An evidence-based approach to workplace anaesthesia training. Part 2
Susanna Taylor, Liz Armitage-Chan
Saturday, October 2, 2021
Part one of this article considered the value of using educational evidence to teach student veterinary nurses (SVNs), discussed the characteristics of SVNs as learners, and described the importance of developing SVNs—not only in their anaesthetic skills, but also in becoming more self-directed professionals. As part one highlighted some of the challenges that SVNs experience as they attempt to learn in a veterinary practice, this second part will consider some common questions about veterinary nursing teaching and provide examples of techniques that can be used by registered veterinary nurses (RVNs) to improve teaching strategies for anaesthesia in the workplace. While some of the educational theories mentioned may be dated, this article aims to use supportive contemporary evidence to show how they are still relevant to help guide our teaching.
Workplace learning can be challenging for both the student veterinary nurse (SVN) (Taylor and Armitage-Chan, 2021), and the registered veterinary nurse (RVN). This article discusses some questions that may arise in a workplace teaching situation.
Question 1: I know my student has covered anaesthesia theory at college, but they don't seem to remember any of it. I get so frustrated reteaching the theory. How can I avoid having to do this?
When a SVN enters a workplace, they are expected to begin to ‘put into action’ what they have learned in the classroom. This is no simple transition (Konkola et al, 2007). Students may struggle to contextualise their classroom lessons into an applied, higher-order form of knowledge that is required in an authentic clinical environment, which may appear as ‘forgetting’. Bloom's taxonomy (Bloom et al, 1956), later revised by Anderson and Krathwohl (2001), describes six levels of learning (Figure 1). These levels of learning represent the difference between being able to define the meaning of a word, for example, ‘hypotension’, and being able to predict the physiological consequences and how these would be identified when monitoring the patient. Drawing attention to these levels of learning can help avoid frustration. Although the knowledge of the workplace may seem more relevant than the foundational knowledge of the classroom, learning is most effective when it is constructed developmentally, and the SVN recognises their relevant pre-existing knowledge (Bloom et al, 1956). Focusing on classroom theory in the context of an anaesthetic case can therefore help students recognise what relevant knowledge they already possess, rather than feeling as though all of the information is new. Similarly, when considering student involvement in more complex anaesthetic cases, the SVN can be asked to consider what they have learned from simpler cases, relating to adverse anaesthetic effects and management. In practice, it should be remembered that these levels actually form a cycle, and on reaching a higher level, a student may discover their need to return to a lower level to develop a new skill or idea (Taylor and Hamdy, 2013).
Figure 1. Bloom's taxonomy of learning (Bloom et al, 1956)
Question 2: Placement time is precious: should the SVNs get as much hands-on experience as possible?
Students need time and space to carry out learning activities, and the idea of ‘as much hands-on time as possible’ may be counterintuitive. Encouraging students to spend some time off the ‘clinic floor’ to create notes, plans, or engaging in researching their cases will allow them to fully participate in learning activities.
It is also important to provide students with the space to work and learn when they are engaging in clinical tasks. If a student is responsible for monitoring anaesthetic depth, recording monitor parameters on a chart, responding to demands from the veterinary surgeon, and is then heavily questioned by the RVN, it is unlikely that they will be able to achieve any of the tasks to the required level. This is explained by cognitive load theory, which describes that the brain is limited to processing only a certain amount of information at a time (Sweller, 1988; Young et al, 2014). When a student is still learning how to transcribe information to an anaesthetic record, a high amount of cognitive processing is taking place. After this skill has been learned and practised enough that it is almost ‘automatic’, much less cognitive effort is required, freeing up capacity for other tasks. Instructors must take care not to cause cognitive overload by expecting too much at one time, and instead reduce a complex task, like managing an anaesthetic case, into elements that can be individually focused on (Mind Tools, 2020). The simple action of taking over the monitoring chart while a student considers and responds to a question during a case is an example of this.
At the workplace, SVNs should also be gaining professional cognitive skills, such as those used for nursing assessments and nursing diagnoses of patients. These skills include decision making, analysing situations, problem solving and evaluation (Orpet, 2011; Welsh and Wager, 2013). Bloom's taxonomy of learning (Figure 1) shows that these are all higher levels of learning (Bloom et al, 1956; Anderson and Krathwohl, 2001). To reach these levels, SVNs need to engage with a task in-depth, which takes more time. If SVNs are constantly moving from case to case, they miss out on the opportunity to develop a deep understanding from engaging with a single case — knowledge which could then be applied in the future to many patients. For this reason, encouraging SVNs to follow a patient's care from start to finish can be a useful learning experience.
Question 3: When I ask my SVNs questions, they often answer very briefly, and I end up doing all the talking. I also feel bad if I ask a question and they don't know the answer. How can I better use questioning as a learning technique?
Asking students questions is a common technique in active learning and may easily be initiated between a student and RVN during management of an anaesthetic case. When putting questions to a student as part of a learning activity, an instructor should construct questions to facilitate development of understanding, rather than focus on assessing it. The instructor should phrase the question clearly and provide time for the student to process their thoughts. At least 3 seconds has been recommended (Ellis, 1993). Students should not be made to feel uncomfortable if they are unable to answer; instead, the instructor should rephrase the question, or break it down into smaller more manageable questions until the student can answer (Pickford and Race, 2007). A student who is struggling to generate an in-depth answer could also be given the opportunity to research the question and answer at a later time. This allows the student to think more carefully about the question, releases the pressure on them, and will be more effective in addressing the knowledge gap.
Different types of questions should be used and are beneficial in different ways; see Table 1 for a summary.
Examples of different question types that can be used during management of an anaesthetic case
|Question type||Answer type||Useful for||Example|
|Factual recall questions||Have a single correct answer, often a very short answer||Reviewing material, assessing basic comprehension, determining student readiness for further exploring a subject||‘What type of opioid is Methadone?’|
|Conceptual convergent questions (low level)||Have a correct answer, but require more explanation||Determining if the student can recognise and organise facts and ideas||‘What do you think about the shape of the capnograph trace?’|
|Conceptual convergent questions (high level)||Have a correct answer and encourage students to use evidence to support their explanation||Encouraging critical thinking and analysis||‘What do you think is causing this abnormal capnograph and what can we do about it?’|
|Conceptual divergent questions||Have more than one answer, may be different to instructor's ‘model answer’ but student should be able to defend it||Brainstorming, hypothesising, problem solving||‘What are our options if this patient's blood pressure drops?’‘What other analgesia could we use in this case?’|
|Evaluative questions||May be factual or opinion based, depending on the question. Student should be able to defend their answer||Making judgments, expressing opinions||‘Do you think our local block has worked? Why?’‘What do you think about the clarity of the record form you have kept?’|
If a student gives an incorrect answer, it can be tempting to immediately correct them, but if we can rather lead the student to recognise their own mistake, we better drive further learning (Piaget, 1957; Wadsworth, 1984). Discrepant questioning is a technique that causes the student to re-evaluate their answer and find dissatisfaction in it, effectively ‘unlearning’ their misconceptions (Rea-Ramirez et al, 2009). For example, if a student answers the question, ‘How does vasoconstriction affect blood pressure?’ with ‘It would cause blood pressure to drop,’ discrepant questions such as ‘what happens to blood vessel size with vasoconstriction?’ or ‘How does size relate to pressure?’ could be asked to prompt the student to consider their answer. This is also a non-judgmental approach and can better improve student morale when they reach the correct answer. Acknowledgment should be given for correct responses and praise linked to the reason for the praise (Ellis, 1993).
Question 4: All my SVNs seem to prioritise clinical skills, but I'm worried about their lack of experience. How can I help inexperienced students with these skills, some of which carry a risk for the patient?
There are various, anaesthesia-related, psychomotor skills that SVNs must master, and the workplace is often a platform to achieve this, sometimes supported with previous simulated clinical skills labs. The RVN instructor must balance education of the student with patient welfare. A 5-step method, described by George and Doto (2001), can be used to ensure a student-centred approach, without putting the patient at undue risk. The technique is described in Table 2. If the student has some prior experience with the skill, they can be questioned as to what stage they judge themselves ready for, between 2–4, and advance or go back a step as needed each time the skill is repeated. This means that each step should be repeated as many times as needed before progressing to the next step.
A simple five-step method for teaching clinical skills
|Step 1||Theoretical introduction to the skill: clinical relevance||Often occurs before workplace learning|
|Step 2||Silent demonstration by the instructor showing all key steps correctly||Allows student to form a mental picture of the skill without risk of cognitive overload|
|Step 3||Described demonstration by the instructor including all key steps||Student able to ask questions to clarify reasoning or technique|
|Step 4||Student talks through the skill while instructor demonstrates||Ensures student commits to memory the key steps. Allows instructor to judge student's knowledge of the steps|
|Step 5||Students perform the skill with instructor providing feedback or coaching as needed||Student can describe each step just prior to carrying it out|
George and Doto, 2001
We have a range of anaesthetic cases at my clinic and some of them seem too advanced for students to join, but I'm worried they are missing out on experience. How can I maximise the learning potential of these cases?
A range of complexity in cases allows SVNs to build on their prior knowledge and experience. However, our teaching style, the student's ability, and appropriate goals must be carefully considered and matched to their involvement in the case (Grow, 1991; Newman and Peile, 2002; O'Shea, 2003). Less complex cases will allow dependant learners to grow in confidence or can be used to give more advanced learners a higher level of independence. A student's abilities may differ between cases; for example, a student who is confident to take the lead managing a dog castration may be a more dependant learner with an anaesthetic for a patient with gastric dilatation and volvulus, and therefore need more direction and instruction during this case. The key is to correctly match the student's activities with their abilities for the complexity of a case. Figure 2 shows how a student may progress through the levels of self-directed learning in relation to different American Society of Anesthesiologists (ASA) (2020) levels of anaesthesia risk.
Figure 2. Showing how a student's ability level differs between anaesthesia case complexity but can progress over time if suitable teaching styles are used (also see part 1; Table 1).
Question 6: I know I should be providing feed-back to my students and encouraging them to reflect on it, but I don't really know how to do this.
Reflective practice in the veterinary profession has gained attention in recent years and has become commonplace within veterinary education (Groot and Mastenbroek, 2017). A key element of the reflective cycle, and crucial to deliberate practice, is feedback (Quinton and Smallbone, 2010; Krackov and Pohl, 2011; Ericsson, 2012). Feedback can be from self-assessment or gained from peers and instructors. Timely feedback allows the student opportunity to make changes to their performance before summative assessment, so RVN instructors should aim to offer formative feedback after key learning events. Effective feedback is based on direct observation and is always a two-way conversation, in which not only does the teacher provide information regarding the student's performance, but the student is invited to discuss how they perceived they performed a task, and what they found difficult. They could also comment on what they felt went well and how they may challenge themselves with a more difficult example in future (Ramani and Krackov, 2012). Inviting the student to self-assess can also soften the severity of the assessor's negative feedback if they are able to identify their own weaknesses or areas for improvement (Branch and Paranjape, 2002). The instructor should provide balanced feedback, taking care to reinforce correct behaviours, as well as explaining required improvements with specific examples and recommended corrections (Ramani and Krackov, 2012). Feedback should focus on discussing the previously agreed learning objectives and should end with a jointly agreed action plan, ensuring that the student understands their next steps for improvement (Krackov and Pohl, 2011; Ramani and Krackov, 2012). The formation of new learning objectives then leads into the next teaching/learning activity, which continues as a cycle of learning.
Workplace learning can be challenging for both the SVN, as discussed in part 1, and the RVN, as shown by the questions posed in this article. By using an understanding of educational literature surrounding student-centred teaching techniques, RVNs can ensure that their students thrive; developing their clinical skills, professionalism, and ability to continue learning throughout their careers. Although this article used anaesthesia to provide examples, the same techniques can be applied to other subjects. Through this continued cycle of support from clinical RVNs to SVNs, the veterinary nursing profession can continue to progress and develop.
- ‘Learning’ encompasses a range of different levels, from low-to high-order cognition. Students should be encouraged and supported as they progress during workplace learning.
- Students should be given time and space for learning, and engaging in suitable student-centred learning activities.
- Students should be provided with regular feedback and encouraged to reflect on it and their learning experiences
- Correct use of questioning techniques, and systematic teaching of clinical skills may prevent overloading the student, encourages learning and protects patient safety.