The last question is, at my facility, nurse anesthesia residents are not allowed to be left alone. What can be done to get them experiences so that they can function independently when they graduate? I think this is a really important question. I didn't write this question, but it certainly defines where I practice right now. Certainly, you start early in their education. Our Wake Forest is an integrated program. Dr. Riker is in the audience, so I hope I'm getting this right, about six weeks after they begin the program. We start getting our first set of the newer students in January. For the senior students, our facility is actually an elective because we do hearts, we do very large vascular cases and difficult spine cases as well. The first thing is you just start very early on in their clinical education and trying to help them think critically. What would you do? I try to give them, well, first is advocacy and everything, right, for our students and their learning opportunities they have. I try to encourage those opportunities for learning, tailoring it to where they are in the program. If they're in their first year of a clinical setting, they don't necessarily need to walk in the heart room their first day on a rotation. They need to try to get an experience of mass airway cases as few and far between as we do those now. We have no anesthesia competition at our facility. When they come back for their senior year, they can do any case that comes through the OR. And then we get very good evaluations on our CRNA clinical preceptors in the clinical area. Most of them love teaching the anesthesia students and so that helps too. Second is the mentoring and coaching. These are adult learners that we're working with and so you always have to keep that in perspective. They do know how to put on blood pressure cuffs. They do know how to put on EKG leads and start IVs very well. So taking that into consideration and then I enjoy encouraging the sharing of knowledge with them. Seek their thoughts. You know, what does the research say about that? And if they don't know something right away, I'm like, okay, let's look it up and learn it together because Google's become our friend. You know, when I got out of training in the 90s, you didn't have all these quick references available to us. But certainly it's worked our favor now. And then finally, at the end of the day, I try to make, take a few minutes. We're all ready to go and leave and get home and start our afternoon and evening activities or whatever time that might be. But take a few moments with that student and ask them, what'd you learn today? And that's difficult I find for a lot of them because they don't want to appear, you know. And I always joke with them, I know you did something right today. I'm thinking of a few things. So if all you can think of is, I got here, I found the locker room and I got my scrubs on and got to the area. But I said, learn to recognize in yourself things you did well. And then on the flip side of that, we talk about what learning needs they have identified. And again, I share with them, I've been given anesthesia for 26 years. I have learning needs every day that I need to address. So that's just kind of my little pearls that I've learned over the years. So yeah. Anything else from our panel? I'll just add. So we have clinical sites that are very similar to what Lucy has described. And then we also have clinical sites where our students are actually very autonomous. And it's interesting the students' perspectives. You know, we get kind of a mishmash of feedback from them. A lot of them actually like when the CRNA is in the room, when they are a quality educator like what you're describing, because they feel like they've actually gotten more out of their day than if they had been left alone. So I think that just because there's a policy in place at some of our clinical sites that dictates that the CRNA has to stay in the room with the student does not mean that we cannot still foster that critical thinking and independent decision making. But I do think we have to educate our clinical preceptors and instructors. You know, they learn on the job, right? They don't get formal training. And some of them just take to it like a fish in water, and some of them not so much. And they need our support. And so, you know, one of the things that we've been toying with at Baylor is implementing regular education grand rounds for our clinical instructors and coordinators so that we can help, you know, formally train them to be better clinical educators. Anything from our audience? Anything? Lorraine had a question. Oh, here. And then I'll take it back when you're done. Hi everybody. Bernadette Johnson. I work for MUSC. And I think to speak of what you were saying is that we can build autonomy when we are in the OR. We just sometimes can tell them, you know what, I'm going to step over here and talk to the circulating nurse. Or what I love the most is when I'm working with a student and they come in and I always say, what do you need from me today? And some of them say, I need you to sit on your hands. So this is what I do. Here's the phone. And I'm going to sit on my hands. And so I try not to get into their way, but yeah, I think whether we're in the room or not, it's how we show them that, yes, we respect you. You're in our space, right? And it's hard because a lot of us are type A personality. We want everything done our way. And if they make one little mistake, sometimes you're like, it's not supposed to go there. Put it back here. And then they feel like I'm not going to do anything because that's not what she wants. But what do you want? How do you want to do your anesthetic today? And let them know right from the beginning, I respect you and I'm going to sit on my hands. So I'm going to do a little plea. Just because one of the things that I see is I see the way reimbursement is headed. I see the way we are evaluating quality. And the way we operate in our models with two providers providing one anesthetic is not sustainable. Absolutely not sustainable. And so I'm here to encourage that if your program can continue to help students be very invested in being autonomous providers when they graduate, we really need to continue down that road. Because right now we're in a very nice situation in the way we get paid from CMS. I know not private payers, I won't even get into that. But my point is that we cannot become dependent on someone else being outside of the room supervising us. And we have to have our students prepared so that they can continue to be autonomous providers. So I'm just here to encourage whenever possible. I know what your environments look like overall. So I know it's not possible everywhere. But when given the opportunity to sit on your hands and not get too excited when they put the blade where you wouldn't have put the blade and those kind of things, I really think it's important because for our profession to flourish and the opportunities are better than ever, the doors are wide open for us to grow. It can't get any better. The needs are off the wall as far as needing us as CRNAs to provide anesthesia in this country. We've got to be able to walk through that. So I'm just here to say keep doing as much as you can do to help your students be autonomous so that they're able and they feel comfortable as providers when they graduate. So mine's just a rah-rah speech. That's all that was. But I really want you to know our environment in measuring quality and measuring reimbursement is going to change. So we've got to be able to say we can run a room and we can be in there by ourselves and we have to make sure our students when they graduate do the same. I know Heather wants to say something. Heather Rankin, I work at Children's of Alabama so it's, you know, a highly, we have lots of learners. We have physician learners. We have all kinds of learners. And we are a place where you have to stay in the room and we're kind of unique because the physician and the nurse anesthesia residents have to have a CRNA in the room. So I totally agree. To your point, Rachel, we, I think the biggest part where we're, I'm sorry, where we're missing out is educating clinical preceptors because we've got 45 different CRNAs in our department. We all teach very differently and I'm, it's hard for me to sit on my hands without my head exploding sometimes. But I agree having that conversation at the beginning of the day. What do you need from me? What do you want me to do? And obviously assessing what the situation is. But letting them know, even if you have to be in the room, yes, I'm going to walk away. I'm going to go sit inside. I'm back here. Let me know if you need me. You don't have to ask me, can I give 10 more fentanyl every time you think they need it. These are things that you can learn on your own. Yeah. Thanks. Michael Riker, Wake Forest School of Medicine. So to answer the question, I think something I always think about, something that's very important to tell our clinical instructors is that simulation is a process, not a technology. Right? And professional athletes know this. If you watch the Olympics, you see those ski jump people. They're sitting there and they're going through, they're visualizing the whole thing in their head. There's learning that comes from that. And so I think that something that I always did when I was a clinical instructor, hey, Rachel was going to do this, I think a little bit, is I play the what if game. I do this with myself too, by the way, you know, on a daily basis. I sit there and to say to the student, what would you do if the heart rate started to rise right now? At what point would you do that? How would you know when to do that? When would you call for help? Right? And so you're really, you know, the physical skills of drawing up the drugs and stuff, that's not as important as the critical thinking piece. And so I think for a lot of instructors, you know, they get in the middle of a case and they're like, oh, everything's very stable. Nothing's really going on. Good time for me to take a break. And I think that's a great time to stay and enrich the learning opportunity with the experience that they have. Right? So there's a lot of learning that can go on. There's a lot of independence because independence is really about the thought process, not necessarily that they're actually just doing the skills themselves. I think there's a lot of independence that can be built by just putting the students in a simulated situation of saying, if the patient coughed right now, tell me what would you do and in what order and what steps. So I think there's a lot of ways that we can do that, even when we're in a situation that the instructor has to stay in the room. Yeah. I'll just say, I think probably one of the biggest challenges that program directors face is the ability to reach those clinical preceptors and engage them in actively teaching our students. We've tried lots of different things. I try to go to some of their morning meetings and do a quick little presentation. We've held preceptor workshops, free CEs. We invite them to regional workshops. You may get a few, but when you have students in all these different facilities and they're assigned to a different clinical preceptor every day, we know that there's probably only a handful that are doing the active teaching that we want for our students. And then there are other clinical preceptors who really are looking for that opportunity to go and maybe take a break for a few minutes. It's a challenge. It's a true challenge to ensure that when the students are in the operating room, that they're actually getting teaching from the clinical preceptors. That would be, if anybody can figure out a way to get that education out to the clinical preceptors, I think it would be very welcomed. I also use the feedback, because probably, I'm sure in every institution, you have an evaluation of each of your CRNA preceptors. I don't know if I'm using the correct terminology. The CRNAs that are working at the facility that teach and mentor the students for the clinical day. And I do evaluate each. And historically, we have received very good feedback and very positive feedback with most of the comments being, oh, they let me try this. I got to use this new drug. I got to do this and that. And on the rare occasion, there is a comment that might be, well, they didn't even listen to my anesthesia plan. I certainly take some time just to have a crucial conversation with that CRNA and evaluate what, you know, maybe that person had a bad day or something. There might could have been a valid reason for that particular encounter. But I think that's important, too, to use that feedback that you receive from the anesthesia program. So we've hit our time. And I want to give you a minute to get to your next session. So thank you for sharing your lunch with us. We enjoyed the conversation. And you all have a good rest of your day. Thank you.

nurse anesthesia residents

clinical autonomy

critical thinking

preceptor training

simulated learning