Veterinary Clinical Skills E-Book
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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Provides instructors and students with clear guidance on best practices for clinical skills education Veterinary Clinical Skills provides practical guidance on learning, teaching, and assessing essential clinical skills, techniques, and procedures in both educational and workplace environments. Thorough yet concise, this evidence-based resource features sample assessments, simple models for use in teaching, and numerous examples demonstrating the real-world application of key principles and evidence-based approaches. Organized into nine chapters, the text explains what constitutes a clinical skill, explains the core clinical skills in veterinary education and how these skills are taught and practiced, describes assessment methods and preparation strategies, and more. Contributions from expert authors emphasize best practices while providing insights into the clinical skills that are needed to succeed in veterinary practice. Presenting well-defined guidelines for the best way to acquire and assess veterinary skills, this much-needed resource: * Describes how to design and implement a clinical skills curriculum * Identifies a range of skills vital to successful clinical practice * Provides advice on how to use peer teaching and other available resources * Covers veterinary OSCE (Objective Structured Clinical Examination) topics, including gowning and gloving, canine physical examination, and anesthetic machine setup and leak testing * Includes sample models for endotracheal intubation, dental scaling, silicone skin suturing, surgical prep, and others Emphasizing the importance of clinical skills in both veterinary curricula and in practice, Veterinary Clinical Skills is a valuable reference and guide for veterinary school and continuing education instructors and learners of all experience levels.
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Veröffentlichungsjahr: 2021
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Table of Contents
Cover
Title Page
Copyright Page
Acknowledgments
Emma
Matt
Sarah
List of Contributors
Preface
About the Companion Website
1 What Is a Clinical Skill?
References
2 Clinical Skills Curricula: How Are They Determined, Designed, and Implemented?
Introduction
Steps in Clinical Skills Curricular Design
Conclusions
References
3 How Are Clinical Skills Taught?
Introduction
Conclusions
References
4 How Are Clinical Skills Practiced?
Introduction
Conclusion
References
5 How Do I Know if I am Learning What I Need to?
Introduction
Conclusion
References
6 How Do I Prepare for Assessment and How Do I Know I Am Being Assessed Fairly?
Introduction
Psychological Preparation for Exam Performance and Common Barriers to Good Performance
Standard Setting Techniques – What Are They, Principles of How They Work and Are Applied
Quality Assurance in OSCEs – Reasons Why Stations and Learners Exhibit Variability
References
7 How Can I Best Learn in a Simulated Environment?
How Are Skills Taught?
How Are Skills Learned?
Combinations That Work
Hints for Learning Clinical Skills
Conclusions
A Clinical Skills Training Example
References
8 How Do I Make Use of Peer Teaching?
Introduction
What Are the Benefits and Limitations of Peer‐assisted Learning?
How to Use and Implement Peer Teaching
Conclusions
References
9 What Other Skills Are Vital to Successful Clinical Practice?
Introduction
Conclusion
References
Appendix 1: OSCEs (Objective Structured Clinical Examinations)
Making a Cheese and Pickle Sandwich
Asepsis – Gowning and Closed Gloving
Grading for Gowning and Gloving
Asepsis – Draping
Bovine Anatomy and Surgical Landmarks ‐ Part One
Bovine Anatomy and Surgical Landmarks ‐ Part Two
Canine Physical Exam
Surgical Towel Placement Rubric
Pedicle Ligature (two‐handed tie) Rubric
Equine Handling & Restraint
Intramuscular Injection in a Canine Model
Anesthetic Machine Set‐Up and Leak Testing
Appendix 2: Recipes for Making Clinical Skills Models
Canine Castration Model
Steps for Making the Model
Reference
Dental Scaling Model
Steps for Making the Model
Acknowledgments
Reference
Endotracheal Intubation Model
Steps for Making the Model
Top Tips for Making and Using the Model
Supporting learning resources for use when teaching/learning with the model
Reference
Equine Abdominocentesis Model
Steps for Making the Model
Top Tips for Making and Using the Model
Acknowledgments
Canine Leg with Cephalic Vein Model
Steps for Making the Model
Tips for Making and Using the Model
Silicone Skin Suturing Model
Steps for Making the Model
Supporting learning resources for use when teaching/learning with the model
Acknowledgments
SimSpay Model
Steps for Making the Model
Top Tips for Making and Using the Model
Supporting learning resources for use when teaching/learning with the model
Acknowledgments
Reference
Surgical Prep Model
Steps for Making the Model
Top Tips for Making and Using the Model
Acknowledgment
Tea Towel Suturing Model
Steps for Making the Model
Paper about the model
Index
End User License Agreement
List of Tables
Chapter 3
Table 3.1 The five‐step method for teaching clinical skills.
Table 3.2 Characteristics of novice to expert.
Chapter 6
Table 6.1 The elements of assessment literacy as described by Price et al. ...
Table 6.2 Example OSCE checklist for assessment of surgical skills.
Table 6.3 Example blueprint for a 12‐station clinical skills OSCE.
Table 6.4 Tips for students preparing for an OSCE
Table 6.5 Angoff method to calculate the standard on a five‐station OSCE.
Table 6.6 Traditional components of validity.
Table 6.7 Quality assurance checklist.
Chapter 7
Table 7.1 LMU CVM clinical skills laboratories with gentle animal handling ...
Chapter 8
Table 8.1 Benefits of PAL.
List of Illustrations
Chapter 1
Figure 1.1 Flexner model (with separation between preclinical and clinical b...
Chapter 2
Figure 2.1 Kern's six step model for curricular design.
Figure 2.2 Relationship between EPAs, nested EPAs, and clinical skills.
Chapter 3
Figure 3.1 A template for practical class preparation, set up, and delivery....
Figure 3.2 Dual process theory.
Figure 3.3 The challenge of the teacher (expert) and the learner (typically ...
Chapter 4
Figure 4.1 A generic representation of the learning curve demonstrating key ...
Figure 4.2 Diminishing returns learning curve.
Figure 4.3 Increasing returns learning curve.
Figure 4.4 Sigmoid (S‐curve) learning curve.
Figure 4.5 Complex learning curve.
Figure 4.6 Adaptive versus automatic expert (adapted from Pusic et al. 2011)...
Figure 4.7 Forgetting curve.
Figure 4.8 Example of a completed EPA assessed with an entrustment scale (Re...
Chapter 5
Figure 5.1 Miller’s pyramid of clinical competence.
Figure 5.2 The Johari Window (see text for explanation).
Chapter 6
Figure 6.1 The “overlapping groups” method can be used to determine the stat...
Figure 6.2 The borderline regression method to calculate the station standar...
Chapter 7
Figure 7.1 Students perform physical examinations on live dogs as part of th...
Figure 7.2 A canine cadaver head awaits a student to perform a dental cleani...
Figure 7.3 A student performs a circumferential ligature on an ovariohystere...
Figure 7.4 The epitome of low fidelity, this frozen cabbage with two corn co...
Chapter 8
Figure 8.1 Modified version of Walker and Peyton's four‐step‐approach.
Figure 8.2 Example of possible sections and content for tutor training.
Chapter 9
Figure 9.1 The critical reflection process.
SimSpay Model
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6a
Figure 6b
Figure 6c
Figure 7
Figure 8
Figure 9
Guide
Cover Page
Title Page
Copyright Page
Acknowledgments
List of Contributors
Preface
About the Companion Website
Table of Contents
Begin Reading
Index
Wiley End User License Agreement
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Veterinary Clinical Skills
Edited by
Emma K. Read, DVM, MVSc, DACVS
College of Veterinary Medicine, The Ohio State University
Columbus, OH, USA
Matt R. Read, DVM, MVSc, DACVAA
MedVet, Worthington, OH, USA
Sarah Baillie, BVSc, PhD, MRCVS
Bristol Veterinary School, University of Bristol
Bristol, UK
This edition first published 2022© 2022 John Wiley & Sons, Inc.
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The right of Emma K. Read, Matt R. Read, and Sarah Baillie to be identified as the authors of the editorial material in this work has been asserted in accordance with law.
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Library of Congress Cataloging‐in‐Publication Data
Names: Read, Emma K., editor. | Read, Matt R., editor. | Baillie, Sarah, editor.Title: Veterinary clinical skills / edited by Emma K. Read, Matt R. Read, Sarah Baillie.Description: First edition. | Hoboken, NJ : John Wiley & Sons, Inc., 2022.Identifiers: LCCN 2021032454 (print) | LCCN 2021032455 (ebook) | ISBN 9781119540052 (paperback) | ISBN 9781119540144 (adobe pdf) | ISBN 9781119540151 (epub)Subjects: MESH: Education, Veterinary | Clinical CompetenceClassification: LCC SF756.3 (print) | LCC SF756.3 (ebook) | NLM SF 756.3 | DDC 636.089/0711–dc23LC record available at https://lccn.loc.gov/2021032454LC ebook record available at https://lccn.loc.gov/2021032455
Cover Design: WileyCover Images: © Emma K. Read, Matt R. Read
Acknowledgments
This work would not have been possible without the contributions of many colleagues with whom we have worked over the years. We are grateful to the efforts of so many talented instructors and staff members in making our clinical skills training programs a reality. We are also delighted to have had the opportunity to watch our learners grow and mature into competent and caring practitioners. Thank you to them for taking care of the profession, animals, and their owners on a daily basis. Your work is difficult and vitally important.
We would also like to recognize the team at Wiley, specifically Erica Judisch and Merryl Le Roux. We have enjoyed working with you and appreciate your tremendous support on this project since from the beginning.
Emma
Thanks to my parents and family members who always supported me and helped me to achieve my career aspirations by encouraging me to work hard and seek out broad opportunities to learn. Thanks to my husband Matt for his unfailing support of all my projects and dreams, and for being my rock along the way.
To our co‐editor, Sarah, a special thanks for being such a wonderful collaborator and friend over the years. We feel very fortunate to have met you and have really enjoyed working with you ever since.
To Grace and Kate, thank you above all else. You are the light of our lives. Words can't express the love we have for you or our admiration for the people you are. Your patience with our many work hours, projects, and life changes are so appreciated. We love you with all our hearts. Chase your dreams with all your being – we are here for you!
Matt
For my incredible wife, Emma, for having the vision and passion to create this book despite everything else going on around us. I learn something new from you every single day. But enough with the summative assessments already!
For our two daughters, Grace and Kate. I am looking forward to again using evenings and weekends for the things you want to do! You are simply amazing and I am so thankful to be your dad.
And to my parents and friends who have supported and helped me through thick and thin. Life can be hard, but you make it easier.
Sarah
Thanks to Emma for inviting me to join this project, it is one of many we have collaborated on over the years. It has been a pleasure as always. Thanks to my husband John who is so supportive in so many ways in all my endeavors at work and at home. And finally this book, and my ongoing enthusiasm for “all things” clinical skills, wouldn't be such fun without all the help from my colleagues in the clinical skills lab team at Bristol.
List of Contributors
Stacy L. AndersonCollege of Veterinary MedicineLincoln Memorial UniversityHarrogate, TN, USA
Elizabeth Armitage‐ChanLIVE Centre, Department of Clinical Sciences and ServicesRoyal Veterinary CollegeHatfieldUK
Sarah BaillieBristol Veterinary SchoolUniversity of BristolBristol, UK
Teresa BurnsCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Alison CatterallBristol Veterinary SchoolUniversity of BristolBristolUK
Kate CobbSchool of Veterinary Medicine and ScienceUniversity of NottinghamSutton BoningtonUK
Sarah CrippsSchool of Veterinary Medicine and ScienceUniversity of NottinghamSutton BoningtonUK
Marc DillyFaculty of Veterinary MedicineJustus Liebig University GiessenGiessenGermany
Robin FarrellUCD School of Veterinary MedicineUniversity College DublinDublinIreland
Andrew GardinerRoyal (Dick) School of Veterinary StudiesUniversity of EdinburghScotlandUK
Rachel HarrisBristol Veterinary SchoolUniversity of BristolBristolUK
Jennifer HodgsonVirginia‐Maryland College of Veterinary MedicineVirginia TechBlacksburg, VAUSA
Steven HorvathCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Julie A. HuntCollege of Veterinary MedicineLincoln Memorial UniversityHarrogate, TNUSA
Keshia JohnSchool of Veterinary MedicineSt. George's UniversityGrenadaWest Indies
Jennifer T. JohnsonCollege of Veterinary MedicineLincoln Memorial UniversityHarrogate, TNUSA
Rikke LangebækDepartment of Veterinary Clinical ScienceUniversity of CopenhagenCopenhagenDenmark
Rachel LumbisRoyal Veterinary CollegeHatfieldUK
Susan M. MatthewDepartment of Veterinary Clinical Sciences, College of Veterinary MedicineWashington State UniversityPullman, WAUSA
Missy MatusickyCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Catherine MayFaculty of Veterinary ScienceUniversity of PretoriaPretoria, South Africa
Tatiana MottaCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Máire O’ReillyUniversity College DublinDublinIreland
Carolina Ricco PereiraCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Megan PrestonCollege of Veterinary MedicineLincoln Memorial UniversityHarrogate, TNUSA
Lindsey RamirezCollege of Veterinary MedicineLincoln Memorial UniversityHarrogate, TNUSA
Emma K. ReadCollege of Veterinary MedicineThe Ohio State UniversityColumbus, OHUSA
Matt R. ReadMedVetWorthington, OH USA
Alfredo E. RomeroFaculty of Veterinary MedicineUniversity of CalgaryCalgary, AlbertaCanada
Elrien ScheepersFaculty of Veterinary ScienceUniversity of PretoriaPretoria, RSA
Jennifer SchleiningCollege of Veterinary Medicine & Biomedical SciencesTexas A&M UniversityCollege Station, TXUSA
Lucy SquireBristol Veterinary School,University of BristolBristolUK
Jean‐Yin TanFaculty of Veterinary MedicineUniversity of CalgaryCalgary, AlbertaCanada
Abi TaylorCollege of Veterinary MedicineNorth Carolina State UniversityRaleigh, NCUSA
Sheena WarmanBristol Veterinary School,University of BristolBristolUK
Catherine WernersSchool of Veterinary MedicineSt. George's UniversityGrenadaWest Indies
Lissann WolfeSchool of Veterinary MedicineCollege of Medical, Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
Preface
Our original vision for this book was to try to collate the content of many years of conversations that we have had with colleagues and students about Clinical Skills teaching and learning into a single, useful resource. Many of those discussions centered around what is known about how to teach and learn better – in essence, where to spend one's precious time, effort, and resources in order to see the best returns. To this end, we wanted to create a book that would appeal to both instructors and students and provide a broad overview of what is already known about teaching and learning Clinical Skills for those starting out so they had a good base from which to take the leap.
We have been fortunate to help institute modern clinical skills training programs into our own institutions at a time when they were just beginning to be implemented across veterinary medicine. In the early days, we learned by trial and error by adapting “hard knocks” lessons we had learned in private practice to our academic learning environments. As programs evolved, so did the research that proves that there is value in learning how to use best teaching practices to inform Clinical Skills instruction. However, even though so much has been published, clinical skills instructors are a generous group and much of the sharing of information still tends to be open source or available by simply asking a colleague. Websites, conferences, and Zoom calls all serve as a means for sharing what we have learned, making sure that someone else does not have to reinvent the wheel.
The basis for this book is that, despite all of the sharing of ideas and best practices that has occurred to date (or maybe as a result of it!), it can still be challenging for instructors and students to review what has been documented about teaching and learning Clinical Skills in one concise place. New instructors often feel overwhelmed with all there is to know about teaching and assessment and, although many teachers may not be new to veterinary medicine or to teaching Clinical Skills, it is the evidence‐based teaching of others that is novel and challenging. Students tackling clinical skills training are often overwhelmed with where to begin and how best to practice the huge volume of skills and procedures that a veterinarian needs to be able to perform following graduation. Although handbooks have been published that list skills and explain “how to” perform a variety of procedures, a concise reference that summarizes all that is known about teaching, learning, and assessing clinical skills all in one place has still been missing.
We hope that this book helps point newbies of all types in the right direction while also serving as a go‐to reference for experienced teachers. The enthusiasm and dedication to clinical skills training is as evident now as it was when it started over 10 years ago and we are immensely grateful to all of the authors who participated in this project and shared their expertise and experiences so openly. Together, we look forward to further innovations that will make even more confident and competent day‐one graduates who will be better prepared to treat the animals in their care.
About the Companion Website
This book is accompanied by a companion website:
www.wiley.com/go/read/veterinary
There you will find valuable material designed to enhance your learning, including:
Appendices 1
and
2
from the book as downloadable PDF
1What Is a Clinical Skill?
Emma K. Read1 and Sarah Baillie2
1 College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
2 Bristol Veterinary School, University of Bristol, Bristol, UK
Historically in veterinary medicine, degree programs have been based upon the Flexner model described in medical education, with two basic blocks: two to three years of preclinical training and one to two years of clinical training (Flexner, 1910). Approximately 10–15 years ago, a trend developed in veterinary education to include more hands‐on training during veterinary programs, often beginning in the start of the first year, with an emphasis on teaching day‐one skills necessary for success in practice (Hubbell et al., 2008; Doucet and Vrins, 2009; Welsh et al., 2009; Smeak et al., 2012; Dilly et al., 2017 RCVS, 2020;). The idea of moving clinical training earlier in the program and further emphasizing integration of knowledge and other skills into the clinical workplace led to current veterinary programs being more like two inverse wedges rather than two blocks placed one on top of the other as separate units of the same program (Figure 1.1).
Formal veterinary clinical skills training programs, which emphasized the use of models and simulators and constructed dedicated clinical skills centers for teaching, began in the early to mid‐2000s as a way to accommodate this need for earlier training (Baillie et al., 2005; Scalese and Issenberg, 2005; Pirkelbauer et al., 2008; Read and Hecker, 2013; Dilly et al., 2017). Reports of objective structured clinical examinations (OSCEs) that are used to assess learners' hands‐on skills, and descriptions of best practices for implementing skills curricula, began to follow (Smeak, 2007; Rhind et al., 2008; May and Head, 2010; Hecker et al., 2010; Read and Hecker, 2013; Dilly et al., 2017).
Concurrently, over the last 10 years, there has been a recognition of the need to incorporate more professional skills training (NAVMEC, 2011; Cake et al., 2016). Today's employers are not only searching for confidence and technical competence in new graduates but good communication abilities as well (Perrin, 2019). Rather than simply being competent in one's hands‐on skills alone, effective integration of professional communication and technical skills performance is crucial for successful practice (NAVMEC, 2011; Rhind et al., 2011). Other “marketable skills” described in a recent report of the characteristics most often sought by employers posting job advertisements in the United Kingdom included enthusiasm, special interest, communication, all‐rounder, client care, team player, autonomous, caring, ambitious, and high clinical standards (Perrin, 2019). These “skills” are important to employers and are key to minimizing dissonance and dissatisfaction for the graduates as well (May, 2015; Perrin, 2019).
Figure 1.1 Flexner model (with separation between preclinical and clinical blocks) versus the more recent curricular models that are more like inverse wedges introducing clinical content earlier into the start of the curriculum.
The Royal College of Veterinary Surgeons (RCVS) Day One Competences and the American Association of Veterinary Medical Colleges’ (AAVMC) North American Veterinary Medical Education Consortium (NAVMEC) report are both recognized as early frameworks that defined competencies across a number of areas that lead to graduate success (NAVMEC, 2011 RCVS, 2020;). More recently, there have been other developments toward employability of new graduates and improved teaching of professional skills. The VetSet2Go project represents an international collaboration of educators (https://www.vetset2go.edu.au), who surveyed employers, clients, new graduates, and other stakeholders before combining this information with what was already published in the literature. The resulting white paper and framework have been used to guide development of resources, as well as tools for educators and learners (Cake et al., 2016; Hughes et al., 2018). This framework highlights professional identity formation, skills needed for practice career longevity, and development of resilience. More recently, outcomes‐based frameworks have been described (Bok et al., 2011; Molgaard et al., 2019; Matthew et al., 2020). The AAVMC's competency‐based veterinary education (CBVE) framework is currently being considered and implemented across multiple international veterinary schools simultaneously, which brings exciting opportunities for conducting comparative analysis of students and graduates across schools. Having a shared framework of competencies, entrustable professional activities, milestones, and terminology is critical for training educators, comparing learners, and generalizing results across programs (Molgaard et al., 2018a; Molgaard et al., 2018b; Salisbury et al., 2019). With schools historically only focusing on their own programs, this opportunity has not existed in veterinary medicine to date.
In the strictest sense, veterinary clinical skills are psychomotor tasks that can be assessed in a simulated environment (satisfying “shows how” on Miller's pyramid of clinical competence) or within the actual clinical workplace (satisfying “does” on Miller's pyramid of clinical competence, see Figure 5.1) (Miller, 1990). Obvious examples might include donning and doffing a surgical gown, suturing skin, performing venipuncture, safely restraining a patient, or performing a complete physical examination. But what about interpreting herd records, observing animal behavior, or designing an isolation facility? Recently, authors have argued that the pinnacle of Miller's pyramid of clinical competence is not just related to technical skill competence as Miller originally described but is actually “is trusted” (to perform on one's own) (ten Cate et al., 2020) or “is” (to incorporate the development of professional identity) (Cruess et al., 2016).
During curriculum development or program revision to incorporate further clinical skills training, there can be heated debate among educators and practitioners about what skills are the most necessary to teach, or even about what constitutes a “clinical skill.” Before the more recent rise of competency‐based education, some educators and practitioners used Delphi‐like processes and developed lists of skills to be taught in veterinary programs such as Day 1 Skills, first published in 2002 (RCVS, 2020). These practitioners tended to focus on what they believed was important for their own daily practice and based the skills list on what might be needed for their particular geographical location. Practitioners also focused on what they wished to be taught to students who were soon to become their employees and colleagues. Educators tended to focus more on their own areas of specialty and what they believed new graduates should be able to perform based on past teaching experience.
The more recently described competency‐based approaches to education have tried to focus more on “outputs,” rather than only on “inputs” for determining what should be taught in the curriculum. The majority of veterinary graduates today will enter private small animal, first‐opinion practice, and it has been suggested that educators focus on asking practitioners working in that environment what skills the graduate will need (Bain and Salois, 2019). It should be noted that a broad range of practices must be consulted because there are differences in equipment and personnel available from practice to practice. Surveys of practicing veterinarians engaged in performing authentic veterinary tasks in general practice have also proven critical to determining the frequency, importance, and perceived difficulty for performance of these skills (Hubbell et al., 2008; Doucet and Vrins, 2009; Smeak et al., 2012; Luby et al., 2013; Kreisler et al., 2019). Not being limited in licensure at present, veterinary graduates ultimately require a broad range of skills for commonly seen conditions and diseases of all the major domestic species, and they require different skills than a specialist working in a tertiary referral environment (May, 2015). It is critically important that information be gathered across all types of practice, and published surveys exist in the literature for skills in surgery, equine practice, bovine practice, and small animal practice (Hubbell et al., 2008; Doucet and Vrins, 2009; Smeak et al., 2012; Luby et al., 2013; Kreisler et al., 2019). These resources are very useful and essential to consult when considering what to incorporate into an educational program.
Integration of clinical skills in the curriculum requires consideration of when to present the material and whether to integrate it with other competencies. It is not enough for learners to learn the technical performance alone because without the knowledge of when to use the skill, when not to use the skill and how to modify the performance of the skill when needed, then the learner performs as a trained technician (Michels et al., 2012). The development of a veterinary professional requires that the learner has declarative or background knowledge, procedural knowledge about how to perform the skill, and can also apply diagnostic reasoning and clinical decision‐making. In effect, developing a clinical skills program means achieving a comprehensive consensus on all of these aspects and not simply generating a list of skills (Michels et al., 2012).
Initially, the emphasis of outcomes‐based education in the health professions was on the postgraduate learner, but more recently there has been a shift to incorporate undergraduate training as well (Ferguson et al., 2017). The competency‐based educational approach supports the continual documented improvement of learner performance from novice to proficient and emphasizes training in the clinical workplace (Dreyfus, 2004). Assessment is becoming increasingly focused on a programmatic approach that includes multiple direct observations of student performance that are then integrated to provide a complete picture of learner competence (Bok et al., 2018; Norcini et al., 2018; van Melle et al., 2019).
The development of entrustable professional activities (EPAs) is ushering in a new era for skills training where students are ultimately encouraged to bring individual skills and competencies together in a comprehensive authentic workplace procedural performance (ten Cate, 2005). EPAs are activities that are performed in the workplace and offer a chance for observation and assessment. Assessors have a chance to observe “in the moment” and comment on the learner's ability to perform tasks required in practice. The repetitious completion of such activities in the clinical veterinary teaching environment allows the trainee to grow and learn from the formative feedback provided to them. The AAVMC's CBVE working group recently defined nine different domains and 32 competencies in a framework, which represents consensus across a number of veterinary programs (Molgaard et al., 2018a; Molgaard et al., 2018b). The group then described eight EPAs that can be used for assessing and documenting learner development during the clinical years of the training program. Clinical skills training is now evaluated across programs through the use of OSCEs to assess introductory individual skills and short procedures in the years prior to clinical rotations, and EPAs and workplace‐based assessments that evaluate more complex procedures or activities where multiple competencies need to be performed simultaneously in the clinical environment (Petersa et al., 2017; ten Cate et al., 2018; Molgaard et al., 2018b).
Programmatic assessment has recently been validated in veterinary medicine and shows that a change in performance is not simply due to variability between raters but is due to variance in learners’ growth (Bok et al., 2018). This is important because we can now demonstrate learner change over time and predict the rate at which mastery will occur (Pusic et al., 2015). Limitations of accreditation (e.g. American Veterianry Medical Association’s Council on Education mandating the maintenance of a four‐year program) and reduced financial support (e.g. in the United States, many colleges have poor public support and rely heavily on tuition dollars) may mean that true time‐independent advancement may prove challenging for veterinary programs.
In summary, veterinarians used to talk about “see one, do one, teach one,” but today this is no longer considered a valid approach to teaching and learning skills (Michels et al., 2012). Clinical skills teaching, learning, and assessment have evolved. There is a growing body of evidence regarding learning theories, teaching and assessment principles, and learner development that can be used to the advantage of learner, teacher, and other stakeholders. An abundance of research and scholarship has changed the way that educators teach and the way programs are designed. This book is intended to focus on teaching, learning, and assessment of clinical skills in the modern veterinary curriculum and is a resource guide for students, as well as their instructors. This book is written for both veterinary and veterinary nursing students and includes chapters regarding development of skills curriculum (Chapter 2), how skills are best taught and learned (Chapter 3), and how skills are best practiced prior to assessment (Chapter 4). Also included are chapters on how learners know if they are learning what they need to (Chapter 5), how learners know they are being assessed fairly (Chapter 6), how learners can best learn in a simulated environment (Chapter 7), how to make use of peer teachers (Chapter 8), and what other skills are vital to a successful practice career (Chapter 9). The appendices include examples of OSCE assessments and recipes for simple models that instructors and learners can use and make.
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2Clinical Skills Curricula: How Are They Determined, Designed, and Implemented?
Jennifer Hodgson1, Elrien Scheepers2, and Sarah Baillie3
1 Virginia‐Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, VA, USA
2 Faculty of Veterinary Science, University of Pretoria, Pretoria, RSA
3 Bristol Veterinary School, University of Bristol, Bristol, UK
Box 2.1 Key Messages
The same principles of general curricular design should be adhered to when designing or evaluating a clinical skills curriculum
A six‐step model developed by David Kern provides fundamental, yet flexible, principles of curricular design
Student, societal, professional, and accreditation needs should be considered
A backward design process, with initial attention to the desired outcomes, will focus curricular design
A prioritized Day‐One Competencies list and identified core Entrustable Professional Activities will further drive the design process
Learning objectives for clinical skills must be as specific and measurable as possible
A variety of educational methods may be used to teach clinical skills, which are not restricted to clinical skills laboratories or clinical settings
Implementation of a clinical curriculum will depend on available resources, buy‐in from stakeholders, and a properly planned management and roll‐out plan
Evaluation of the implemented clinical curriculum must be done early and repeated as needed
Introduction
The goal of veterinary curricula is to educate students to be optimally prepared to enter the veterinary profession with entry‐level medical knowledge and appropriate mastery of an array of clinical skills (Read and Hecker, 2013; Dilly et al., 2017; Thomson et al., 2019; Duijn et al., 2020). Not only will the qualified veterinary professional be expected to display knowledge and mastery of skills, but he or she will also have to function as part of the veterinary team, working with veterinary nursing professionals where both the veterinarian and veterinary nurse (or “vet tech”) have input into patient care and treatment (Kinnison et al., 2011). Good veterinary interprofessional practice may have benefits for the practice, the individual team members, the client, and the patient (Kinnison et al., 2014). It can, and should, be argued that this relationship between members of the professional team should be nurtured and developed from an early stage, ideally at the level of educating students. While published studies in interprofessional education interventions are sparse, it must be acknowledged that at teaching institutions where the two groups of students are educated together, opportunities for integrated curriculum design are ample and should be fostered. Even if these opportunities do not exist because of physical separation of teaching facilities, it must be kept in mind that there are many more similarities in designing clinical skills curriculum for veterinary and veterinary nursing/veterinary technology students, than there are differences. This chapter will discuss processes in the design of clinical curricula that are similar for veterinary and veterinary nursing (or veterinary technology, as called in Australia and United States) students.
The veterinary degree, perhaps more than any of the other health science degrees, poses a challenge to curricular design due to the breadth of material that must be covered, expectations of the level of competence at graduation, and the variety of career options available to veterinarians. By recognizing the close correlation between the veterinary knowledge and clinical skills also expected of newly qualified veterinary nursing professionals, it follows that near‐similar challenges are posed to the design of curricula for veterinary nurses.
Despite its importance, it is easy to slip into a pattern of ad hoc curricular development with little attention to desired outcomes (Schneiderhan et al., 2018). Therefore, contemporary veterinary curricula must refocus on the fundamental knowledge, skills and behaviors required of graduates and utilize modern methods grounded in educational theory to best achieve these (Hodgson and Ilkiw, 2017).
In the broadest sense, a curriculum is defined as the totality of student experiences that occur in the educational process (Wiles, 2009), but any planned educational experience is also considered to be an example of a curriculum (Kern et al., 2016) with this latter definition being applicable for a section of a veterinary curriculum focused on clinical skills development. Although a clinical skills curriculum would not be the totality of veterinary training, the same principles of curricular design should be adhered to when developing, or evaluating, a clinical skills curriculum for veterinarians and veterinary nurses.
There are several fundamental tenets when approaching curricular design that have been well articulated by Kern (2016): “First, educational programs have aims or goals, whether or not they are clearly articulated. Second, medical educators have a professional and ethical obligation to meet the needs of their learners, patients and society. Third, medical educators should be held accountable for the outcomes of their interventions. And fourth, a logical, systematic approach to curricular development will help achieve these ends.”
To help achieve the last of these principles, Kern developed a six‐step model for curricular development in medical education (Kern et al., 2016) (see Figure 2.1). This model will be used as a framework for this chapter as all the steps are equally relevant to a veterinary clinical skills curriculum, for both veterinary and veterinary nursing students, with some modifications for the different educational contexts. Further, these principles of curricular design are fundamental, yet flexible enough to yield different types of curricula in different hands, depending on the local environment and the available resources in which the clinical skills curriculum is developed.
Steps in Clinical Skills Curricular Design
Step 1: Needs Assessment and Statement
The prompts for the development or review of a clinical skills curriculum can be multifactorial including both extrinsic (e.g. accreditation) and intrinsic (e.g. student performance evaluations) factors. A needs assessment will help answer “What are you trying to achieve, why is it important, and who will benefit?” The answers to these questions should point to the distinction between the current teaching content and strategies surrounding a learning need, and what should change about it (Kern et al., 2016).
Figure 2.1 Kern's six step model for curricular design.
Source: Based on Kern et al., 2016.
At the start, it is wise to consider whose needs are the priority. This may start with learners' needs (either skills or knowledge‐based needs, readiness to learn, or time available for learning) but likely extends to the patients and communities whom the learner will be serving (Kern et al., 2016). Furthermore, when justifying changes to time or funding, an articulation of how this curriculum, or curricular change, might meet regulatory or board requirements may be useful (Schneiderhan et al., 2018). To help with this step, it may also be helpful to develop a Clinical Skills Development or Review committee, as this has been a successful strategy used by some veterinary colleges (Read and Hecker, 2013; Morin et al., 2020).
The mechanics of a needs assessment includes utilizing readily available information, as well as the collection of new information (Kern et al., 2016). The acquisition of this information can be structured (e.g. surveys), semi‐structured (e.g. series of discussions with stakeholders), research/data‐driven (data on learner's performance or clinical quality data) or based on regulatory requirements (Schneiderhan et al., 2018). While a needs assessment will differ between institutions, there is some information available for veterinary clinical skills that may help inform this process.
Student Needs
Feedback from faculty, staff, and veterinary and veterinary nursing students may help indicate the students' needs for clinical skills review and revision. In a recent review by Malone (2019), it was noted that while graduating students do show improvement in confidence and competence from the start of the clinical year, they remain less than confident in many technical skills and abilities at graduation, which is echoed in other studies (Lofstedt, 2003). Similarly, only 69% of 2008 University of Queensland veterinary graduates felt satisfied with their overall skills, and only 70% felt prepared to enter practice (Schull et al., 2011). Feedback from faculty and staff may also be helpful to identify specific skills that require attention. For example, a University of Minnesota in‐house survey of technicians, interns, and residents identified student challenges with animal restraint and venipuncture (Malone, 2019).
Societal and Professional Needs
The needs of clients, as well as employers, should be considered when designing a clinical skills curriculum. For example, it was shown that the majority of veterinary clients viewed technical skills (such as prioritizing patients according to illness or injury, collecting blood samples, performing a preliminary examination of an animal on admission, assisting with physical therapy techniques and making radiographs) together with emotional intelligence and professional attributes, important in the clinical practice of veterinary technology graduates with whom they interacted in the veterinary practice setting (Clarke et al., 2015). Client interviews showed that clients attached importance to graduates demonstrating professional competence, and it was therefore concluded that data such as this is useful in the design of a professional and market‐driven veterinary technology curriculum (Clarke et al., 2015).
Veterinary students are licensed to practice unsupervised directly after graduation and therefore should be graduating with the knowledge and skills required to meet professional and societal demands (Greenfield et al., 2004). However, as described under student needs, many graduates do not have confidence in their own skills and abilities, which is also recognized by employers (Greenfield et al., 1997; Prescott et al., 2002; Lavictoire, 2003). In the review by Malone (2019), she described a collaboration between Banfield® Pet Hospitals and the University of Minnesota to identify challenges that were encountered among the 800 new small animal graduates hired each year. The survey identified surgery, dental skills, catheter placement, and venipuncture as being “critical barriers” to the success of the new graduates, leading to decreased confidence and productivity along with medical errors and increased stress to the entire team.
Lastly, Duijn et al. (2020) used entrustable professional activities (EPAs) to evaluate graduate readiness for practice. An EPA is defined as “an essential task of a discipline (profession, specialty or subspecialty) that an individual can be trusted to perform without direct supervision in a given health care context once sufficient competence has been demonstrated” (ten Cate, 2005). Duijn et al. (2020) identified five EPAs they believed were core educational objectives for veterinary curricula and surveyed new graduates regarding their readiness to perform these EPAs, including the degree of supervision they required. They found that, on average, it took graduates approximately six months until they felt ready to execute all five EPAs with distant supervision. Only after 10 months did participants feel fully competent to execute EPAs unsupervised. The authors noted that these results suggest the expectations of graduate performance may need to be nuanced but also the importance of adequate preparation of veterinarians during their education and the importance of guidance during early career to foster a successful transition from veterinary school to clinical practice. Clinical coaching of veterinary nursing students in practice is well established in certain parts of the world, but this could also be extended to veterinary nurses at the beginning of their careers to help navigating the new work environment and adapt to new situations (Kerrigan, 2018).
Accreditation Needs
There are a number of veterinary accrediting agencies worldwide, including the American Veterinary Medical Association's Council on Education (AVMA COE), the Royal College of Veterinary Surgeons (RCVS), European Association of Establishments for Veterinary Education (EAEVE), and the Australasian Veterinary Board Council (AVBC). There is significant harmonization of accreditation standards among these organizations, with each recognizing the importance of clinical skills development within the curriculum. More specifically, Standard 9 (Curriculum) of the AVMA COE requirements states the “Curriculum must provide… instruction in both the theory and practice of medicine and surgery applicable to a broad range of species. The instruction must include principles and hands‐on experiences in physical and laboratory diagnostic methods and interpretation (including diagnostic imaging, diagnostic pathology, and necropsy), disease prevention, biosecurity, therapeutic intervention (including surgery), and patient management and care (including intensive care, emergency medicine and isolation procedures) involving clinical diseases of individual animals and populations” (AVMA, 2017).
Additionally, Standard 11 (Outcomes Assessment) states “The college must have processes in place whereby students are observed and assessed formatively and summatively” on nine competencies, the majority of which include clinical skills requirements (e.g., comprehensive patient diagnosis, anesthesia, basic surgical skills, basic medicine skills, emergency and intensive care management, communication skills) (AVMA, 2017). The standard also requires colleges and schools to provide evidence of timely documentation to assure accuracy of the assessment for having attained these competencies.
Step 2: Determining and Prioritizing Content
Before a decision can be made regarding which clinical skills can, and should, be included in the curriculum, there must be a common understanding among the people involved in its implementation as to what constitutes a clinical skill in their context. For example, one study used a Delphi process and showed a marked variation between participants (British doctors involved in teaching) as to what this term meant, ranging from simple physical examination skills to include other diagnostic, communication, and practical skills (Michels et al., 2012). They concluded that acquiring clinical skills involved three components: learning how to perform certain movements (procedural knowledge), why one should do so (underlying basic and medical science knowledge or declarative knowledge), and what the findings might mean (clinical reasoning); and that these three components should be taken into account during instructional design.
Once a decision has been made as to what constitutes the range of clinical skills required for veterinary and/or veterinary nursing students to be taught in the program, the specific skills should be identified and prioritized. This may be easier said than done, as although clinical skill training is an integral part of all veterinary curricula, the specific skills that are required and how they are taught has been the subject of much debate (Malone, 2019). This is particularly the case when veterinary programs become overloaded as more and more content is added, requiring specific decisions to be made regarding the clinical skills content, as well as when and how they are taught (Malone, 2019).
Generation of a prioritized, Day‐One skills list will help focus both program and student efforts on core skills, with potential additional lists that may be taught to a smaller cohort of students for colleges or schools with a tracking curriculum. These lists could be adopted from those published in the literature, and potentially modified by local practitioner input to account for regional differences (Greenfield et al., 1997). Published skills lists for veterinary students exist for general Day‐One practice (Greenfield et al., 1997; Doucet and Vrins, 2009; Rush et al., 2011; Schull et al., 2011; Read and Hecker, 2013; Dilly et al., 2014; May, 2015; Kreisler et al., 2019; Malone, 2019), a variety of career paths, including those focused on small animals (Clark et al., 2002; Greenfield et al., 2004; Greenfield et al., 2005; O'Neil et al., 2014), horses (Hubbell et al., 2008; Christensen and Danielsen, 2016), and cattle (Morin et al., 2002a; Morin et al., 2002b; Miller et al., 2004; Luby et al., 2013), as well as lists focused on specific fields such as surgery (Johnson et al., 1993; Bowlt et al., 2011; Hill et al., 2012; Smeak et al., 2012; Schnabel et al., 2013; Carroll et al., 2016; Zeugschmidt et al., 2016; Cosford et al., 2019), dentistry (Thomson et al., 2019), or theriogenology (Root Kustritz et al., 2006). Additional resources may include those skills required by accrediting agencies (e.g. the AVMA COE's 9 clinical competencies), internal surveys of faculty, and Day‐One skills lists shared by other colleges (Morin et al., 2020). For veterinary nursing students, Day‐One competencies lists have been published by the Royal College of Veterinary Surgeons, the Veterinary Nursing Council of Australia, and the South African Veterinary Council (RCVS 2015; VNCA 2019; SAVC 2020).
Care must be taken to prioritize these lists, as they can quickly become exhaustive, and thereby both unattainable and confusing for the student. For example, an informal survey of eight US veterinary colleges in 2009 generated a list of over 900 different, individual clinical skills, of which approximately three quarters were considered core by college faculty, but only 105 were shared by half or more of the colleges (Lizette Hardie, personal communication). Consideration, therefore, should be given to those skills considered essential for a Day‐One veterinarian versus those that may be better learnt or mastered by a subset of students, or after graduation, for example in clinical practice or in continuing education programs (Malone, 2019; Duijn et al., 2020). This consideration should also take into account those skills that may be life‐saving if done correctly, and those that might be life‐endangering if done incorrectly (Malone, 2019). In this context, a short list of crucial skills could be valuable and could ensure we are “teaching to the common uncommonly well” (Henry J. Heinz), rather than providing exposure but not necessarily competence (Malone, 2019).
