Hi, I'm Stephanie Kelley-Parks, and this is still the Art of Precepting. This is the second module, Understanding the Learner. The objectives for this module, Module 2, is going to focus on more the student and what the student brings to the clinical experience, and we're going to start further back from that involve the nurse anesthesia program, talk about the modern student and some of the statistics for the modern SRNA, talk about the different clinical levels and program development for the SRNA. We're going to talk about Dr. Patricia Benner's Novice to Expert Theory in more detail, discuss the Teamwork Foundation, talk about that standardized debriefing, and something that I call the Contract for Success. These are some current statistics on the nurse anesthesia programs here in the United States. So all accredited nurse anesthesia programs had to have students enrolled in a doctoral accredited program by January of 2022. So all programs now are a doctoral program. There's three degree programs, the DNP, which is the most popular, the Doctor of Nurse Practice, the DNPNA, which is the Doctor of Nurse Practice, Nurse Anesthesia, and the DNAP, the Doctor of Nurse Anesthesia Practice. So they're all very similar, but those are the three degrees that you can get now in the U.S. in a nurse anesthesia program. The average length is around 36 months, and remember the addition of the DNP curriculum, there were some programs that were shorter, and they're all on average around 36 months in length. Some statistics on educational cost. Right now the cheapest program is around $14,000, with the most expensive program being at $218,000. So the cost of tuition has gone up dramatically. Just to compare, 2013 the most expensive program was $80,000, so now it's $218,000. And the average class size is 25 students. The nurse anesthesia programs are typically two different styles. There's the front loaded versus integrated. Most of the programs in the U.S. are front loaded, meaning the first year of anesthesia school is almost strictly didactic classroom content, which is going to be your anatomy, physiology, pharm, some simulation, and then some of those classes that were added as part of the DNP curriculum, such as like leadership and statistics. So the student learns almost all of their didactic stuff in the first year, or first three semesters, before they start clinicals in the OR. So the transition is usually pretty smooth to the OR, but this is typically the first time a student has had clinical hands-on application to concepts that they learned potentially the first semester of school. So some students feel a little bit of the disconnect from learning something in that first semester, and now two semesters later, they're actually taking care of a patient with maybe that disease process. Now then the integrated programs are a little bit different. Clinicals begin somewhere in the third or fourth month of the program, which is a lot sooner than the front loaded program. So students are often learning a concept and go almost immediately to practice those concepts in the OR. So they are going to class and they're starting to perform clinicals almost immediately, a lot sooner than the front loaded program. So concepts have a lot of time to be grasped because there's not as much didactic, there's not as much school in these integrated programs. So it's a little, it's perceived as being a slower pace that the didactic material is given and instructed to the student. And then somewhere they call the hybrid program, it's sort of a mix of those two, and it's a design by usually the program director. But those are two of your big program styles here in the United States. The average age of the nurse anesthesia program, whenever they begin, is 30. The average time a student has in the ICU right now, in anesthesia programs, is three years of ICU experience. And just another statistic I found, 30% of these students have children. One thing that has happened, a lot of changes occurred because of COVID. But one of the things that happened because of COVID is the significant amount of applicants to CRNA programs that started really showing in 2021, 2022. So schools that had close to 100 applicants prior to COVID now had three to four times as many applicants that are all trying to get a spot in an anesthesia program that has most of them the same amount of spots in a program. And there's really three things that contributed to the massive increase of applications to school. The low job satisfaction of the nurses, the bedside nurses, basically a lot of the nurses post-COVID were burned out and decided they were going to do something different. On the opposite end of the spectrum, the satisfaction scores of CRNAs were much higher at that time. And as everyone is aware of, the increase in incomes in CRNAs and travel CRNAs really took off shortly after COVID. And at the time of collecting this data, there were 131 CRNA programs in the United States. So there's just some program statistics for you. This is a chart that shows the SRNA levels where they should be based on where they are in their anesthesia program. And this is based off of a front-loaded program on their student evaluation form. So just to read the chart so you can understand what this is, it's based off what semester they are in the program, front-loaded. So on the far left is the third and fourth semester. So the student is expected to be disorganized. The student is expected to require constant direction. And the student is supposed to be and expected to be really unable to put it together. So this is why it's so important to know where they are in their training so you can evaluate them based on the expected level and where they should be in their program. And as you can see, the longer they're in school, the more they're expected to be able to do. And their independence is increased into the ninth semester. So ninth semester, this is their student that's just basically waiting to graduate. They have gotten what they call all of their numbers. Their DMP project is completed. So the student on the far right of this is very organized and is able to function independently. This is a student that's able to run their room. This student is organized, and this student is able to predict and manage events that come up in their case. So completely different, the evaluation system and the way that you assess where they are based on their placement in the program. So this is really important to understand, and it really makes sense when you look at it whenever you get that student that is right out of didactic in a front-loaded program and where they're supposed to be. And it's exactly where they need to be. And they're not expected to be in that seventh, eighth, or even ninth semester. So this is some adult learning theory that we're going to talk about here. Again, this is Dr. Patricia Benner, and she wrote, she's a nurse theorist, and she developed this model that talks about the stages of clinical competence. And from novice to expert is her theory. And she bases theory on education and experience. Basically, we become more clinically competent because of the experiences that we have that take time to develop. So it's the difference between knowing this and knowing how. And starting at the top, you've got the novice beginner, advanced beginner, competent student, proficient student, and expert practitioner. And we're going to talk about each of these, and we're going to apply it to the sRNA when they show up at our clinical sites. We've all had this student. This is the novice beginner, and I call it the hero to zero because, again, this was the ICU nurse that was the top of their game, the person that everyone went to when they were having trouble troubleshooting equipment or trying to figure out the patient or getting advice on how to manage it. But now suddenly, they are the novice beginner. They are the new kid on the block. It's been, for some of these front-loaded programs, it's been 10 to 12 months since some of these students will say, since I've laid hands on a patient. So they have a lot of anxiety because they haven't been in clinical practice. They haven't started an IV. They're very focused on their hands-on, their psychomotor skills. They, again, have no operating room experience. They have very little sterile technique experience. They're the ones that are running into the back table and contaminating things. They have a ton of knowledge, though, very, very, very book smart, but they don't have any operating room experience, and they're just trying to tie that book knowledge into clinical practice knowledge. So I put the other things, and we talked about this. They're eager and excited because they're progressing through school. They haven't been dismissed. They're exhausted, and they have significant time management issues. So this is the novice beginner. This goes with what we just talked about, the novice beginner. So as a preceptor, you should, for this novice beginner, get some really clear goals and expectations between you and the student, and try to establish some consistency. Remember, they're coming in here. They're watching you. They're wanting to model something. So establish some consistency, and this is where you might consider having that student go with the same person for a week or the same at least two people for some time period to establish just some good organizational foundations at your clinical site. Use cognitive aids and checklists. The modern student is equipped with some type of cognitive aid, and that's fancy speak for like a checklist or some laminated something the university probably gave them or someone in their class made, and students are very heavy on these checklists and aids and stuff that they've created or had made, and so use that, and cognitive aid, I'll go ahead and throw that clinical care plan that they bring into that. So use that. This is sort of their crutch. This is what they like to refer to, and be familiar with that yourself. Review their care plans with them. Again, this is what they have spent a lot of time on. This is what they plan on doing, so please review that because they've put the effort into it, and show them that it's important to you too, and go over it. And lastly, cheer these guys on. Cheer them on. This is the second phase of learning in the novice to expert. This is the advanced beginner. You'll see this student start to emerge around the third or fourth semester of clinical experience. This student still needs constant supervision. This student is better than the novice learner, but still needs constant supervision. Their cases and their skills are starting to become acceptable or satisfactory. They're starting to make some clinical, critical care decision making based on what they're seeing. They're starting to put it together, and they're starting to feel more comfortable about it. However, this is the advanced beginner. Little small things that go off script, or it just derails them completely for this person. They're still making improvements with some things, but they're still struggling with certain tasks. I put masking in there, because they may have mastered maybe intubating, but they're still struggling with some of these other tasks that do take a while, such as masking. The advanced beginner is now able to think past that first case. They're in this case, and they're thinking about that next case, and how they're going to do that one, and start to mentally, maybe even start to prep and get stuff ready for that next case. This is the advanced beginner. The advanced beginner, you should encourage and assist them on these psychomotor skills. They're starting to get more proficient, so fine tune them, because you are really the airway expert. Fine tune them, and give them pointers, and help develop them to become airway masters as well. Encourage their opinions. Seek their opinions out whenever you're talking about a case. Get some of their feedback, because these students are very, very smart on a lot of different comorbidities. See what they would think, ask them how they want to do the next case, and then allow them to make mistakes, but never at the detriment of patient safety, but allow them to get behind a little bit. Allow them to be late getting their INOs. Allow them to be slow to recognize that they're closing. Allow some of these mistakes, because that's learning. This is where they realize that they should have seen this, and maybe moved sooner to get something started, or to finish something. And then this is a great time for you to be able to sit back a little bit as the preceptor, and sort of see how you're doing. Evaluate your teaching methods. What's working good with this student? What is not working good with this student? And then ultimately, keep cheering them on. This is the third level, the competent student. You see this level start to emerge around 150 to 200 clinical cases. So this student requires very little assistance. They have been in clinical practice for several months now. They understand what needs to happen, and what they need to have ready. They're able to anticipate events in cases, such as like insufflation and things that happen with that. They're able to anticipate when the surgeon is going to request for something. They're more organized. Their workstation doesn't look like a dumpster fire. And they're able to get ready for the following case. They're able to see past the case that they're in, and mentally start thinking about the next case. This is the competent student. So the preceptor's role for the competent student, you should recommend something that gets them out of this comfort zone that they have started to get into. And that could be something like, have you considered maybe a MAC blade instead of the Miller blade that you tend to use for all of your general anesthetics. So recommend something to get them out of the zone that they have put themselves in that is working really well for them. So this is the time they need to experiment with different stuff. And then this is a great time again for you, the preceptor, to become the student, to ask them about what they're learning or ask them about some of the things that they are experiencing in classroom. And this is a great time to start asking them about their doctoral program because at this point, they should be well into their DNP project and be able to give you a great idea of what they're writing about and researching. And then this is another time because the student is so competent, the workload on the preceptor is significantly less. So then this is a good time to get with a student and just start doing some critical thinking and discussing things because the student is more relaxed and they're able to have discussions based on the case that they're in or just something clinically related. And this is the competent student. Next is the proficient student. So this student is starting to perform like a new grad CRNA. Some of their psychomotor skills are excellent. This might be the student that gets all the A-lines and may be better than you on doing some tasks. This student sees the big picture on things. This student also could consider their knowledge more up-to-date and more current than yours. And this student, instead of just doing things satisfactorily, like, yeah, able to do it, this student is actually getting very good at their task. And this student is always seeking improvement, always seeking feedback. So this student's always asking you for ways to improve because they're getting comfortable with tasks and they're wanting to raise the level of their proficiency up. So they're seeking that information out from you. So for the proficient student, you're really wanting to cheer their independence on. I mean, they're growing and have grown by leaps and bounds and you're happy for them and you're happy for you too, because this is a great addition to your room. And this is someone that is now able to run that room. And just also remind them, because this is the proficient student, they're getting very good, but then remind them, you still sometimes need help. And even the best practitioners, even the best CRNAs sometimes need help. So encourage them to recognize when they need to help and when to call out for help. So this student is starting then to battle the complacency because at this point, they are at the end of their time as a student. They are getting very, very close to graduation. So then you got to look for and be prepared for the senioritis. This is a student that's maybe has already job lined up and it might not be at your facility and they're just waiting to graduate. So be on the lookout for the student that is very good, but also very over being a student and very over being broke and tired. And so this is the proficient student. And one thing you should do is just remind them they're still not out of school and they still need to finish school and they still need a job. So encourage them to strong finish to the end. So this is the proficient student. This is the pinnacle of practitioners. This is the top of the food chain. This is the expert practitioner. Few students achieve this level while in school. And very important point is not all practicing CRNAs reach this level of mastery. So the expert practitioner is excellent. They are typically a lifetime learner. They can revert to that novice role if they're doing something new, unfamiliar or completely first time doing a particular case with new equipment or something's new, they can revert to that novice role quickly. But this is the expert practitioner who will quickly then get back up to their knowledge base. They can still make errors and it is still possible to make wrong decisions. But these decisions and how they run their case is not really dependent on checklist or guidelines. It's more based on their clinical experience, their critical thinking skills. This is the best of the best, the expert practitioner. The last slides of this module are gonna talk about the teamwork and really focusing on the relationship with the SRNA. These are some really good team building tips that you can use to establish a great start with the SRNA when they come to your facility. So integrate and introduce this student with the rest of the staff members as if they're part of the team. Introduce them as they are part of our anesthesia team. They're a student at this university. They will be here for this many months. Give them a tour of the place. Show them all the big stuff. Show them where the cafeteria is. Show them where to put their lunch if they bring it and really integrate them in and make them feel like they're part of the team because they really are part of the team. You wanna establish the clear communication. In other words, you want their contact information in the anesthesia room where anybody can reach them at any time and it's very easy for the student to be able to find any of the CRNAs there. Ask this student what their goals are for that clinical rotation. That is very important to establish because they could be focusing on some tasks that maybe at their last clinical site they were struggling with. And ask them what their goals are. What do they feel like they need to work on the most? And make that goal part of the learning process. And you would be surprised at what some things are at the very front of these students and what they have made to be a large mountain in their book to climb. So ask them what their goals are. And then ultimately give them some really good feedback. Timely, constructive, start to finish in working with this student every day. This slide is called the standardized debriefing. And what I'm referring to is their university's eval process or system. And you are making a judgment on this student's performance based on those goals of their learning experience. And what I'm referring to is where they are in their clinical rotations and understanding at what level they are in correlating their performance to that level. And if you think back several slides previously, we talked about that student in that third and fourth semester, how disorganized they are and how they need constant supervision. So you're evaluating them based on only where they're supposed to be at that time. And preceptors are a lot more comfortable to give positive feedback. It is difficult for some preceptors to give negative feedback or constructive feedback, bringing up some things that the student is not doing well. Evaluations should be based on what the program says the student should be at though at that time. And if you understand the program's evaluation requirements and tools, everybody is on the same page. And what I mean by that is every student knows how many evaluations they need for each week. And that is important for you to understand too, because you want that student to continue to progress and you want to make sure that that student is getting the evaluations they need for them to grow and for the program to have on them. And you need to make sure that you are giving them the evaluation numbers that they need. Some programs will allow you to do paper evaluations. Most programs have electronic evaluations and I will encourage you to do the electronic evaluations if possible. And there's many reasons for that. First of all, it's really very easy to do if the student sends you through their computer program like Metatracks to do the eval. It's very easy to do. It is very easy to track as well. And the reason why we want to track this is because of the Class B reporting document that the AANA has and that's on this next slide. This is a QR code that's going to take you to the AANA Class B reporting document. As most or maybe all of you know, you get one Class B credit for every day that you are precepting an SRNA. You also get a Class B credit if you precept med students and what the AANA describes as an RN gaining airway management experience. So in this document, you just upload it to the AANA and there are certain things they want on there. They also want to email someone to validate that you perform the skill. And sometimes that's your chief CRNA or just somebody at your facility to provide that role. But this is why it's so important to give electronic evaluations because it's trackable and it's something that you can use to gain Class B credits through the AANA. This is the last objective, but I think it might be the strongest objective in this entire module. And I call it the contract for success. So when students come to our facility, we have them review and we go over page by page this document that we have created for our facility with SRNAs. And this, it's a role and expectation contract. And in this document, it's very clearly described expectations for the preceptor and for the learner. And this is something that the preceptor goes over with the student, preferably in the first week of their clinical rotation. And this is what sets the stage for success. It is a powerful document. And it is, everything in there is very clear because then the student knows exactly the role and the expectations that they have for there. And our performance of the students has been drastically improved when we started using the contract for success. So I pulled out the big pieces of what this document is, and it's like four pages long. It's not huge, but it talks about stuff that you'd have to discuss with the student. And one of the first thing is their arrival time and what I call the exit ticket. So the arrival time you have to set with your facility, understanding that some cases go early, but there needs to be a clearly understood expectation for when the student should arrive in the morning. The exit ticket is what we call, if you have a student and they can only be dismissed from the clinical site that day when they have reported to the, for us it's the CRNA that's running the board that day. So that's their exit ticket. And that just creates a lot of understanding of when students leave and where they are. And someone is always accountable to that student of when they left. So that's the exit ticket. And they have to report to that CRNA to get cleared out to go for that day. Then in this contract for success, we have if a student, I call it the no show clause, like if something happens, if they get sick, if they have any kind of car issue on the way, who they need to contact and how that goes. It discusses how assignments are made. And then that's gonna be very site specific, but it talks about that, how the assignments are made, the setup expectation. And this is where we've worked with the school to find out what the student knows about the machine setup and what we can expect them to know when they first come here. And that is very site specific, this is what we also expect the student to have in their room ready for their case. This is where we talk about the evaluations and this is where we described how student evals are gonna go. This is also, we talk about the CRNA assignments and how those assignments come out every day. We also have them print out their log, their case log and bring it in for this. And this is where we can see if they need spinals, if they need their epidurals or they need certain cases. This is where we try to make the clinical site work for them. And we try to help the student get the numbers they need. So have them print that out and bring that in that first day and then ultimately during this rotation and we have students for typically two months at a time, they are required to give a presentation at the end of their clinical rotation based on something either that occurred there while they were there or something that they felt like the CRNAs there could benefit from some increased education and they present that on one of their last clinical days before they leave. But this is a document that we go over and we actually have them sign and date this. So everybody is on the same page and it has been huge on how we communicate and what the student is expected to do and what the CRNAs expected, their role as well as a preceptor. So I encourage you to embrace this contract for success with your organization. This is the how to start strong and this is my experiences and recommendations whenever a new student comes to your facility is develop that expectation document, that contract with them, get those clearly defined expectations ironed out and so everybody's on the same sheet of music and it makes the student really comfortable then knowing what is expected from them and I think it decreases the amount of anxiety on the student when they have that in hand and they understand how we roll at that facility. Also know the student's level, know what they are likely to be good at and not good at and then everyone then has that expectation, we know where they're going to be, we know have an idea of where they're gonna need some help and then this helps ultimately establish the team and like most clinical sites, we love our students, we love to see them grow, we love for them to come back and join the team and this is what I tell a lot of students, this is a two month job interview, you're gonna interview us and we're gonna interview you to see if this is a good fit, maybe we'll see you after graduation, there's no better way to evaluate a potential new hire than to see how they work as a student and how they interact with your organization. This module describes several different techniques and suggestions on how to create an environment of learning that is safe and the student feels respected in. Preceptors have an incredible role as role models for the anesthesia resident but also they have a huge role in bridging that gap between didactic knowledge and clinical practice. This is the last slide of this module and I appreciate it and I hope that you're able to take away a lot of these important concepts and add them to your practice, thank you.

Stephanie Kelley-Parks

Understanding the Learner

Nurse Anesthesia Programs

Transition from Student to Expert Practitioner

Clinical Competence

Teamwork and Communication

Precepting