In this historical before-and-after controlled study, we conducted an evaluation from July 2019 to December 2021 of nursing staff who had specialized training as an anesthetist in the Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, China. The study framework is displayed in Fig.
Study framework
A convenience sample of 59 NA students were included in this study. Inclusion criteria were as follows: the Nurse Licensure Examination has been passed by all nurses; the Nurse Licensure Examination is reliable and impartial for determining whether a candidate possesses the skills required to practice nursing; and they were voluntarily provided written consent. Exclusion criteria were as follows: nurses who dropped out of the training. Currently, although anesthesia nursing is developing rapidly in China, the total number of nurses is relatively small; therefore, all anesthesia nurses in our hospital who met the inclusion and exclusion criteria during the study time period were included in this study.
From July 2019 to December 2019, our unit adopted conventional single-teaching in nursing (SN), during which time 30 recruited trainees were enrolled into the SN group. Co-teaching in medicine and nursing (CMN) was used from July 2021 to December 2021. The CMN group was formed by the 29 trainees who were recruited during this time.
To implement CMN, we further developed a common medical and nursing course together with anesthesiologists, in addition to the nursing-specific training course with senior NAs as instructors. The curriculum design was reviewed by a panel of experts consisting of two physicians, two nurses, and one teaching professional, all with at least 5 years of teaching experience.
We matched the post competency of NAs from the International Federation of Nurse Anesthetists (IFNA) [14] with the competencies of anesthesiology residents to derive core competencies for primary care in anesthetist practice. Furthermore, we used this as the basis for curriculum screening and reorganization of the existing textbook process to obtain a common curriculum for medicine and nursing applicable to CMN (Additional file 1: Appendix 1). The content of the common curriculum ultimately included basic anesthetist theory, perioperative anesthetist management, anesthesia and analgesia management, and medical and nursing collaboration training; the curriculum was taught by teaching-qualified anesthesiologists. CMN trainees attended training together with anesthesiologist residents.
The special nursing curriculum covered basic anesthesia theory, nursing anesthesia methods for each specialty, anesthetist nursing in the post-anesthesia care unit, the management of narcotic drugs and psychotropic drugs, and a discussion of clinical nursing safety events. The teaching materials used included Clinical Anesthesiology, Morgan & Mikhail’s Clinical Anesthesiology, and Nursing–Anesthesia. The curriculum was taught by senior NAs and included nursing staff only.
The common curriculum for medicine and nursing and the nursing special curriculum together formed a structured co-teaching curriculum in medicine and nursing for the training of the CMN group. The SN group received the special nursing curriculum only. The common curriculum for medicine and nursing was taught every Thursday for 45 min.
In the co-teaching in medicine and nursing, anesthesiologists led lectures and NAs and anesthesiologist residents were trained as a group. Teaching was driven by clinical activities and oriented to post competency. Teaching methods included lectures by the instructor, case discussions, and exercises simulating clinical activities that were conducted by medical and nursing teams of NAs and anesthesiologist residents. The curriculum was aimed at improving the professional knowledge base of NAs and the capacity for physician–nurse collaboration.
The period of this training was 6 months. At the end of training, trainees were given knowledge and clinical practice assessments, and surveys and interviews were conducted on teaching satisfaction. To maintain training consistency, all faculty members received training in providing step-by-step scripted guidance. All instructors had at least 5 years of work experience and 3 years of teaching experience. Figure 1 depicts the study timeline.
Before the start of training and after the end of training, the assessment team selected eligible clinical cases and used the Objective Structured Clinical Examination (OSCE) to conduct the assessment. The examination was conducted with the cooperation of an attending anesthesiologist on staff. The assessment includes four stations: preoperative anesthesia preparation, induction of anesthesia, anesthesia management, and post-anesthesia recovery care. The assessment is based on two dimensions: anesthesia task performance and safe patient care, with a total score of 180 points. Anesthesia task performance was assessed using a tool developed for this study. The tool consists of a total of 16 items, including 5 items on skills needed to achieve patient outcomes, 5 items on the provision of patient-centred care, 3 items on attitudes need to improve team collaboration, and 3 items on professional responsibilities. The scale uses a 5-point Likert scale, ranging from 1 for “strongly disagree” to 5 for “strongly agree,” with a total of 80 points. The face validity and content validity were completed with the panel. The panel comprised 4 anesthesiologist specialists, 2 NA specialists, 9 attending physicians, and 9 NA instructors. A questionnaire was conducted among the panel to assess the face validity and content validity, including realism and utility. The questionnaire is based on a ten-point scale, ranging from 0 for “not realistic/not useful” to 10 for “realistic/useful”. face validity: The majority of the panel considered the tool to be “very realistic” (median 9/10). Content validity: the panel also approved the tool was a “very useful” evaluation tools for NAs (median 9/10). The tool was completed by the examiner who was observing the NA students during the exam. Safe patient care was assessed primarily using the operational assessment form, which was scored with a total of 100 points. The tool was also completed by the examiner who was observing the NA students during the exam.
Before the start of training and after the end of training, the assessment team developed tests according to the syllabus and teaching objectives and organized examinations to assess the expertise of NAs. The assessment team comprised two physicians, two nurses, and one teaching specialist. The examinations were reviewed by a panel of experts and required a reliability (reflecting the degree of consistency) > 0.85 [15], discrimination (reflecting the quality of the paper and the basis for screening the questions) at 0.2–0.3, which was conducive to distinguishing differences in students’ abilities and also had good control over the failure rate [16, 17], and a medium difficulty of 0.3–0.8 [18].
Drawing on the Medical Student Clinical Reasoning Skills Assessment Form, trainees self-assessed whether their clinical reasoning skills had improved. The Cronbach’s α coefficient of the scale was 0.91, and the test–retest reliability was 0.84. The scale includes six items on critical thinking skills, 11 on systematic thinking skills, and seven items on evidence-based thinking skills. A total of 24 items in three dimensions are used to assess the clinical reasoning skills of medical students. As for the evaluation criteria, a 5-point Likert scale was used to assign values, as follows: very good = 5 points, good = 4 points, average = 3 points, poor = 2 points, and very poor = 1 point. The full score is 120, which was converted to 100. A clinical reasoning skills score of 80–100 is considered very good, 60–80 is good, 40–60 is average, 20–40 is poor, and a clinical reasoning skills score of 0–20 is considered very poor.
A self-designed student evaluation questionnaire was used to investigate students’ evaluation of the teaching model after training. The questionnaire consisted of seven entries, including difficulty of the course; whether the training course had facilitated study of the specialty of anesthetist; whether the training course helped improve clinical workability, motivation to learn, and motivation to work; whether the training course had an impact on the manner of thinking about clinical work; and whether clinical work experience was improved. Each topic was rated using a 5-point Likert scale, ranging from 1 for “strongly disagree” to 5 for “strongly agree”. The questionnaire was designed and modifed according to previous studies and the purpose of this study, with its validity verifed in a previous study [19, 20].
At the end of training, some participants were randomly selected by the teaching staff for semi-structured interviews. The interviews addressed feelings about co-teaching in medicine and nursing, suggestions for future course content and format, and professional identity.
Kolmogorov–Smirnov test was used to assess the normality of continuous variables. Measures satisfying a normal distribution are expressed as mean ± standard deviation, and as median (interquartile range) with a non-normal distribution. Categorical variables are reported as frequency and percentage. Comparisons between groups were made using t-tests for normally distributed data and Mann–Whitney U-tests for non-normally distributed data. Comparisons between groups of count data were made using the chi-square test. Repeated measures information such as pre- and post-training healthcare collaboration competency scores and knowledge evaluation scores were analyzed using repeated measures analysis of variance. The data in this study were analyzed using IBM SPSS 26.0 (IBM Corp., Armonk, NY, USA), and statistical significance was set at P < 0.05.
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