, audio and video courses, social networking, and web-supported simulation. In asynchronous online courses, students can move at their own pace, for example, repeating a lecture. Both synchronous and asynchronous methods require self-motivation, self-discipline, and good written communication skills. Learning management systems are software used to deliver, track, and manage training and education. Instructors can post announcements, grade assignments, check on course activity, and enter into class discussions. Students can submit their work, read and respond to discussion questions, and take quizzes. Internet-based learning management systems, like Blackboard and Moodle, allow educators to run a learning system partially or completely online, asynchronously or synchronously. There is a learning curve for both faculty and students who are new to using learning management systems. Ideally, instructional support resources are available to faculty so that meaningful and evidence-based student learning opportunities can be provided through online learning. The advantages of online learning include an increased access to education. This is especially good for students in remote areas or working different shifts. There are also more opportunities for part-time students. Online education allows far greater flexibility with course activities in online rather than a live class environment. Student-faculty interactions are fostered. Online education may provide more opportunities for student-faculty interaction than a live class environment and having to rely on faculty office hours for a meeting time. It provides tools to help students solve problems. There is integration of search engines, collaborative working platforms like GoToMeeting or Panopto, providing a wider array of options that allow students to solve problems independently. And finally, students can learn at their own pace so that the lecture content can be replayed and reviewed as necessary. These are the disadvantages of online learning. Ease of cheating. Vendors like ProctorU provide monitoring of students taking tests at distant sites. Online learning may be easier for technology-advanced students. Slow internet connections or older computers may make accessing course materials frustrating. Managing computer files and online learning software can sometimes be challenging for students with novice-level computer skills. Instructors may be unfamiliar with how to manage virtual teacher-student interactions. Instructors need to consider the implications of distance students who request disability accommodations or how to provide additional instructional support to distance learning students. Lack of faculty and student interaction. Online students may feel isolated from the instructor as well as their classmates. Chat rooms, discussion forums, and virtual office hours can provide additional opportunities for faculty-student and student-to-student communication in online courses. There is lack of immediate feedback from instructors. Since students have 24-7 access to online courses, they often expect 24-7 access to course faculty. Online faculty need to establish parameters for communication with students. For example, messages will be responded to within 24 hours. Asynchronous communication can create delays in response to student questions. Instructors may not always be available when students are studying or need the help. There is a danger of procrastination. Learners with low motivation or bad study habits will fall behind. Without the structure of a traditional class, students may get lost or confused about course activities and deadlines. Educators are responding to changing professional, economic, and technological circumstances. Students are increasingly using instructional technology. For example, massive open online courses, MOOCs, M-O-O-C, offered at Stanford, UC Berkeley, MIT, Duke, Harvard, and Yale. Faculty and students may seek to use technology to video record, save, and update presentations, which could be uploaded to YouTube, allowing class time to be used for group work. Flipping the classroom. This is also described as blended learning, where students learn new content online. What formerly was homework is done in class with the instructor, providing more student interaction and direction, rather than lecturing. The long-term outcomes of MOOCs and flipping the classroom are yet to be determined. Preliminary evidence shows a drop-off in class attendance over the term that massive open online courses are offered, and that attainment of learning competencies are not significantly impacted by flipping the classroom. Historically, accreditors have placed greater emphasis on learning outcomes and assessment than on competencies. The competency-based education movement values competencies more than learning outcomes and assessments, which creates new teaching and learning alternatives. The traditional three-credit hour Carnegie unit drives workload, units of learning, resource allocation, space utilization, salary structures, financial aid regulations, transfer policies, and degree definitions. The three-credit hour Carnegie unit fixes time while learning is variable. Competency-based education inverses the relationship, allowing time to be variable while learning is fixed. The logic that underlies what is fixed and what is variable in competency-based education may be appealing to some educators. The three domains of learning are cognitive, affective, and psychomotor. The clinical instructor teaches and reinforces new knowledge, which is in the cognitive domain. Teaching of specific anesthesia skills and techniques is in the psychomotor domain. Teaching of professional values and attitudes is in the affective domain. To effectively teach in each one of these domains, clinical instructors must determine which domain subcategory is best applied to their assigned student. As clinical instructors, we need to assess the knowledge base and experience level of our assigned student. Hartland quotes Schon, who said, the most effective teachers live a life of reflection about their teaching practice, and described this type of teacher as a reflective practitioner. Clinical instructors need to continually evaluate and re-evaluate their teaching strategies, techniques, and outcomes. The needed information may be gleaned from the types of questions the students ask. It may come from observing the affect and behavior of their students. For example, does the student look or act confused? Are questions from the instructor met with a blank stare? These signs may alert the clinical instructor of a learning problem. Once learning difficulties are identified, strategies to help the student can be developed. For example, a rephrased explanation of the issue under discussion or a demonstration of how to perform a technical skill. The traits of an effective clinical instructor will include clinical competence and judgment. The clinical instructor is technically skilled and demonstrates sound application of theory and knowledge into practice. The clinical instructor has a calm demeanor and is poised and composed, reacting to stress in a professional and skillful manner. The clinical instructor should have a strong ego and be self-assured. The clinical instructor demonstrates confidence in his or her own abilities and recognizes his or her own limitations. Flexibility. The clinical instructor encourages his or her students to learn various anesthesia techniques that are appropriate to the needs of the patient. The instructor should be able to provide appropriate encouragement of independence. The clinical instructor assigns responsibilities to students and encourages them to act and think for themselves according to their level of education and competence. The clinical instructor should engender confidence. The clinical instructor helps students develop self-confidence in their abilities to perform appropriately. And finally, an effective clinical instructor will motivate their students. The clinical instructor expects students to assume an active role in the discussion and problem-solving process while encouraging them to perform and communicate at their level of knowledge. Traits of an effective clinical instructor continued. Empathy and respect. The clinical instructor demonstrates sensitivity toward their students, understands their needs, supports their self-esteem, and relates to them in a non-threatening manner. Evaluates and counsels. The clinical instructor evaluates and counsels students systematically and objectively with appropriate, constructive, timely feedback. Enjoys teaching. The clinical instructor conveys interest, motivation, and satisfaction in clinical teaching. Stimulates student involvement. The clinical instructor encourages his or her students to actively participate in all aspects of anesthesia care. Is a positive role model. The clinical instructor serves as an appropriate model for the type of anesthetist students want to emulate. Is open-minded. The clinical instructor discusses different views related to anesthesia care and encourages students to develop their own sound viewpoints. Is sensitive. The clinical instructor demonstrates understanding of the feelings of others and supports the self-esteem of students. An effective clinical instructor engages in scholarly teaching and has a broad knowledge base. The clinical instructor demonstrates a broad knowledge base referring to and applying pertinent articles and research to patient care and explains the basis for their clinical actions. Is accessible. The clinical instructor is available and devotes the necessary time to his or her students. Has communication skills. The clinical instructor demonstrates a variety of effective verbal and nonverbal communication patterns. Individualizes teaching. The clinical instructor sets objectives and adjusts teaching methods specific to the level and learning needs of each student. Provides timely feedback. The clinical instructor evaluates the performance of students in a timely manner, especially important for today's students who expect real-time performance feedback. Actively teaches. The clinical instructor interacts with students throughout the clinical period. Stimulates effective discussions. The clinical instructor skillfully encourages and facilitates discussions. Uses the student care plan. The clinical instructor analyzes, evaluates, and allows students to implement the care plan whenever possible. When nurse anesthesia students and practitioners are presented with a clinical question, evidence-based analysis consists of the following steps. Define the problem or question in terms of the patient or problem, the intervention, or comparison of interventions used to answer the questions and the findings of the research reviewed. Outline the current steps in one's clinical practice to address the problem. Use a ranking system to determine the quality of evidence available in the literature. This hierarchy, in descending order, consists of findings from systematic reviews of well-designed clinical studies, meta-analyses, results of one or more appropriately designed studies, randomized trials, cohort studies, results of large case studies and case reports, editorials and opinion pieces, animal research, and in vitro research. Identify resources available to implement any proposed changes to practice to differentiate which evidence is applicable to the current setting. Assess the validity of research presented with a consistent rubric to review clinical trials. A. Did clinical trials include randomization of subjects, adequate sample size, and appropriate statistical analysis? B. Were the results relevant to clinical practice? C. Were the therapeutic interventions reported feasible for clinical practice? And D. Were all research subjects accounted for at the end of the study? Consider the implementation of evidence-based change in an individual case management or larger-scale recommendation to colleagues. Evaluate the impact of evidence-based change on individual case management or practice as appropriate. In 2003, the Institute of Medicine Committee on Health Professions Education Summit called for a paradigm shift for health professions education in which all health professionals are educated to deliver patient-centric care as members of interdisciplinary teams with an evidence-on-evidence-based practice, quality improvement approaches, and informatics. Human-patient simulation, ranging from clinical task trainers to standardized patient encounters, use of high-fidelity human-patient simulators, or web-based simulation, provides opportunities to foster evidence-based interprofessional education. Curricular integration of simulation with scenarios that have clear, measurable learning objectives, including appropriate post-encounter debriefing, creates immersive learning opportunities where clinical skills and decision-making can be taught. While nurse anesthesia educators agree that there is no substitute for hand-on learning in the clinical environment, all would affirm that patient safety in clinical situations comes first. There may not be time to properly repeat a skill, such as correct performance of a rapid-sequence induction or a wake intubation. Simulation is about the learner and provides opportunities to accelerate learning through application of didactic content and guided feedback on clinical performance. The degree of emotional buy-in with simulation compared to lecture discussion alone can lead to improved knowledge retention. Stopping action during a simulation to seize a teachable moment and or using recorded, annotated simulation images helps teach trainees and learners based on their performance. Learners can perform an array of clinical skills depending on the available equipment, obtain feedback, and develop mastery in areas such as central venous access and difficult airway management without risk to patients. When simulation is integrated into the curriculum, increased standardization of teaching, learning, and measurement is possible. Educators and students don't have to rely on the luck of the draw during clinical rotations for needed clinical experiences when simulation resources are available. Less commonly seen clinical scenarios, such as malignant hyperthermia, anaphylaxis, and bronchospasm can be simulated and learners may be able to better manage these conditions in clinical practice after completing related simulation-based scenarios. Simulation is a growing part of real practice. For example, crew resource management has been used in the aviation industry for over 30 years to improve air safety and reduce fatal accidents attributable to human error. Crew resource management models have been adopted by health care organization where the concern is less with technical knowledge, skills, and abilities, but with the cognitive and interpersonal skills needed to effectively manage a team-based, high-risk activity. However, the transferability of didactic knowledge and clinical skills from the classroom and simulation lab to clinical performance is of great interest to health care educators. There is an increasing body of research evidence that demonstrates knowledge transfer from simulation to clinical practice. As the knowledge base grows, educators will continue to be interested in developing self-aware, lifelong learners who can transfer knowledge, skills, and abilities in new ways. Experiential learning with simulation can be an effective bridge to or reinforcement of clinical training. For example, preclinical simulation training can ease the transition to the clinical environment. Simulation-based crisis management education can reinforce didactic and clinical learning through use of rare but potentially lethal scenarios such as intraoperative fires, malignant hyperthermia, anaphylaxis, or bronchospasm. Simulation provides realistic experience. Debriefing after a simulation encounter provides students and trainees opportunities for structured reflection, including opportunities for faculty to reinforce principles of evidence-based care and appropriate clinical decision making. Simulation assists students in learning how to learn from experience, gaining awareness of their strengths and vulnerabilities. Simulation accelerates the speed and quality of human learning and may enhance the capacity to prevent human error. There is a growing interest in near-misses as precursors to adverse clinical events. Simulation can provide opportunities to replicate near-misses or sentinel events with interprofessional training to prevent or minimize future occurrences of similar near-misses or sentinel events. Simulation scenarios provide realistic opportunities for clinical data gathering, including completion of a history and physical exam, including differential diagnosis and grading of illness severity. During simulated scenarios, participants engage in leading and or following behavior along with workload management. Vigilance and anticipating problems can be addressed in real-time or during post-encounter debriefing. The importance of communicating effectively within and across professions often can be integrated into simulation scenarios. The management of complex scenarios by team members, including prioritization and implementation of tasks, is another important area for learning in simulation. Simulation provides the opportunity to show how deliberate practice, for example, correct performance of a procedure or scenario, can be performed before the trainee or student performs the procedure on a real patient. Simulation requires resources beyond task trainers and human patient simulators. Space requirements consistent with the planned simulation activities need to be considered. Visits to existing simulation centers can help with planning or remodeling existing simulation space. Committed faculty are needed. Instructor certification is available through the Society for Simulation in Health Care. The CAE human patient simulator requires medical gases, including oxygen, air, nitrogen, and carbon dioxide, for operation. Depending on where the lab is situated, a tank farm or accessing clinical gas supplies may be options. Technical support is valuable. In addition to programming scenarios and operating simulators during scenarios, simulation technicians may help troubleshoot information technology issues and be trained to perform functions, including debriefing. A robust audiovisual recording system is essential for real-time image and sound capture. A data collection system that permits recording and annotation of scenarios is essential. Technical data collections for simulation include B-Line and CAE Learning Space. An aptitude for performance evaluation methodology and case writing is helpful in simulation education. Faculty involved with simulation need to have an affinity for non-technical skills that impact clinical performance, including evaluation of leadership qualities, teamwork communication, and clinical decision making. Manufacturers and professional organizations will provide training opportunities for simulation software. Practicing with experienced simulation educators helps with learning the software interface. Scenarios can be programmed with distinct states and events, but changes in physiological responses may be necessary based on actions of the involved students or trainees. Multiple cameras providing several views, for example overhead and from the side, ability to provide close-up, medium, or long-shot views are helpful to capture action during simulation scenarios. Data recording is important for providing feedback to simulation participants, as well as for when IRB-approved simulation research is conducted. In the COA Trial Doctoral Standards, Section B-17 notes that core CRNA program faculty, including the program administrator, assistant program administrator, and course directors have formal instruction in curriculum evaluation and instruction. This includes completed educational content that can be viewed on a transcript from an accredited higher education institution, an AANA-approved continuing education program, or a continuing education program approved by another nationally recognized professional approval organization. The content on curriculum instruction and evaluation in this CE series may help fulfill the requirement for formal instruction in curriculum instruction and evaluation. Nurse anesthesia has survived and thrived because of the pantheon of dedicated educators and expert clinical practitioners. Helen Lamb's writing on thoracic anesthesia, educational standards for nurse anesthetists, and other topics continues to inspire. We know many other nurse anesthetists, including John Gard and Ira Gunn, who were highly skilled educators and mentors to many nurse anesthetists who they educated. What is andragogy? It's the art and science of helping adults learn and focus more on the process and less on the content being taught. Andragogy is learner-focused instead of teacher-focused. Pedagogy involves instruction that is totally directed by the instructor, while the student passively listens and observes. In clinical education, this may be appropriate when the student is new to the clinical environment or unfamiliar with procedures and techniques. Hartland noted that in its purest sense, andragogy involves self-directed learning. At this end of the continuum, the student is completely immersed in the anesthetic management of the patient, while the clinical instructor monitors and observes student performance. For the majority of clinical experiences, it's unlikely that the clinical instructor functions exclusively at either extreme of the clinical teaching continuum. Most clinical instruction occurs somewhere between these extremes. The clinical instructor determines where on the continuum of teaching, based on his or her knowledge of the student's performance, profession, and growth in the program. The elements of exemplary teaching have been described as comprising two dimensions. The first involves the skill of the instructor at creating intellectual excitement in learners. This includes the clarity of the instructor's presentations, as well as their stimulating emotional impact on students. Clarity is related to what material is presented, and emotional impact is a function of how the material is presented, including interpersonal rapport with the students. This includes the skill of the instructor at communicating with students to increase their motivation, enjoyment, and independent learning. Desirable characteristics in this realm include being warm, open, predictable, and student-centered. Exemplary instructors excel in both the clarity and impact of their presentations. Learners have mindsets of themselves as learners that affect all the decisions they make about learning, the effort exerted, risks taken, and how one deals with failure and criticism, as well as how much of a challenge is acceptable. Learner mindsets are most likely formed by middle school and affect learning thereafter. Human intelligence is malleable. It can be changed through exposure to new information or by looking at what is already known from a fresh perspective. There is no limit as to what can be learned. Individuals' views of themselves fall into two categories, fixed and growth mindsets. Those with fixed mindsets believe that intelligence is a fixed trait. Students with fixed mindsets typically put forth less effort in a course if the course is viewed as difficult because the student does not believe they are smart enough to pass. People with growth mindsets believe that intelligence grows as new knowledge and skills are added. These individuals value hard work, learning, and challenges and see failure as a message that they need to change tactics to succeed next time. Students with a fixed mindset, who put in less effort and avoid going to tutoring or an instructor's office hours, may be characterized as lazy, irresponsible, or immature. Students with fixed mindsets often take on only easy tasks, try to make others look less capable, and discount the achievement of others to protect their self-image. Researchers have found that the brain is like a muscle that gets stronger with use and that learning prompts neurons in the brain to grow new connections. We all need to understand that we are the agents of our own brain development. Failure provides learning opportunities. The student should be encouraged to focus on the strategies they used and effort expended to determine what caused the failure. Students should be encouraged to seek faculty feedback. Hopefully, these insights about human intelligence and the fixed versus growth mindset help inform effective teaching practices. Blumberg describes a learning outcomes-oriented strategy to drive course planning, knowledge acquisition, problem solving, and critical thinking skills. Learning outcomes are central to the teaching and learning process. Developing learning outcomes is the first step in course planning as these outcomes set the direction for the entire learning process. Learning outcomes frame the content to be learned and guide necessary learning assessments. Learning outcomes tell the students about faculty intentions and direct student study efforts. Learning outcomes help instructors and students to monitor student progress. Learning outcomes comprise the big picture. Oftentimes the complex goals that instructors expect students to achieve or learn by the end of the course. Learning outcomes should be stated in terms of student performance, not what the instructor hopes to achieve. Learning outcomes are also called instructional goals. Learning objectives are smaller units of learning that flow directly from the learning outcomes. For example, a course may have about five larger learning outcomes with each learning outcome having several associated learning objectives. Learning objectives may describe what students will learn from discussions in a specific class. Learning is now an integral part of the teaching process. Instead of just lecturing to students, instructors now engage students in different active learning activities, include role playing, simulations, debates, case studies, small group learning, and problem-based learning. Learners need to interpret content in ways that make it meaningful to them. Active learning methods that foster deep, intentional learning often involve interactions with others. In these situations, students take control of their own learning. Active learning through discussing the content or solving problems in small groups leads to better long-term retention and the ability to use the material in new situations in the future. To help students learn, instructors need to break down complex concepts into tasks or component parts and provide the students opportunities to perform these skills or cognitive processes separately. The current view of learning is described as knowledge construction. The most effective learning happens when students create their own associations between new information and their previous knowledge base, not when they memorize how others have framed it. Effective teachers find out if their students have incorrect prior knowledge, such as misconceptions or stereotypes, by assessing students. Instructors address any erroneous knowledge, challenging the misconceptions directly. The relationship between the difficulty of a course and student learning is curvilinear. The best learning occurs when the course is perceived as difficult enough to be challenging, but still perceived to be achievable. If a course is too easy, students don't try. If a course is thought to be too hard, students aren't motivated to try because they think there's no way they'll succeed. The impact of education is directly related to student effort and level of involvement. Employers and society expect college graduates to be able to apply facts for critical thinking and problem solving, which depends on in-depth knowledge of the discipline and context. Effective problem solving draws on these processes, selecting the appropriate strategy, applying this strategy to solve a given problem, and monitoring the success of that strategy. Effective teaching involves providing students with opportunities to learn and practice different strategies in different types of situations. Developing lesson plans from syllabi includes writing objectives, which may use Bloom's or other taxonomies as a framework. Bloom's taxonomy involves learning outcomes in the cognitive, affective, and psychomotor domains. Instructors need to establish learning goals that reflect the knowledge, task, or behavior that's expected of students. You may want to create student and instructor versions of the lesson plan. Supporting materials may include class handouts that include applicable tables and figures. The instructor version of the lesson plan may have more detailed information that is related during class, but not provided on a handout, which may take more of an outline form. Truver noted that by targeting material toward the appropriate level or domain of learning, an instructor can help the student nurse anesthetist develop critical thinking skills. This is especially important because this final level of understanding is required to deliver safe anesthesia care. For example, after memorizing numerous induction doses, students must be able to critically assess which patients require dose adjustments. When learning objectives are appropriately constructed and sequenced to reflect various stages of learning, the instructor and students can measure progress toward their goal. Tables on the next two slides provide examples of verbs that can be used for different levels of cognitive, affective, and psychomotor learning. Verbs with concrete meanings such as define, apply, or analyze are more helpful for assessment than phrases such as be exposed to, or understand, know, or be familiar with. When learning objectives are established, the instructor analyzes teaching needs to determine appropriate goals for the students. This starts with describing the overall learning goal for a topic. The instructor then defines the smaller tasks or specific learning objectives. The desired behavior should be specific and measurable. To measure an objective, the instructor needs to confirm that the desired outcome was obtained. With lecture material, this includes writing exam questions that assess the student's level of comprehension. Learner objectives may be accompanied by the conditions for learning, including suggested resources and methods for obtaining information. If there is a standard institutional format for the lesson plan, use that. Don't reinvent the wheel. The institution, instructor, and targeted audience should be identified. Provide the course number, placement of the course in the curriculum, location of the class, and type of instruction employed, for example, live, hybrid, online, live, if online, synchronous, or asynchronous. Create a file name to identify the lesson plan. Insert your reference list and create the body of the lesson plan, which includes, one, introductory comments, two, a list of lecture objectives, three, an outline of the material to be covered, four, perhaps a separate handout with figures and tables, and five, a thorough summary of the presentation. Lesson plans and syllabi need to be linked while addressing the unique aspects of each document. Here is a sample lesson plan format. Take a few minutes to review this.

Didactic Instruction

Clinical Instruction

Nurse Anesthesia

Active Learning

Critical Thinking

Teaching Methodologies

Simulation Scenarios

Growth Mindset

Student Engagement