Hello, and thank you for joining us today for part one of two podcasts on the Everyday Essentials. I'm Rebecca Lee, and my everyday fun job is to serve as program director of Bayer University's Nurse Anesthesiology Program, located here in sunny South Florida. I've had the pleasure over the last two years of chairing an important task force for the AANA, the CRNA Faculty Stabilization Task Force. The Faculty Stabilization Task Force began important work this year on the implementation of content into the CRNA Knowledge Network Education Portal. This podcast is one of two sessions on understanding the use of the newly adopted AACN competency-based model and documents, the essentials, for nurse anesthesiology education. Joining us today is Dr. John McFadden. Welcome Dr. McFadden. Thanks, Rebecca. It's good to be here. It's great having you. Dr. McFadden, may I call you John? Please, please. We've known each other a long time, right? Thanks so much. Just for our audience to know who you are, you currently serve as a professor of anesthesiology and you are the beloved dean of the Bayer University's College of Nursing and Health Sciences, overseeing approximately 2,100 students and about 80 full-time faculty. Yeah, that's about right. It's a pretty robust college and it's one of the most fun jobs that I've had. Wonderful. And you were educated as a CRNA, you're still a CRNA, doing some anesthesia on the side and you were, I think you're quickly approaching, yikes, 40 years of healthcare? Yeah, it's hard for me to even believe that as well. That just means I've got a lot of gray hair and I've got a lot of good stories to tell. So it's been just a really amazing trajectory over the past few decades, but I think I'm in a place right now where I'm comfortable, I feel like I'm able to give back and I'm having a lot of fun while I'm doing it. That's awesome. You have worn many hats. These include positions in hospital administration, as a consultant, as an educator, as a hospital and professional accreditation reviewer, and you have presented nationally and internationally on topics such as nursing, healthcare, and leadership topics. In addition, knowing you personally, I know you consider your roles in nurse anesthesiology education as the highlight of your career. Yeah, it truly is. I love educating other nurse anesthetists, nurse anesthesiologists, and nurses in general, right? Because that's where we get our colleagues. They come from nursing programs and I can't under-emphasize or over-emphasize the importance of us really making sure that we take care of that group so that we have a strong group coming into our specialty. Terrific. Well, let's get started. I'll throw out the first ball, if you will. So my first question to you is, what are the essentials? Yeah, so this somewhat scary topic, the new essentials, is really just a document that was published last year by the American Association of Colleges of Nursing. So of course, the natural initial question is, who are they? And the acronym is AACN. Well, AACN began in 1969 and it's the Professional Association for Academic Nursing or that facet of the profession that deals with the education of nurses. AACN works on a variety of issues relevant to faculty, to programs, to students, and it represents academic nursing on policy issues at all levels. So nursing, like medicine, law, social work, and other professions, committed to establishing quality educational practices and standards many years ago. And I think every CRNA learned about our beginnings and knows that as far back as 1930, Agatha Hodgkin set forth the need to establish educational standards for CRNA education. Similarly, in 1950, a plan for accreditation of nurse anesthesia schools was established. Well, our base profession, nursing, also developed similar practices and standards. Now, it would take a whole other podcast to trace the complicated historical timelines of the development of nursing educational standards, but briefly, as far back as 1986, AACN developed quality markers for research doctorates in nursing education. And then similarly, the bachelor's standards or curricular guides were developed by AACN in 1998. And then the DNP essentials were published in 2006, and then the master's essentials were revised and developed in 2011. And while I wouldn't call them accreditation standards because AACN, like our AANA, is not an accrediting body, the publications identify and describe the content and the outcomes that should be part of any high-quality nursing curriculum. And by doing so, it promotes consistency among graduates. And that provides the greater public with a description of what can be expected of a graduate of any type of nursing program. So this new document, which covers all degree programs and levels of nursing practice, provides a really solid framework for what should be in a curriculum and what are the expected competencies of graduates of an entry-level nursing program and an advanced-level nursing program, regardless of the specialty or role. They don't replace our COA standards. They're generic, and they describe what all advanced-level nurses should be able to know and do. And in that way, they're foundational, and they complement the COA standards. Thanks, John. I just had an aha moment. This really helps me understand the history of where the essentials came from and how they differ from accreditation standards and how we can fit them into our nursing curricula today. So my next question for you is, these essentials for nursing education have been around a long time. It begs the question, why change them now? And why did the essentials need to be revised? Yeah, so I'm often asked why the Board of Directors for AACN decided it was time to make a major overhaul of the essentials. And as you just heard, the essentials has provided that educational framework for the BSN and MSN and the DNP degrees for many years. And they worked well since their inception, right? You heard their publication dates. But you and I also know both higher ed and health care are changing in leaps and bounds. And just consider this. The DNP essentials were written before the iPhone was released, just to give you a frame of reference. So I'm hedging a bet our listeners would agree that if we continue to educate our future nurses, our nurse practitioners, our midwives, our CNAs, following the same structure we have followed since the early 2000s, or even using the same teaching techniques, then our outcomes, our product, that is entry-level nurses and those who engage in advanced nursing practice will be obsolete before they even graduate. We on the task force had an aha moment when the practice partners on the task force voiced their perspectives. And these were the chief nursing officers, nurse managers, those that hire all levels of nurses in a variety of settings, and those who are out there on the front line of health care organizations, even insurance companies. And we learned that we all continue to struggle with high turnover, nurses leaving the profession, partly because they're not well prepared for the real world, but also because there was a lack of focus on self-care to prevent burnout. And that's clearly a growing concern for us, the mental well-being of nurses, all involved in the healing professions, actually. So we're seeing this issue emphasized, particularly now because of the pandemic. Thankfully, AANA has been ahead of the curve on addressing issues of wellness. But we draw our students from the core of entry-level nurses and sometimes nurse practitioners. So this is really important to all of us. There are other issues that our practice partners highlighted. One of our practice partners told us she has consistently observed inconsistency among our graduates across all degree levels and variability in the length and expectations of programs. And she came right out and told us, we're not even sure what your product is at the end of a degree program. If there's a difference between an associate's degree nurse and a bachelor's prepared nurse, this needs to really be evident. And she expressed concern about the quality of our programs and the variability of the product. And others echoed those sentiments. And I won't lie, I've thought similar thoughts myself. So this is an issue we struggle with, and we struggle with it in anesthesia also. Now, this can be pretty tough to hear when you're a dean or an educator, right? It's like holding up a mirror and turning all the lights on in the room. And we have to come up and admit to chaos that exists within our educational structures. I'm sure you encounter some colleagues in nursing who can't really articulate what nursing is, what nurses do. They can't differentiate between the levels of practice. They don't know what a CRNA does or even be able to explain the myriad of educational pathways in nursing. So if we're not able to explain nursing, no wonder the general public and other health professions don't understand what we do or the differences in our goals. So we had to use this opportunity to reexamine our traditions of nursing education and really seize the energy that came from the chaos that we've identified and try to look at some patterns and structures and rethink the way we do things. I guess I could sum it up by saying I've been frequently quoted as saying we just couldn't put lipstick on the pig. We had to blow it up and really create a completely re-envisioned set of essentials. Thanks for that visual. Now I'm picturing a lipstick on a pig. But I've often heard many nurses say that, you know what we need to do because nursing is so fragmented. We just need to blow up nursing. And that's essentially what I think you and the task force has done, which certainly makes sense in the direction that we need to go. But it sounds like such a monumental undertaking. Can you share with us who were involved in these revisions? So besides me, as a PhD prepared CRNA and a dean, we had two other co-chairs, Jean Giddens, dean and professor at Virginia Commonwealth University, and Cynthia McCurran, dean and professor at the University of Michigan-Flint. We had some wise consultants, including a former college president who was a nurse at a former university provost who was a nurse and a professor emerita who's an accreditation consultant. We had an amazing group of AACN staff, just like our AANA staff. I mean, we just couldn't have done it without them. And we initially started out working as three distinct groups, with me being over the DNP essentials. But the members of the task force realized that there had to be consistency across the documents. And that's when we realized we could not work in silos and we really needed to merge the groups. So that's what we did. And in its entirety, the task force consisted of educators and deans from private and state schools, really across the United States, APRNs, non-APRNs, DNPs and PhDs. And as I said, practice partners. And we met frequently, sometimes every two weeks, sometimes once a month. Sometimes we met for three-day weekends. And then we called meetings for feedback from many, many stakeholders. CCNA, the COA, the National Council of State Boards of Nursing, the clinical nurse leaders including SPECS, ANA, NLN, all the various specialty organizations of nursing. And based on that feedback, we revised and we revised and re-revised. And the process took 18 months longer than we anticipated because we kept incorporating feedback and making edits. When we began, we really wanted to honor the uniqueness of nursing. What it is we contribute uniquely to health care. But we also wanted to make sure we were not speaking a totally different language from our other colleagues. And I think that's important for us as nurse anesthesiologists. You know, some of you, like me, may be old enough to remember the fun we had using and learning the original taxonomy from nursing diagnosis back in the 1980s. Alterations in skin integrity, et cetera. No one else in health care understood us. And I think we recognize now more than ever, health care is truly interprofessional. And the complexity of our patients and our situations can't be addressed by just one health care professional alone. We have to have some commonality. As much as we recognize our separate identities and what we contribute to health care. So, like every good researcher, we turned to the literature and we decided to use a modification of a framework first described by Englander and his colleagues in 2013 when the discipline of medicine and some other allied health groups began working on competency based education. And we didn't use the framework verbatim. I like to think we evolved it a bit while staying within its spirit. And if you have glanced at the new essentials, you know that this framework includes the use of domains which are simply a category of like elements, in this case competencies that relate to each other. And this helped us explicate the competencies we were seeking to define and ensure that they complement all the other health care disciplines. So you're going to find similar language with medicine and our other allied health professional groups. Wow, we do certainly learn a lot from our physician colleagues and the medical model. I'm starting to get a good picture and a handle on understanding how the new essentials will evolve in our nursing curriculum. John, can you give us an overview of what competency based education is and how do we venture into it? Wow, so where do you start? Again, I could do a whole other podcast just on competency based education. But let me try to share those important bullet points that are in my head. You know, CDE, as competency based education is known as, is something we've been doing for many years. Some have traced its roots back to the 1950s in the US. And you may have heard of it referred to as performance based education. So it's not something that's radically new. I remember attending lectures back in Philadelphia at Penn back in the 80s and learning these concepts from Dorothy Del Reno. It moves faculty from focusing on the content outline of a lecture and memorizing so that students can pass the NCLEX, or in our case, the NCE. And at its essence, it focuses instead on the desired outcome for the learner. And that is the ability to think and reason like a nurse or in our case, nurse anesthesiologist. So from that perspective, it helps you as a faculty member know when a student is competent enough to enter practice and no longer be supervised by a preceptor or an instructor. And I think we've all had to wrestle with that decision. You know, even when we're precepting a brand new nurse anesthesia student, at what point can you leave the room for a few minutes and let them stand there by themselves? So CBE involves a lot of formative assessment and feedback. This provides the student with the opportunity to figure out early on what they understand and they can do rather than relying on, you know, the classic two or three exams or and then finding out that you failed a course at the end of the semester. So the focus is on creating assessments so that learning can be tailored along the way. CBE also is making sure that students can do something with what they know. It's not about simple recall facts and multiple choice tests, but instead it's about applying what you know. So our assessments, they can include multiple choice tests, but not only multiple choice tests. Faculty can choose to incorporate things like case studies and critiques of articles and reflection papers and simulation and of course, clinical experiences that include evaluation and feedback. And I know most of us are already doing many of these things so those assessments have to be, have to really include performance and not just simply recall exams and then they have to be mapped or tied back to the competencies. That is where you may have some work to do, mapping what you're doing now back to the domains of competencies. And just because someone is able to demonstrate competence once doesn't mean that they're done. That's not the definition of CBE. In fact, that brings us back to the old days of a skills checklist. If you did one machine check or one induction set up, you were checked off. But in anesthesia education, we know that watching someone perform an intubation once doesn't verify or equate to competence. I think all of us would agree. You don't want someone who's intubated one time or even 10 times, going to the head of the bed alone to do a case. The ability needs to be repeated in multiple contexts and settings. So you wanna make sure the student can intubate healthy young people. They can intubate elderly people. They can intubate in the operating room. They can intubate in the critical care unit. They can intubate in the ER or the trauma pad, et cetera. That's the difference between a skills lab checklist and verification of competency. And it's also why competency can't be captured in a multiple choice test alone. It's great if a CRNA can describe, or a CRNA student can describe the anatomy of the upper airway through a test question, but they have to use that knowledge of anatomy when they're managing an airway. So that's why you need to have multiple forms of assessment. You know, it's true that CBE does place less emphasis on time-based learning. I've heard that over and over again. What we often call seat time, right? But we're not even close to ending our relationship with credit hours and contact hours and clinical hours. Our federal and state regulators aren't there. So those hourly requirements, I just don't see going away anytime soon. No doubt, some students will achieve, you know, some select competency outcomes more quickly than others. I can tell you my classmates were correctly placing the endotracheal tube much quicker than me, but that doesn't mean that you graduate them before the curriculum ends. And as I previously said, one and done doesn't demonstrate the progressive and consistent nature of competency attainment, particularly in anesthesiology education where repetition plays such a valuable role in reinforcing knowledge and skills and values and attitudes. So repetition, you know, it's gotta be intentional and unintentional, and it's gotta really cover the complexities and context nuances of a skillset. Speaking of hours, there really is no strong evidence to support a specific number of hours or experiences or case numbers. And we've been debating this as nurse anesthesiology educators for decades. So a minimum threshold of hours of practicing engagement, it remains necessary because we just simply don't know. We don't have a minimum number for entry-level nursing. That's never been set before. We've set the minimum of 500 practice hours in the discipline of nursing as the requirement for the advanced-level subcompetencies. So that is 500 hours after someone has completed their entry-level education and attainment of the level one subcompetencies. For us, as nurse anesthesiologists, we set 2,000 clinical hours as the minimum acceptable number. With all these thresholds, some students are gonna require more. The amount will vary, again, based on role and specialty requirements and the design of the curriculum and the needs of the student. And I think what will happen as the strength of evidence to support valid and reliable assessment techniques builds, the role of practice experiences and the number of hours will evolve in the future. But we're not there yet. So learning about competency-based education is something we're all gonna be engaging in over the next few years. It's going to require us to think differently about how to deliver content and how to perform assessment. Traditional teaching with lectures, which is how I learned and how I taught for many years, may have worked for the majority of students when college campuses were more of an ivory tower filled with well-resourced and supported students. But I don't know about you. I don't think any of us are educating similar types of students or groups of just elite students. Our college campuses aren't ivory towers for the wealthy, nor do I believe we want them to be. Our institutions of higher ed are somewhat like lifeboats for many students. And like you, I teach with a wonderfully diverse group of students that we are working with to prepare for an increasingly complex world. The days of rigid course structures and simply offering high-stakes exams and lecture-based classes really set up students to either flounder or fail, particularly some of our disadvantaged students. So active learning, competency-based practices, such as building small assignments and assessments or scaffolding have really been shown to close the performance gaps and help all students succeed. And that to me, more than anything, is going to lead to the more current need to decolonize our curricula. Very interesting. By the way, I love that word, decolonizing. So as I understand it, for example, this is the premise to why physicians require, say, X amount of procedures before a hospital will grant them privileges to do a particular specialty. Or when a physician learns a new procedure, they must complete 10 or 20 of that number before they are, say, let loose, if you will. This is in addition to the didactic and scientific knowledge acquired in that field. And to recap what you have said so eloquently just now, we are already doing competency-based education in our nurse anesthesiology curricula. That's really great news. That's right. John, as CRNA educators, how can we begin to digest the information and understand this model? Well, I'll tell you, Rebecca, my thought is to really approach this with a wide aperture and become familiar with the sections and contents of the actual published document. If you find yourself tending to gloss over introductory pages and only accessing the glossary as needed, well, maybe now's a good time to chunk up a document and read through it in its entirety. It might be helpful to discuss a section at a time when your faculty come together for meetings or retreats. The second suggestion is to take a look at the competencies and the sub-competencies. And this is gonna take a little bit more work, but you've got to map them back to your curricular content. So the question is what content is already covered, like ethics, head-to-toe assessment, informatics, HIPAA, and then identify the things you don't cover. Maybe your curriculum is scarce on safety science or perhaps the social determinants of health. And that way you're creating a gap analysis. And probably more importantly, how and what do you assess to determine your students' knowledge and abilities? Do you use purely exams in some of your courses? I would imagine all of our programs use a daily clinical evaluation tool. And I know our association has been behind really creating a prototype tool for that. Well, could that be structured using some of the domains or some of the competency statements, even if just for portions of clinical education? Do you use simulation, for example, to learn only technical skills, or do you use simulation to practice interdisciplinary collaboration and conversation techniques or role modeling a professional comportment? Maybe consider how to use some self-reflection even to assess some of the competencies. I'm watching you and I'm sure you're as overwhelmed sometimes as I get with this, and perhaps your brain's a little bit itchy. Well, again, I've been there throughout this whole process. When I said yes to serving on this task force, I didn't thought we were simply revising the existing essentials and infusing a little bit more current language in them, but as a group, the task force, from the academicians involved to the practice partners involved, let us know that we needed more than a change. And so we really did, I think, transform the way we want our next generation of nurses and advanced practice nurses to be educated. As I hear more and more about this task force, I'm more and more impressed with you, John. No, it was a team approach. We had such incredibly bright folks on there, and without a doubt, I learned more from the process than I think I was able to contribute. In this next few sentences, can you quickly walk us through the document? Sure, and there's good news. The essentials document is less pages than the IRS tax code, considerably. It's less than 80 pages. So let me just give you a quick overview of the document. It begins with an introduction. This component, the introduction, represents information that sets the stage by providing the context and the purpose for the essentials. The importance of the introduction, I just can't overstate it. The introduction intentionally nests the discipline of nursing and our values clearly as the foundation of the essentials. And some of the topics addressed in the introduction include the current state of higher ed and future trends, the current state of healthcare and nursing's changing roles and the role of nursing education and workforce development, plus some key concepts that are pervasive in the domains. The next section of the essentials are an introduction to each of those domains and an explanation of how domains, competencies and sub-competencies relate to each other. There's also an introduction to competency-based education and it's followed by a section on implementing the essentials and then the actual tables of domains with their corresponding competency statements and sub-competencies. I think sometimes we become so focused on anesthesiology education that we've not holistically considered how our students arrive in our programs. That is, what should they know and be able to do as entry-level nurses? That is vital information. You should not be repeating information that is considered essential, no pun intended, for every entry-level nurse to know. Similarly, if you think a new anesthesiology student comes in with a specific skill or knowledge base, but they don't, you could be failing to build on that correct prerequisite knowledge. So it's really important for us to know the whole trajectory of nursing education. That makes sense. I think we made lots of assumptions when we accept students into our programs. My next question for you is, do you have any suggestions as to how one should get started? Yeah, so while the work the task force ended last spring in 2021, a new group has been formed by AACN, the Essentials Implementation Steering Committee and that group picked up where we left off. They're constructing the resources for faculty and monitoring for issues and challenges to implementation. And there's a large cadre of our colleagues assigned to each domain. So that's the group that's gonna help identify learning strategies and give examples of assessment measures to help schools transition their programs. If you've never been to the AACN website, I think that's a good place to start. Search for the AACN Essentials and the Implementation Committee and also the Essentials Corner, which is a forum started by the AACN. Their work is evolving. Talk to your nursing dean or chair, get access to the site if you don't already. And when you log on, look for the implementation toolkit. The purpose of the toolkit is to provide recommendations and examples of strategies. Once you're there, you can download a copy of Essentials. There are some examples of curriculum mapping tools. There's general resources about course descriptions and competency-based education and assessment. And you'll be able to find recorded webinars, but also get information about upcoming programs. AACN offers many conferences and webinars, but so does COA and the AAMA. They're also providing content. This podcast is a great example. Fantastic. These are great resources to share with our audience. Another popular question that may be on our mind is, what is the timeline for CRNA educators? Yeah, boy, that's a tough one. And no one's expecting that faculty change their curriculum and have something ready to go by the end of 2022. This is really a long-term project. As I said, start by becoming familiar with the document and collaborate with other nurse anesthesiology faculty and even other nursing faculty. Look at some of the tools already developed by those who have started already. But I have to caution everyone. I don't mean to tell you we're living in some strange times. Our mood and disposition is not quite ready to embrace more uncertainty and change. It's been a tough 22 plus months with our current global health situation. So be thoughtful about how much change you and your colleagues can handle right now. Those of you who remember me from A and A practice committee remember me using the old saying for some of our work back then, and that is, how do you eat an elephant? Well, the answer is one bite at a time. And that certainly applies to this. That is so true. I use that expression all the time as well. Thanks for sharing such a compassionate approach for our faculty to consider. Thank you so much, John, for sharing this important work. As CRNA educators, we all want to understand the impact of the new essentials on CRNA education. You have made them so significantly easier to digest through this podcast. Folks, if you enjoyed this podcast, stay tuned for part two of the series on the everyday essentials, where we get into the weeds a little bit more with Dr. John McFadden. ♪♪

AACN competency-based model

nurse anesthesiology education

competency-based education

curricula mapping

implementation process

nursing education trends

faculty resources