Creating Entrustable Professional Activities (EPAs) for Acute Care Pediatric Nurse Practitioner Students

 From the 3/5/2021 newsletter

Perspective/Opinion

Creating Entrustable Professional Activities (EPAs) for Acute Care Pediatric Nurse Practitioner Students

Jill C. Kuester, MSN, RN, CPNP-AC, Katie McDermott, MSN, RN, CPNP-AC, Jennifer K. Pfister, MSN, RN, CPNP-AC, C-NPT, Christine Schindler, PhD, CPNP, and Leslie Talbert, DNP, RN, CPNP-AC/PC

 

EPAs are widely used in measuring the progress of residents in graduate medical education. The members of the Marquette team describe their KINETIC3 capstone in which they adopted an EPA approach to graduate nursing education…

Nursing and medicine go together like peanut butter and jelly. Although distinct, we complement one another. As interdisciplinary teams improve at working together, we have found the ability to gain insights from the more traditional pathways of each other’s endeavors.

The Kern Institute holds a yearlong program known as the KINETIC³ Teaching Academy where the goal is to improve medical education. Character, caring, and competence in medical education are at the center of the program with each participant or group focused on completing a project incorporating these traits.

The five core faculty members from Marquette University’s Acute Care Pediatric Nurse Practitioner (MU ACPNP) program completed a capstone project focused on creating Entrustable Professional Activities (EPAs). Guided by the Code of Ethics published by the American Nurses Association which explicitly states that nurses have compassion and respect for their patients and families, nurses already have a strong reputation for caring. We knew that the KINETIC³ program might offer a different perspective to build upon this foundation.

As nursing has been named the most trusted profession for nineteen years in a row (Gallup), we wondered how this could be operationalized into our graduate level curriculum. EPAs have been widely used in medical education but remain a novel concept in nursing education. The MU ACPNP faculty believed the act of entrustment was well suited to our nurse practitioner students. 

Utilizing this concept from medical education and knowledge gained through the KINETIC3 courses, our group conducted a systematic literature search, synthesized that literature, and created a template to guide development of the individual EPAs. Each member then focused on one of five EPA topics: 

• Reflective practice 
• Leadership identity 
• Holism 
• Social justice 
• Magis - the concept of using talents to strive for excellence 

Each project team member was the designated lead on an individual EPA and drafted the EPA using the template. Iterative cycles of reflection, collaborative review, feedback, and revision were conducted to ensure consensus regarding content, outcomes, and assessment sources. These collaborative sessions were held synchronously, both in-person and virtually, to promote clarity in communication. The final stage of revisions included alignment of language and descriptors used across all five EPAs to promote continuity of content and universality of tone. 

Each EPA includes a succinct action-oriented title followed by a more robust description linked to key literature, as well as a justification statement calling out its significance and impact beyond the walls of Marquette. Each EPA encompassed several nurse practitioner competency domains and described the required knowledge, skills, and attitudes the students must possess for success. Some of the methods of assessment we will use include, but are not limited to, direct observation, critical review and evaluation of projects, reflective journaling, and exit interviews.

As graduate students move into professional practice, our goal is for them to embody the values we espouse as a faculty in alignment with MU’s mission, vision, and core values. EPAs hold the promise of operationalizing the transformation to a competency-based education framework for PNPs by defining a pathway with a common language and clearly articulated ideal outcomes. The KINETIC3 program afforded us the opportunity to learn and work as a team to intentionally develop key strategies to enhance the development of the competent and compassionate nurse practitioner.

Jennifer K. Pfister MSN, CPNP-AC, C-NPT, is a Pediatric Critical Care Nurse Practitioner at MCW/Children’s Wisconsin and a Transport Team Clinical Educator at Children's Wisconsin. She also has a joint appointment at Marquette University where she is part-time faculty within the Acute Care Pediatric Nurse Practitioner program. 

Christine Schindler, PhD, CPNP, is a Pediatric Nurse Practitioner and Advanced Practice Provider Director for Critical Care/Palliative Care At MCW/Children’s WI. She has a joint appointment at Marquette University where she serves as a Clinical Associate Professor and director of the Acute Care Pediatric Nurse Practitioner program. 

Leslie Talbert, DNP, is a Pediatric Nurse Practitioner at MCW/Children’s Wisconsin. 

Katie McDermott, MSN, RN, CPNP-AC, is a Pediatric Nurse Practitioner for Critical Care at MCW/Children’s Wisconsin and has a joint appointment at Marquette University where she is part-time faculty within the Acute Care Pediatric Nurse Practitioner program. She also serves as the Program Director at the Dairy Cares Simulation Lab at Children's Wisconsin. 

Jill C. Kuester, MSN, RN, CPNP-AC, is a Pediatric Critical Care Nurse Practitioner at MCW/Children’s Wisconsin. She has a joint appointment at Marquette University where she serves as Part-time Faculty in the Acute Care Pediatric Nurse Practitioner program.

 

What Learners Tell Us About How They Know When They Matter

 From the 3/5/2021 newsletter

Perspective/Opinion

What Learners Tell Us About How They Know When They Matter

 

Preliminary results of a KINETIC3 project by Caitlin Patten, MD, Rana Higgins, MD, and Karen Marcdante, MD, with data from Alexandra Lutley, MD, and Adam Szadkowski, MD

 

Drs. Patten, Higgins, and Marcdante describe how they used qualitative methodology and semi-structured interviews to understand and design future interventions to help all learners feel that they matter...

 

We have all been students at some point in our life. Do you remember a day when you were in a classroom, meeting, or a clinical learning environment when you wondered why you were there? Perhaps, no one acknowledged your presence or asked your name. Or they dismissed what you said. Or when you returned after a prolonged absence, no one realized you had been gone. These behaviors make you feel like you don’t matter. Knowing that you matter means that others’ behaviors, actions, and words make you feel valued and useful. They are aware of you, make you feel important by paying attention to/going out of their way for you, and rely on you. It turns out that mattering (the perception that you matter) is an enabling concept – when you feel you matter you have more self-esteem and self-efficacy which leads to less anxiety and depression, allowing you to learn more! Helping others matter is one way to improve the learning environment.

But, how do our learners perceive that they matter? A group of faculty participating in the 2019-2020 KINETIC3 faculty development program asked that question. While participating in this structured program, Dr. Rana Higgins and Dr. Caitlin Patten (Surgery – M3/M4 students), Dr. Adam Szadkowski (Pediatrics - fellows) and Dr. Alexandra Lutley (Neurology - residents) each used qualitative methodology and semi-structured interviews to find out what learners at various levels perceived as evidence that they matter. 

While there are some differences in specific stories among the learners based on their training levels, they all needed to know that others were aware of them. Here is some of what they said: Learners felt they mattered when residents and Faculty called them by name (yes, it is that simple!). They also feel they matter when you make eye contact and put the phone down while talking with them. Part of being aware is also finding out what makes each learner a unique individual– where they are from, their past experiences, and what their current interests and/or career goals are. Identifying learners’ interests and strengths were not only a way to be aware of them, but it also made them feel important. 

Importance was highlighted when medical students were assigned meaningful tasks - making them a valued member of the team. When students perceived their educators relied solely on them to complete an assigned task that was essential to success of the team, they had a strong sense of mattering. Additionally, learners feel important when those supervising them (residents /faculty) “went out of their way” to see how they were doing, ask about one of their projects, or perform an impromptu mini education session. 

The third component of mattering is when someone relies on you. For our learners, this varied with level of training. For medical students, mattering occurs when they are trusted to collect information that is needed and not getting duplicated by another team member. For residents and fellows, they felt that others relied on them when they provided care in an emergency or when others came to them for help or advice. 

This is the first work of its kind with learners in medical education. The faculty’s projects for KINETIC3 utilized a small group of learners to help direct future interventions to improve mattering for all learners. Their findings can help us all recognize which words, actions and behaviors make learners feel they matter, allowing them to be more curious, comfortable, and creative. It is essential to understand that mattering requires building a relationship. Educators and students alike all want to matter and will feed off each other. If a learner has a sense of mattering, they will be more engaged with learning and with their educators. In turn, educators will feel their time spent with students was worthwhile and they may be more motivated to teach. Moving forward, remember how it felt when you did not matter as a learner and how easily you can prevent others from feeling that same way through awareness, importance, and reliance. 

Caitlin Patten, MD, FACS, is an Assistant Professor in the Department of Surgery/Division of Surgical Oncology specializing in Breast Surgery. She is Associate Program Director for the Surgery Clerkship and enjoys partnering with colleagues in the Kern Institute to improve the educational experience for all learners. She is a 2019-20 graduate of the Kern KINETIC3 program. 

Rana Higgins, MD, FACS, FASMBS, is an Assistant Professor in the Department of Surgery focused on robotic hernia, foregut and bariatric surgery. She is an Associate Program Director of the General Surgery residency and a 2019-20 graduate of the Kern KINETIC3 program.

Karen Marcdante, MD, is a Professor in the Department of Pediatrics (Critical Care) at MCW. She is Director of the Human-Centered Design Laboratory, a member of the Faculty Pillar, and serves on the steering committees of the KINETIC3 Teaching Academy and Philosophies of Medical Education Transformation Laboratory in the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education. 

Three Questions For Teresa Patitucci, PhD

 From the 3/5/2021 newsletter

Three Questions For Teresa Patitucci, PhD 

Assistant Professor Cell Biology, Neurobiology & Anatomy 

Medical College of Wisconsin

What was most beneficial about KINETIC3? 

The KINETIC3 Training Program was valuable for learning more about becoming an effective medical educator. This included various modalities that can be used for effective classroom sessions, like different active learning strategies, as well as how to assess learning from those sessions and provide feedback to learners. As a foundational scientist, it was hugely valuable to me to participate in these workshops with those engaged in clinical teaching to get a better understanding of where students are headed once they are finished with my courses. It was great to learn teaching tips from other participants in the courses! 

 How have you incorporated what you learned?

 I incorporate what I learned in KINETIC3 all the time! I had some teaching training experience prior to KINETIC3 where I learned nuts and bolts of writing learning outcomes and assessment questions, but really benefitted from learning more about adult learning theory, incorporating character into teaching, culturally responsive teaching, and turning education into scholarship. I regularly apply these lessons when designing courses and sessions, looking for “teachable moments” and ways to go over material that is engaging to an adult learner and trying to put the concept in context of how they will use it in the wider world with their patients. As an anatomist training learners for direct patient care, I find it important not just to talk about a structure on the body, but also how we as a culture interact with that region of the body and when a patient may need extra reassurance. 

What was your capstone and where has it gone? 

My capstone project focused on using critical reflection of strengths and weaknesses to develop character and emotional intelligence. Our project examined reflective writing pieces from M1 learners enrolled in Cliical Human Anatomy on the MCW-CW campus. We learned a lot about the student experience during their first 6 months adjusting to medical school, specifically analyzing comments in the domains of emotional intelligence, wellbeing, and teamwork. Students received feedback from a faculty member and completed self-assessments as follow-ups to the reflective writing activities. Since then, my capstone partner and I have continued working on this project, now with the help of a Transformative Initiatives (TI2) Grant from the Kern Institute. We are enrolling students from campuses other than MCW-CW, adding discussion sessions, and evaluating impact of repeated critical reflection on selfawareness and professional identity.

Setting the Expectation for a Growth Mindset in KINETIC3’s Excellence in Teaching Track

From the 3/5/2021 newsletter 

Perspective/Opinion 

Setting the Expectation for a Growth Mindset in KINETIC3’s Excellence in Teaching Track

Alexandra Harrington, MD

Dr. Harrington shares that character development in adults seems dependent on having a growth mindset, a frame of mind adopted by the Kern Institute's KINETIC3 Teaching Academy...

As I reviewed the results of my Values in Action (VIA) character strengths survey, I noted the ‘top 5’ of honesty, judgement, love, perseverance and fairness, but was naturally drawn to those strengths ranked at the bottom, self-regulation, social intelligence, and spirituality. For those unfamiliar with this survey, it is a free survey (available at https://www.viacharacter.org/)- that all KINETIC3 learners take prior to our first course- that ranks your character strengths based on your answers to a series of questions. Can I better control my emotions and reactivity? How do I improve my interpersonal relationships? These questions and other related ones had me reflecting on my mindset. With a growth mindset, I certainly could practice better self-control, but not with a non-acknowledging, resistant fixed mindset. Character development in adults seems dependent on having this growth mindset.

 A growth mindset is defined by Dr. Carol Dweck as the belief that talents and skills can be developed in oneself and/or others. We have adopted this frame of mind in the KINETIC3 program and have set the expectation for having a growth mindset with respect to teaching in the Excellence in Teaching Track. Our learners are asked early in the program to reflect on previous teaching evaluations. We ask learners to share their positive evaluations and reflect on growth opportunities. Then, we ask learners to share any negative feedback on their teaching and again reflect on growth opportunities. We try to explore those opportunities, even if the negativity of the evaluation seems like Jimmy Kimmel’s mean tweets! KINETIC3 learners are given time to reflect substantively on their teaching and character strengths and opportunities for improvement and commit to working on those growth fronts during their coached teaching observations.

“We’re all a mixture . . . it’s true that you can have a fixed mindset in one area and a growth mindset in another and that it’s a spectrum, not a dichotomy,” Dr. Dweck tells us in a videoed interview that we watch in KINETIC3 (https://www.youtube.com/watch?v=-71zdXCMU6A&feature=youtu.be). 

Learners are asked to reflect and share stories wherein they had a fixed mindset and then situations in which they have had growth mindsets. And as Dr. Dweck advises, we ask learners to reflect on the triggers of the fixed mindset. What puts you in the fixed mindset in that moment? The goal in this exercise is to identify the trigger in hopes of avoiding the rigidity in the future. We stretch our learners to mentor themselves hypothetically then towards a growth-minded belief if they encounter similar scenarios in the future. Lastly, we share examples of fixed and growth mindsets related to our previous educational experiences, such as disregarding student evaluative feedback (fixed) and trying a new active learning exercise (growth). It is imperative we recognize that in the teacher-student relationship, our mindset may influence our learners’ mindsets (and vice versa!).

Alexandra Harrington, MD, MT (ASCP), is a Professor of Pathology and Director of Hematopathology in the MCW Department of Pathology. She serves as Director of the Faculty Pillar and the KINETIC3 Teaching Academy within the Robert D. and Patricia E. Kern Institute for the Transformation of Medical Education.