Association of Clinical Timing with Self-Efficacy Among Student Registered Nurse Anesthetists

Objectives: To uncover new findings on how best to implement education and training among students in nurse anesthesia programs. Design and Methods: The target participants are nurse anesthesia students currently enrolled in an accredited Doctor of Nursing Practice (DNP) program that met inclusion criteria. An online survey was distributed to measure self-efficacy using the 10-item Likert-style Schwarzer & Jerusalem General SelfEfficacy Scale. Participants were recruited from a convenience sample of 72 Council of Accreditation (COA) accredited nurse anesthesia programs. Contact was made with program leadership to obtain permission and facilitate the dissemination of the surveys. Inclusion criteria: enrolled in accredited DNP program, integrative or non-integrative curriculum as defined by the study and expected graduation date within 12 months. Sample size, n=847 senior nurse anesthesia students. Independent variable: curriculum structure (integrative or non-integrative). Dependent variable: composite score on General Self-Efficacy Scale, ranging from 10-40. Primary Results: Mean composite scores on the GSE survey were (33.37 ± 3.23) and (33.91 ± 3.52) for integrative and non-integrative programs, respectively. The mean composite score for participants in a non-integrative curriculum was 0.54 (95% CI, -1.69 to 0.60) higher than mean composite score for participants in an integrative curriculum. The independent samples t-test concludes that there was not a statistically significant difference in the mean composite scores between participants in an integrative and non-integrative curriculum t (138) = -0.940, p = 0.35, d= 3.40. Principle Conclusions: There is no statistically significant difference between the reported self-efficacy scores among students in both integrative and non-integrative curriculum. ASSOCIATION OF CLINICAL TIMING WITH SELF-EFFICACY 3 Effects of Curriculum Structure on Students’ Self-Efficacy and Learning Introduction Nursing education is viewed as an esoteric field of study that draws less attention when compared to areas with tangible outcomes in the clinical setting and affect daily practices. The interest in nursing education stems from the authors’ own experiences as student registered nurse anesthetists (SRNAs). The variances among nurse anesthesia programs and disparities among students’ experiences and self-reported level of confidence is worth mentioning when considering all students are subjected to the same eligibility requirements for the National Certification Exam (NCE). As nurse anesthesia programs adopt a doctoral curriculum, it is of value to explore whether curriculum changes can be standardized among nurse anesthesia programs. Background and Significance To increase the number of highly qualified registered nurses, nursing associations have released statements to expand and promote higher education. In 2007, the American Association of Nurse Anesthetists (AANA) advocated the position that all entry-to-practice, certified registered nurse anesthetists (CRNAs) have a doctorate degree by 2025. In 2009, the Council on Accreditation of Nurse Anesthesia Educational Programs (COA) voted to mandate all nurse anesthesia educational programs to transition to a doctoral framework by January 1, 2022. The transition to the Doctor of Nursing Practice (DNP) requires an overhaul of the curricula in order to assimilate doctorate level courses. Furthermore, it culminates with the graduation of nurse anesthetists who have undergone clinical training and developed skills to translate evidence into practice via nursing research. Problem Statement This transition brings a degree of standardization to CRNA programs. What remains is a degree of variability among the programs’ curricula, and therefore, disparities among graduating nurse anesthetists. Major factors in dictating such curriculum design are based on cost, health facility ASSOCIATION OF CLINICAL TIMING WITH SELF-EFFICACY 4 partnerships, and contractual agreements. However, a curriculum with reported high self-perception or efficacy by students is likely to make for a smoother transition to clinical practice because of increased confidence and competency. This translates to improved patient care and patient satisfaction. Despite the benefits to the learner and the patient, there remains limited research to explore students’ self-efficacy in relation to integrative versus non-integrative curriculum. The fundamental question guiding the literature review addresses whether students, enrolled in integrative and non-integrative nurse anesthesia programs, report a significant difference in self-efficacy upon graduation. Literature Review Operative definitions for the purpose of this study were established by the principal investigators. Integrative refers to a curriculum where clinical experiences occur simultaneously with didactic work within the first year of study. Non-integrative refers to a curriculum where didactic work is front-loaded, and clinical experience begins after the completion of the first year of study. Simulation experiences are ubiquitous in nursing education. For this study, simulation experiences are grouped with clinical experiences. Simulation is defined as the replication of real clinical scenarios designed by and under the control of faculty and staff without the involvement of real-life patients. Simulation experiences include, but not exclusive to learning and developing practical skills such as troubleshooting the anesthesia machine, intubation, placement of invasive monitors on a simulation mannequin, or a mocked, high fidelity clinical scenario. The purpose in defining these working terms is to keep the study’s independent variables consistent and controlled. Additionally, by establishing the criteria for integrative and non-integrative curricula, it helps to simplify and streamline the process of filtering out inappropriate studies during the literature review. With the limited number of available studies, the literature review was narrowed down to 5 prior studies (Table 1) found to be most pertinent to the topic. ASSOCIATION OF CLINICAL TIMING WITH SELF-EFFICACY 5 The literature search began with the databases Scopus, EBSCO, and CINAHL. The subject search was kept broad to include health related fields such as, “medical school”, “medicine”, and “nursing. ” These keywords were then coupled with the following terms: “integrated curriculum”, “curriculum integration”, “frontloading”, “block curriculum”, “Dundee Ready Educational Environment Measure”, “clinical model”, “models, education”, “block OR nonblock” “self-efficacy”, “clinical education”, and “curriculum design. ” With more substantial findings using these keywords, an unfiltered literature search was conducted in wider databases including ScienceDirect and PubMed. The selected studies that were most relevant ranged from 2014 to 2020. Due to the finite body of research available, minimal exclusion criteria including “English language only” and “academic journals only” were maintained. With regards to the inclusion criteria, the search was expanded to include all other allied health fields such as medicine, nursing, physical therapy, pharmacy, foreign medical programs, and foreign nursing programs. The literature review initially focused on SRNAs. However, results were limited, which prompted the revision of the research interest to be more encompassing to health-related fields including medicine and nursing in general. By maintaining minimal exclusionary factors, larger results were produced to fit the time frame of 2014-2020. Furthermore, the articles generated provided a wealth of background information to enrich the current discussion on learning models. If a resulting article was able to augment to the growing literature or the data analysis helped demonstrate one learning model was significantly more beneficial than another, it was included in the data evaluation. The organization of the resulting articles is illustrated in the PRISMA Flow Diagram demonstrated in Figure 1.8 The diagram illustrates the process in identifying, screening, and deciding which articles will be subjected to further review and which articles were removed with the appropriate rationale. The Johns Hopkins Evidence Level and Quality Guide was used to grade the research articles. The selected articles were subjected to further evaluation and delineated to their components including research questions to be addressed, the setting and sampling, methodology or study design, variables ASSOCIATION OF CLINICAL TIMING WITH SELF-EFFICACY 6 measured, and outcomes. Thereafter, critical analysis was done to identify the strengths, weaknesses, and any implicit and explicit limitations that may weaken the study. The article was then graded by its level of evidence (level I-IV) and summarized by what conclusions can be drawn from it. The types of study design varied from qualitative, quantitative, and some were a hybrid of both qualitative and quantitative. Birks et al explored nursing students' perceptions on the impact of non-integrative versus an integrative curriculum model on their learning experience and concluded that both have advantages and disadvantages depending on the individual student and their unique situation. The study concluded that block placement was more likely to provide consistency to the students, which was viewed as a critical component to the students’ perceptions of self-efficacy and clinical competence. It was also determined that preference for curriculum structure changed as students progressed through the program. It was found that initially students preferred an integrative structure, but as their confidence and skill set grew, non-integrative was perceived as more suitable. DeSipio et al found early integration was positively received by medical students. At the Cooper School of Rowan University (CMRSU), a pre-clinical curriculum was implemented during the medic