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The use of cognitive task analysis to capture exterptise for tracheal extubation training in anesthesiology

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The use of cognitive task analysis to capture exterptise for tracheal extubation training in anesthesiology

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Content THE USE OF COGNITIVE TASK ANALYSIS TO CAPTURE EXPERTISE FOR
TRACHEAL EXTUBATION TRAINING IN ANESTHESIOLOGY

by

Kären K. Embrey

________________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVIERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

May 2012

Copyright 2012 Kären K. Embrey

ii

DEDICATION
This dissertation is dedicated to my loved ones, Mark and Madison, who have
supported, encouraged and patiently put up with me through this transformative journey
and to my muse, Artemis, the Goddess of the Hunt, who sees the game in every challenge
and runs at my side through every mile.

iii

ACKNOWLEDGEMENTS
First and certainly foremost I am greatly indebted to Dr. Kenneth Yates, without
whom this process would have been impossible. His unending, and often unreasonable
patience has ensured my persistence. My deep gratitude is extended also to Drs Maura
Sullivan and Kimberly Hirabayashi for their time and willingness to co-steward this
endeavor. They have each been readily available for consultation and have provided
valuable feedback on the study proposal and my writing. I am also most grateful to
Dr. Robert Keim for his time and assistance with the study‟s statistical analyses and to
Dr. Gligor Gucev, my friend, colleague and fellow Trojan. I would be remiss not to
thank my dear friends and colleagues, the women who have inspired and supported my
professional development over the past years. Ms Kari Cole CRNA, MS, Chief Nurse
Anesthetist at Los Angeles County Medical Center has been an amazing support and
trusted friend and colleague throughout. Drs Michele Gold and Terrie Norris from the
USC, Program of Nurse Anesthesia have extended their assistance, patience,
encouragement and support in immeasurable ways. Many thanks also to Ms Charlotte
Garcia CRNA, MS for her invaluable assistance in the simulation lab and to Mr. Robert
Olson CRNA, MS for his interest, support and time. I am entirely grateful also to Drs
Mary Joseph, Chiew Lin Liew and Jeb Kucik for their time, support and expertise during
the pre study interviews. Last, but certainly not least, I owe a debt of gratitude to Dr.
Philip Lumb, Chairman, Department of Anesthesiology, Keck School of Medicine at the
University of Southern California for his support and encouragement during this process.

iv

TABLE OF CONTENTS
Dedication ii

Acknowledgements iii

List of Tables vi

List of Abbreviations vii

Abstract x

Chapter 1: Introduction and Review of the Literature 1
Statement of the Problem 1
Purpose of the Study 4
Research Questions 5
Review of the Literature 6
Current Method of Training 6
Limitations to Current Method of Training 7
Expertise 8
Expertise in Medicine and Nursing 10
Expertise in Anesthesiology 11
Types of Knowledge 14
Declarative Knowledge 15
Procedural Knowledge 17
Conditional Knowledge 19
Conditional Knowledge in Medicine 20
Automaticity 22
Automaticity and Expert Recall 23
Expert Recall in Medicine 24
Expert Recall in Anesthesia Practice 26
Cognitive Task Analysis 27
CTA Technique 28
CTA Methodology 28
Effectiveness of CTA 30
Effectiveness of CTA for Instructional Content 31
Effectiveness of CTA in Healthcare Training 32
CTA in Anesthesiology 36
The Current Study 39

Chapter 2: Method 41
Pre Study Curricular Development 41
CTA Instructional Content Procedure 42
The Experimental Study Design 46
Figure 1: Study Flow and Timeline 46
Participants and Recruitment 46
v

The Study Procedure 48
Data Analysis 51

Chapter 3: Results 56
Pretest of Declarative Knowledge 57
Posttest of Declarative Knowledge 57
Procedural Performance 58

Chapter 4: Discussion 63
Question 1 65
Question 2 66
Limitations 67
Participant Performance Anxiety 69
Simulation Laboratory 70
Conclusion 73

Glossary of Terms 74

References 78

Appendices 89
Appendix A: CTA Coding Scheme and Procedure 89
Appendix B: CTA Gold Standard for Postoperative Tracheal Extubation 90
Appendix C: Job Aid for Experimental Instruction Faculty 106
Appendix D: METI® High Fidelity Human Patient Simulator 118
Appendix E: Study Consent 119
Appendix F: Participant Demographic Data Survey 123
Appendix G: Declarative Pretest 124
Appendix H: Instructor Scenario 126
Appendix I: Experimental Lesson Script 127
Appendix J: Student Evaluation Scenario 138
Appendix K: Skills Performance Checklist 139
Appendix L: Declarative Posttest 143
Appendix M: Statistical Tables for Participant Data 145

vi

LIST OF TABLES
Table 1: Study Analyses 54
Table 2: Demographics on Students‟ Prior Extubation Experience 56
Table 3: Question 1, Declarative Pretest, Means Comparison 57
Table 4: Question 1, Declarative Posttest, Means Comparison 58
Table 5: Question 2a, Procedural Performance, Task Accuracy 59
Table 6: Question 2b, Procedural Performance, Task Expediency 60
Table 7: Question 2c, Procedural Performance, Subtask Sequencing 61
Figure C-1: Adult Postoperative Extubation Task List 106
Table I-1: Experimental Lesson Overview 127
Table K-1: Evaluation Simulation Lab Scenario Checklist 140
Table M-1: Declarative Pretest Overall Groups 145
Table M-2: Declarative Posttest Overall Groups 146
Table M-3: Procedural Performance, Overall Control Groups 147
Table M-4: Procedural Performance, Junior Students 148
Table M-5: Procedural Performance, Expediency, Junior Students 149
Table M-6: Procedural Performance, Expediency, All Students 150
Table M-7: Procedural Performance, Correct Sequence, Experimental Students 151
Table M-8: Procedural Performance, Correct Sequence, Control Students 152
Table M-9: Procedural Performance, Correct Sequence, All Students 153
Table M-10: Procedural Performance, Correct Sequence, All Junior Students 154
Table M-11: Procedural Performance, Correct Sequence, All Senior Students 155
Table M-12: Correct Sequence, All Seniors versus All Juniors 156

vii

LIST OF ABBREVIATIONS
AA Anesthesiologist Assistant
ABG Arterial Blood Gas
ACLS Advanced Cardiac Life Support
ACT Adaptive Character of Thought
ACT-R Adaptive Character of Thought-Rational
ACT Anesthesia Care Team
ADU Anesthesia Delivery Unit
ANTS Anaesthesia Non Technical Skills
APL Adjustable Pressure Limiter
ASA American Society of Anesthesiologists
BIS Bispectral Index Monitor
BP Blood Pressure
CDM Critical Decision Method
CPP Concepts, Processes and Principles
CRNA Certified Registered Nurse Anesthetist
CTA Cognitive Task Analysis
CVC Central Venous Catheter
DM Diabetes Mellitus
ECG Electro Cardiogram
ETCO2 End Tidal Carbon Dioxide
ETT Endotracheal Tube
GAETT General Anesthesia with Endotracheal Tube
viii

GERD Gastro Esophageal Reflux Disease
GS Gold Standard
HOB Head of Bed
ID Instructional Design
IRB Institutional Review Board
IV Intravenous
IRR Inter Rater Reliability
KKE Kären Kim Embrey (Nurse Anesthetist SME)
LMA Laryngeal Mask Airway
LPM Liters per Minute
MAC Minimal Alveolar Concentration
METI® Medical Education Technologies Incorporated
NA Nasal Airway
NICU Neonatal Intensive Care Unit
NMB Neuromuscular Blocking
NRE Non Routine Events
NTS Non Technical Skills
O2 Oxygen
OA Oral Airway
OR Operating Room
OR 13 Simulation Laboratory
OSA Obstructive Sleep Apnea
PACU Post Anesthesia Recovery Room
ix

PNA Program of Nurse Anesthesia
PPV Positive Pressure Ventilation
RR Respiratory Rate
RRC Residency Review Committee
SME Subject Matter Expert
SPSS Statistical Package for the Social Sciences
SRNA Student Registered Nurse Anesthetist
SV Spontaneous Ventilation
SIMV Synchronized Intermittent Mandatory Ventilation
TOF Train of Four
TV Tidal Volume
VRE Ventilator Related Events

x

ABSTRACT
Cognitive task analysis (CTA) is a knowledge elicitation technique employed for
acquiring expertise from domain specialists to support the effective instruction of
novices. CTA guided instruction has proven effective in improving surgical skills
training for medical students and surgical residents. The standard, current method of
teaching clinical skills to novices in medical and nursing specialties, including
anesthesiology, relies on recall-based instruction from domain experts. This method of
instruction is limited by task automation in the expert practitioner. Automated
knowledge eludes conscious access and impedes explication of comprehensive essentials
for task execution. CTA guided instruction maximizes declarative and procedural
knowledge gains in the novice by explicating the necessary equipment, performance
objectives, conceptual knowledge, procedural knowledge and performance standards
employed when experts execute a particular task. This study employs CTA elicited
expertise in the instructional content of an anesthesia practice task, adult postoperative
tracheal extubation to 13 junior and senior nurse anesthesia trainees. The declarative and
procedural knowledge gains of these students were compared to those of 12 junior and
senior nurse anesthesia trainees who received standard recall-based instruction on the
same anesthesia task. The study results indicate that CTA-based instruction has a
positive and significant effect on procedural knowledge gains in the novice anesthetist as
well as the trainee with higher levels of prior knowledge. There were no significant gains
in declarative knowledge following either CTA or conventional recall-based instruction
on this task for either junior or senior students. Implications for future CTA guided
instruction in anesthesia training and the study limitations are discussed.
1
CHAPTER 1: INTRODUCTION AND REVIEW OF THE LITERATURE
Statement of the Problem
A critical decision in anesthesia practice, and one which carries implications for
both patient safety and efficiency of care delivery, is the decision to perform
postoperative tracheal extubation following general anesthesia (Karmakar &Varshney,
2008; Miller, 1994; Rudra & Chatterjee, 2006; Weinger & Slagle, 2002). Postoperative
tracheal extubation, the removal of the breathing tube from the larynx at the end of
surgery, is performed to allow the patient to resume respiration via the normal anatomical
airway when mechanical ventilation or an artificial airway is no longer required. Adverse
respiratory events in anesthesia comprised 34% of all closed claims in the 1990 American
Society of Anesthesiologists (ASA) database of reported specialty adverse outcomes
(Caplan, Posner, Ward, Frederick, & Cheney, 1990). Despite comprising seven percent
of the 522 respiratory complication claims in this report, unintended or premature
extubation of the trachea and complications associated with extubation have received
relatively little attention in the anesthesia literature (Asai, Koga, & Vaughn, 1998; Miller,
Harkin, & Bailey, 1995). This finding is especially relevant as respiratory complications
following extubation are three times more common than those occurring with intubation
and induction of anesthesia (Karmarkar &Varshney, 2008).
In the US, anesthesia services are provided independently by a sole professional
such as an anesthesiologist or certified registered nurse anesthetist (CRNA) or by a
combination of anesthesia professionals working together on an anesthesia care team
(ACT). ACTs often include members who are trainees or sometimes individuals trained
as anesthesiologist assistants (AAs). The dynamic complexity of the anesthesia
2
workflow has often been compared to that of aviation (Gaba, Howard, Fish, Smith,
&Sowb, 2001; Gaba, Singer, Sinaiko, Bowen, & Ciavarelli, 2003; Hardman & Moppett,
2010; Hart & Owen, 2005; Kurrek & Fish, 1996; Toff, 2010). Similarly, the highly
coordinated and skilled efforts of the members of an ACT have been compared to those
of a flight crew (Gaba, 2010; Sexton, Thomas, & Helmreich, 2000; Helmreich & Davies,
1996). In line with these aviation parallels, the periods of takeoff, cruising and landing
have been respectively compared to anesthesia induction, maintenance and emergence.
These are the critical periods, during which hypnosis, immobility and analgesia are
induced in the patient, maintained for surgical intervention, and then tapered or reversed
at the culmination of the surgical procedure.
Many procedures in the domain of anesthesia care delivery are complex tasks.
Complex tasks are those that integrate the use of both controlled (conscious, conceptual)
and automated (unconscious, strategic or procedural) knowledge (Van Merriënboer,
Clark, & de Croock, 2002). Postoperative tracheal extubation is a complex task that
requires the deployment of both declarative and procedural knowledge. Effective
instruction of this high-risk task must necessarily then incorporate the conscious,
conceptual components of task execution as well as the unconscious, procedural and
strategic components essential for safe task execution.
While clinical faculty and instructors of anesthesiology typically demonstrate
expertise in these skills, their abilities to teach these procedures to novices may not be
optimized. A lack of information transfer may result from the automated knowledge and
skills of these experts as a result of years of fluid practice. Research suggests that experts
may omit up to 70% of critical action and decision steps when describing how to perform
3
complex tasks (Feldon& Clark, 2006). Such omissions in knowledge transfer confound
clinical education and practice in many healthcare fields (Clark, Pugh, Yates, Early, &
Sullivan, 2008; Yates, Clark, & Sullivan, 2011) and may carry significant patient safety
and fiscal consequences for healthcare institutions.
Advances in cognitive science may offer a solution to the problem of procedural
and declarative knowledge transfer from experts to novices through the application of
Cognitive Task Analysis (CTA) methods. CTA provides a systematic approach for
capturing the knowledge and skills experts use during the execution of complex tasks.
When incorporated into training, the application of CTA elicited expertise, may offer an
improvement over conventional clinical instruction methods that primarily rely on expert
recall (Campbell et al., 2011; Yates, Clark, & Sullivan, 2011). CTA methods can
facilitate the capture and transfer of declarative knowledge, the “what,” and critical
procedural knowledge, the “how to,” required by novices learning complex tasks, such as
postoperative extubation. In general, the goals of CTA are to capture and catalogue, from
multiple subject matter experts (SME), the necessary equipment, performance objectives,
conceptual knowledge, procedural knowledge and performance standards employed
when experts execute a particular task, to define the “gold standard” of practice in a
particular skill set (Clark et al., 2008).
CTA has been used effectively to capture expertise in nursing (Crandall &
Getchell-Reiter, 1993), medical and surgical educational environments (Clark et al.,
2011; Crandall & Gamblian, 1991; et al., 2008; Sullivan et al., 2008; Velmahos,
Toutouzas & Sillin, 2004; Yates, Sullivan, & Clark, 2011) including critical care (Fackler
et al., 2009) and anesthesiology (Segall, 2006; Weinger& Slagle, 2002). Moreover,
4
CTA-based training has been shown superior to standard methods of clinical education in
medicine and surgery (Campbell et al., 2011; Sullivan et al., 2008; Brown & Peyre,
2007; Velmahos, Toutouzas & Sillin, 2004; Yates, Sullivan, & Clark, 2011), which are
disciplines that have historically relied on free recall during clinical instruction.
A review of the literature revealed very few studies employing CTA to examine
the discipline of anesthesiology. The studies located using the search term “cognitive
task analysis and anesthesiology” addressed human factors as they relate to the high risk
clinical decision making processes in this specialty (Segall, 2006; Weinger& Slagle,
2002). Only one study employing CTA to specifically explore postoperative extubation
was located (Weinger& Slagle, 2002).
Purpose of the Study
The purpose of the current study was to evaluate the effectiveness of CTA guided
instruction compared to conventional clinical instruction for the anesthesia task of adult
postoperative tracheal extubation. This study examines the generalizability of the results
of conducting and applying CTA to training in anesthesia practice by replicating the
methods used by Tirapelle (2010), which examined CTA guided instruction of open
cricothyrotomy to surgical trainees. Specifically, the current study compares CTA
guided instruction on adult postoperative tracheal extubation to conventional clinical
instruction delivered to student registered nurse anesthetists (SRNAs). Though CTA was
employed to design the instructional intervention in this inquiry, the primary focus of the
current study was to examine the differences in student performance between the two
instructional models. The experimental instructional model was guided by the
information elicited through the application of Clark‟s (2004, 2007) CTA methodology
5
and the control model consisted of standard clinical instruction on the task. This study is
important as it contributes to the body of existing evidence regarding the effectiveness of
using CTA to capture medical expertise to improve clinical training. Moreover, this
work adds to the body of evidence comparing the effectiveness of CTA guided
instructional methods to current, standard recall-based methods of instruction in
medicine, specifically nurse anesthesia training in the domain of anesthesiology.
Research Questions
The following research questions framed this study.
1. Do participants in the experimental group demonstrate greater declarative
knowledge on postoperative tracheal extubation than participants in the control
group, as measured by pre and posttests?
2. Do participants in the experimental group demonstrate greater procedural
knowledge in performing postoperative tracheal extubation than participants in
the control group, as measured by procedural checklist? This research question
was further divided to explore measures on task accuracy, timing for task
completion and the correct sequencing of subtasks within the main task.

6
REVIEW OF THE LITERATURE
Two essential areas of focus in healthcare delivery today are cost control
(Mongan, Ferris, & Lee, 2008; Orszag & Ellis, 2007) and patient safety (Gaba, 2010;
Gupta & Divekar, 2010; Kohn, Corrigan, & Donaldson, 1999; Leape & Berwick, 2005;
Wachter, 2010; Weinger& Slagle, 2002). To this end, healthcare practice and healthcare
education must incorporate processes to ensure optimal patient safety and optimal
provider education through cost effective measures. As a high stakes, high cost entity;
anesthesia care delivery is perhaps the quintessential platform to discuss patient safety
and the importance of effective practitioner education.
Current Methods of Training in Anesthesiology and Nurse Anesthesia Education
Among the current approaches employed for the clinical instruction of skills in
the education of physicians and other practitioners in the operating room (OR) is the
century old surgical apprenticeship method wherein practice is first observed and then
emulated under supervision by an expert (Halstead, 1904). Over the last two decades this
method has been supplemented by the use of skills labs and simulation training which
continues today in part due to the Residency Review Committee‟s (RRC) mandate on
skills training curricular in all surgical training programs (Scott et al., 2008). Today,
high-fidelity simulation employs life sized mannequins, trained facilitators and
sophisticated software in a setting that allows for additional clinical practice of skills
without the adverse patient risks and accompanying liability of the OR. Simulation has
been employed successfully to teach and assess the skills of anesthesia residents,
students, CRNAs and practicing physician specialists (Henrichs et al., 2009; Murry,
Boulet, Kras, McAllister, & Cox, 2005).
7
Tacit knowledge in medicine or nursing has often been referred to as the “art” of
the disciplines. When this art is coupled with the exact knowledge or the “science” of the
domain, the united realms comprise an inexact discipline (Patel, Archoa, & Kaufmann,
1999; Shortliffe & Buchanan, 1975) that skillfully connects the bench to the bedside.
Comprehensive clinical instruction must then unite both the art and science of a specialty
to incorporate the overt and tacit elements of care delivery. While many efforts to
address safety in healthcare delivery have been undertaken recently, far fewer initiatives
addressing optimal clinical instruction have been proposed (Rodriguez-Paz et al., 2009).
Limitations to current method of training. Given the increased focus on safety
in healthcare delivery and given that residents and students are practicing on real patients
in the OR, the Halstead (1904) apprenticeship model may have restricted application
today. Moreover, this method is limiting, in that exposure to skills in the clinical setting
is dependent upon the opportunity to practice skills when procedures are available, and
when they are medically warranted and ethically justifiable. Furthermore, taking
advantage of opportunities to practice skills on real patients may hinge on whether the
trainee feels comfortable or safe (Rodriguez-Paz et al., 2009) having only minimal
familiarity with the technique to be employed.
The use of simulation training has been suggested as a means to ameliorate
limitations to skill exposure resulting from the 2003 mandatory reduction in resident
work hours (Scott et al., 2008) and similar proposed constraints on student nurse
anesthetist (SRNA) clinical training hours. Effective instruction using simulation
necessarily incorporates oversight by experts in the specific domain to design and teach
scenario content for clinical training and to provide timely, credible performance
8
feedback to trainees. However, a major problem with instruction by experts is that
experts may unintentionally omit up to 70% of the necessary information when teaching
what novices must master to perform a procedure adequately (Canillas, 2010; Chao &
Salvendy, 1994; Clark et al., 2011; Hoffman, Crandall, & Shadbolt, 1998). Such
omissions confound knowledge transfer and adversely affect instructional outcomes
(Clark, Pugh, Yates, Early, & Sullivan, 2008; Clark et al., 2011). This propensity for
experts to omit critical information during instruction may be better understood by the
following discussion on expertise.
Expertise
Expertise has been studied in a variety of domains from the sciences and medicine
to the arts, music, sports and chess, albeit the nature of expertise has undergone
considerable debate (Ericsson, 2004a, 2005; Feldon, 2007) over the years since Galton
(1869/1979) first attempted to explain exceptional performance. Today educational
psychologists generally agree that expertise develops after a minimum of ten years in a
specific domain, during which an expert acquires skills and knowledge essential for
consistently superior performance and complex problem solving in that domain
(Bransford, Brown, & Cocking, 1999; Chi, 2006; Ericsson, Krampe, & Tesch-Römer,
1993; Feldon& Clark, 2006; Kirschner, Sweller,& Clark, 2006). Experts excel in
solution generation, cue and pattern recognition and routinely spend significant time
considering problems qualitatively (Chi, 2006). Experts typically possess superior self-
monitoring skills and are able to gauge their own understanding and comprehension as
well as select appropriate strategies for problem solving, while outperforming others in
domain relevant knowledge retrieval (Chi, 2006).
9
Expertise has been differentiated from experience in a domain, in that expertise
develops, not simply as a result of prolonged exposure, but rather from deliberate practice
(Ericsson, et al.,1993; Ericsson, 2004b) or orchestrated, continuously challenging
engagement in that specific domain. Following sustained and challenging engagement,
performance and knowledge automate in the expert (Anderson, 1996; Clark & Estes,
1996), and become largely unconscious. As a result of this automaticity, experts may not
purposefully or consciously access their knowledge (Ericsson, 2004b) during instruction
or performance and they are often unaware of how much they omit when simply relying
on recall (Sullivan et al., 2008). Experts also typically have difficulty articulating their
tacit knowledge via concrete answers for others (Chi, 2006). Moreover, experts may err
toward over confidence, underestimate the abilities of novices, gloss over facts by
omitting details, rely heavily on domain specific cues for recall and lack flexibility when
the context or setting of practice varies from the routine (Chi, 2006).
Chi (2006) further describes this lack of flexibility as a “functional fixedness”
which predisposes the expert to bias resulting from automated knowledge which escapes
conscious scrutiny. Ericsson (1998) asserts that this automation of knowledge is in fact
the nemesis of continued expertise development. This is because the development of
expertise is dependent on conscious concerted effort (Ericsson, 2004b) not just routine
repeated engagement. Thus the process of knowledge automation or unconsciousness
associated with repeated routine practice in a domain stifles further development of
expertise (Ericsson, 2004b). Feldon (2007) suggests that true expertise is adaptive and
subject to facilitation. This adaptive nature of expertise allows the expert to capitalize on
the automaticity of a large portion of routine elements of knowledge or performances,
10
which unburdens the conscious resources to solve novel or particularly challenging
problems (Feldon, 2007). Indeed, Ericsson (1998) has defined the quintessence of
expertise as the ability to adapt effectively to unexpected, uncharacteristic or novel
situations.
Expertise in Medicine and Nursing
Feldon (2004) informs us that expertise in general is under-defined. In contrast to
domains like sports, chess, the arts and music, most studies examining expertise in
medicine and nursing define expertise via peer nomination, through social recognition of
exemplary performance or credit for years of experience (Ericsson, 2004a, 2007).
Examining empirical evidence both supporting and refuting this notion of presumed
congruence between socially recognized expertise in medicine and performance may be
beneficial. Ericsson (2004a) found that diagnostic capabilities were no more accurate for
peer identified “experts” than for “average” physicians and that indeed crediting
superiority in treatment outcomes to a single expert would be almost impossible to
demonstrate. Assignment of such credit would not be possible, owing to the complexities
of individual patient differences and the fact that at least some of the variance in patient
outcomes results from team, not individual effort. Similarly, an examination of superior
patient outcomes linked to nursing level of education and expertise demonstrated a
relationship between higher level of education and favorable patient outcomes
(Estabrooks, Midodzi, Cummings, Ricker, & Giovannetti, 2005). However, these
improvements in patient outcomes may also have resulted from enhanced nurse-physician
collaboration and communication (Estabrooks, Midodzi, Cummings,
Ricker,&Giovannetti, 2005).
11
Automaticity may be both a hallmark and limitation of expertise in the domain of
medicine (Chi, 2006). Experts in medicine may be disadvantaged by their extensive
knowledge in a particular discipline, inasmuch as their abilities to employ creative
thinking may be limited by inflexibility (Chi, 2006). For example, experts may be
particularly prone to diagnoses bias during consultation. During case assessment, experts
when compared to novices, tended to generate hypotheses that supported diagnoses in
their particular domain of expertise, despite the type of specialized case presented (Chi,
2006). Ericsson et al., (1993) assert that this performance automaticity must constantly
be counteracted through feedback and a quest for continuous performance improvements
by experts. Chi (2006) and Ericsson‟s (Ericsson et al., 1993) findings demonstrate both
the complexities and limitations of expertise in medicine and nursing and elucidate the
importance of structured, systematized expertise elicitation techniques for accessing and
employing the unconsciously automated knowledge of experts for the instruction of
novices. For example, in a pair of studies aimed at eliciting nursing expertise from
experienced neonatal intensive care (NICU) nurses, Crandall and Getchell-Reiter (1993)
were able to facilitate expert nurses‟ access to the unconscious cues they commonly
employed in detecting early signs of sepsis in neonates. Through the use of an expertise
elicitation technique, the researchers and NICU experts ultimately generated a
comprehensive training tool for novice NICU nurses. This instructional tool incorporated
the cluster of previously covert but critically important cues which had evolved
unconsciously over many years in the expert nurses.
Expertise in Anesthesiology. Expertise in any domain, including anesthesiology,
is context specific. In anesthesia practice, expertise is reflected largely by the aptitude for
12
contemporaneous assessment and management of dynamic parameters from many
streams of information. Expertise in this domain requires both explicit and tacit
knowledge (Smith, Goodwin, Mort, & Pope, 2003). Explicit knowledge represents facts
that are unambiguous (Dienes & Perner, 1999); this type of knowledge is overt and easily
communicated. The term, tacit knowledge, has been much misunderstood and
misquoted, but it essentially refers to knowledge that bridges the knower and the known
explicit facts of skills (Tsoukas, 2003). In anesthesiology, tacit knowledge has a specific
definition. Polanyi (1962), first described the term “tacit knowledge” and held that this
type of knowledge, which is difficult to articulate, is subsidiary to, as well as integrated
with, the explicit knowledge necessary for task performance. Though Polanyi did not
specifically use this term with regard to anesthesiology, he did use the term in the context
of medical skill acquisition. He expressly conveys that tacit knowledge is subsidiary to
skill acquisition and not the object of attention (Polanyi, 1962). Tacit knowledge
supports explicit knowledge in the same way that peripheral vision helps us put into
context what we are directly focusing on. As such, if we take our eyes off of the object
of focus, to pay heed to the peripheral or tacit components during task execution, we risk
losing perspective on the goal. The intangible or ethereal nature of tacit knowledge is
largely responsible for its misunderstanding. An example of how tacit knowledge is
responsible for connecting the knower and the known is illustrated by the master
swimmer, who knows she can swim, and trusting this knowledge, dives into the deep end
of the pool, knowing she will float, though she may have no idea how she does this
(Polanyi,1962).
13
In a qualitative study that called for expert anesthesiologists to acknowledge the
tacit knowledge they employ when communicating to trainees, Smith, Pope, Goodwin
and Mort (2005) describe common ground on which medicine and other domains of
expertise overlap. The inquiry specifically examined the types of knowledge employed
by experts in anaesthesia, overt, explicit knowledge and tacit knowledge, which is less
easily codified and must be transferred through personal interaction (Smith et al., 2003,
2005). Tacit knowledge, typically transmitted by observation in anesthesia practice, is
germane to the apprenticeship model of training. Experts in anesthesiology additionally
rely heavily on overt, evidence based explicit knowledge, such as is found in professional
standards, textbooks, and peer reviewed publications and algorithms. A significant
marker of expertise in the domain of anesthesiology however, is the ability to discern
when to diverge from these explicit forms of knowledge. The aptitude for complex
problem solving in anesthesia practice may be based on years of prior experience and the
capacity to tailor interventions to the patient‟s specific needs in the current context
(Smith et al., 2003). This ability to strategize in response to dynamic events, more likely
employs tacit, rather than overt knowledge (Smith et al., 2003). Disadvantages of tacit
knowledge are that it is less easily accessed and less likely articulated to trainees (Smith
et al., 2003). Tacit knowledge in anesthesia practice has been termed ANTS, anaesthesia
non technical skills (Fletcher et al., 2004) or simply NTS (non technical skills) by Gupta
and Divekar (2010). Tacit knowledge has historically received little attention in
anesthesia training; Gupta and Divekar (2010) assert that residents have been expected to
gain certain non explicit knowledge by “osmosis.” To further elucidate the nature of how
expertise is developed we must first understand the ways in which knowledge is acquired.
14
Types of Knowledge
In his Adaptive Character of Thought (ACT), a unified theory of cognition,
Anderson (1996) has proposed how new human competencies are acquired through
interactions between declarative and procedural knowledge. These interactions give rise
to complex cognition. Declarative knowledge represents knowledge of why or that
something is, while procedural knowledge is knowledge about how and when something
occurs (Clark & Estes, 1996). Anderson (1996) asserts “all that there is to intelligence is
the simple accrual and tuning of many small units of knowledge that in total produce
complex cognition. The whole is no more than the sum of its parts, but it has lots of
parts” (p. 356). These “parts” of cognition necessary for complex learning are represented
by declarative knowledge encoded in “chunks” of knowledge and procedural knowledge
encoded in units which Anderson (1982,1996) termed “production rules.”
Encoding is the term applied to the acquisition of knowledge, either declarative or
procedural. Chunks of declarative knowledge and production rules of procedural
knowledge facilitate the efficient deployment and manipulation of knowledge.
Both declarative and procedural knowledge are necessary for the execution of
most cognitive tasks (Clark, 2008) and most individuals are capable of developing these
types of knowledge about any given exemplar. An individual may however possess only
one type and not the other with regard to a specific situation (Clark & Estes, 1996). For
example, a healthcare professional may possess the declarative knowledge about what is
important to document with regard to her patient‟s physical exam. However this same
professional may lack the procedural knowledge to accomplish this task on the
department‟s new electronic medical record. Conversely, a trainee in the same discipline
15
may navigate the electronic medical record fluently, yet lack the declarative knowledge
of what physical exam findings are important to include in her documentation. Hence the
process of complex human cognition arising from interactions between declarative and
procedural knowledge is a dependent one. This process of dependency involves both the
quantity and effective contextual deployment of encoded chunks of knowledge
(Anderson, 1996). During complex thinking, interactions between declarative and
procedural knowledge occur in specific sub-steps or through target specific hierarchical
structure (Anderson, 1987). To further clarify these knowledge types and their
interactions in complex thinking, a discussion on declarative and procedural knowledge
follows. The discussion also covers a specific sub-type of procedural knowledge known
as conditional knowledge (Paris, Lipson, &Wixson, 1983).
Declarative Knowledge
Declarative knowledge is overt and comprised of knowledge about facts, events
and objects or “why or that” something is (Clark& Estes, 1996, p. 3). This is the type of
knowledge employed when one thinks about or recalls facts or data. Miller (1956) first
described the limitations of active memory and noted that accuracy of data recall was
inversely related to amount of data presented. He defined the span of immediate recall as
seven, plus or minus two but went on to describe how smaller units of data could be
grouped to make larger units of data, in the same way that letters make up words and
words make up sentences and paragraphs. Miller‟s early propositions have since
undergone much consideration in cognitive science. Today we understand that this
critical number of concepts, allowing the bottle neck of information recall to be stretched
through a process of long term memory associated chunks of information, is probably
16
closer to four (Cowan, 2000) than seven. Merrill (1983) describes how facts chunked
into concepts, processes and principles comprise the units of declarative knowledge
acquisition. Declarative knowledge is readily acquired, adapted, accessed and explicated
owing to its rapid and conscious availability (Anderson, 1983; Clark & Estes, 1996).
This knowledge type may take the form of imagery, sequences or propositions (Anderson
&Fincham, 1994). Declarative knowledge serves as a nidus for the formation of
procedural knowledge, such as might be necessary for novel problem solving (Anderson,
1983, Clark & Estes, 1996) or the understanding of one‟s own performance (Schraw,
1998).
Alone, declarative knowledge does not effectively generate performance (Clark,
Feldon, van Merriënboer, Yates, & Early, 2008), though it provides the necessary
foundational knowledge for skill acquisition because the facts of declarative knowledge
equate to the “instruments” for productions (Anderson, 1982). When an individual first
acquires information about a skill, it is in the form of declarative knowledge (Anderson,
1982). The acquisition of declarative knowledge in a challenging, novel paradigm may
require concerted conscious effort, but as this knowledge is more frequently accessed,
and the more it is perceived as functional and successful knowledge (Anderson, 1996) it
automates, becoming effortless thus freeing up conscious capacity for other more taxing
demands (Clark, 1999). This is not to say that declarative knowledge becomes
unconscious, it remains consciously recognized and controllable (Clark, 2010).
However, the productions that declarative knowledge helps facilitate, become non
conscious and automated. Declarative knowledge, knowing why or that something is,
17
paves the way for and supports the acquisition of the how and when something is of
procedural knowledge.
Procedural Knowledge
Procedural knowledge can be acquired though instruction or generated through
repeated encounters (Paris et al., 1983). This knowledge type is goal specific and
production oriented (Corbett & Anderson, 1995). As such, this knowledge is employed
to execute procedures or possible behaviors that an individual can select from when
performing tasks (Paris et al., 1983). During knowledge compilation, procedural
knowledge develops from the merger of performance and domain specific declarative
knowledge, or facts that support the new procedural process (Anderson, 1982). As new
procedures are encoded into productions, which are units that Anderson (1996) defines as
rule bound procedures aimed at goal achievement; these productions are repeated until
procedural knowledge becomes automatic. Productions or units of procedural knowledge
are the building blocks of skill acquisition and the condition-action units through which
procedural problems are addressed (Anderson, 1987). These condition-action units are
additionally hierarchically structured into goals and sub goals (Anderson & Schunn,
2000). These goals and sub goals are rule bound processes which occur through
“IF…THEN” couples (Anderson, 1983) of prerequisites and their consequences. An
example demonstrating hierarchy in prerequisites and consequences of structured goals
and sub goals, is adding the ones column in a math problem, before adding the tens
column (Anderson, 1982).
The acquisition of procedural knowledge depends on both a situation in which a
goal or problem solution is sought and prior or present exposure to an analogous goal
18
solution which can then be emulated (Anderson & Schunn, 2000) for the current problem
resolution. Thus the building of procedural skills, through past problem reference and
current problem engagement, illustrates that the acquisition of procedural knowledge
depends on understanding examples and moreover, by active participation and reflection
(Anderson & Schunn, 2000). This active participation in problem solving becomes rapid
and successful over time, resulting in knowledge fluency. Hence, over time and with
repeated engagement, procedural knowledge becomes implicit, covert and less accessible
to the conscious mind as it becomes more rapidly automated (Clark, 1996) toward goal
achievement.
Most cognitive tasks are complex enough to require both conscious and automatic
elements (Bargh, 1989), albeit IF...THEN strategies may not always involve conscious
endeavor. Indeed, cognitive science has demonstrated that many if not most mental
processes occur without conscious engagement (Bargh, 1989; Bargh & Chartrand, 1999;
Frith, 2002; Shiffrin & Schneider, 1977; Wegner, 1994, 2002). Rather, these processes
occur via the deployment of an “autopilot” mode (Bargh & Chartrand, 1999) that
ameliorates the cognitive workload during complex mental functions (Anderson, 1983,
1993;Bransford et al., 1999; Stefanidis, Scerbo, Korndorffer, Daniel, & Scott, 2007;
Sweller, 2006). These automatic processes ensue after repeated task sequences have been
triggered by familiar preceding environmental cues supporting the need, ability, desire or
opportunity (IF…) to initiate an action. Over time, cue-perception-response processes
become involuntary, facilitating efficient and habitual deployment of sequences toward
task (THEN) completion (Bargh & Chartrand, 1999; Moors & De Houwer, 2006).
Through recurrent and consistent triggering of the IF...THEN sequences, a synthesis of
19
both the external events and an internal processes ensues (Shiffrin & Schneider, 1977;
Schneider & Shiffrin, 1977) resulting in seamless automation of cognition. An important
subtype of procedural knowledge that explains the strategic application of procedural and
declarative knowledge to achieve a desired task execution is conditional knowledge,
which Paris, Lipson and Wixson (1983) describe in their research on strategy
development in the domain of reading skills.
Conditional knowledge. Conditional knowledge, a subcategory of procedural
knowledge, reflects adaptive knowledge (Paris et al., 1983). This type of knowledge
facilitates strategic application of declarative and procedural knowledge for successful
task execution, when circumstances differ from the routine (Omrod, 2004). Simply put,
conditional knowledge is knowledge about why and when something is (Schraw, 1998) or
should be. As such, conditional knowledge guides decisions on when and when not to act
or execute a possible task consideration (Paris, et al., 1983). Conditional knowledge is
analogous to the internal process of metacognition, which is defined as thinking about
one‟s own thinking. Moreover, conditional knowledge reflects strategic deployment of
declarative and procedural knowledge to attain a goal (Paris, et al., 1983).
From a cognitive science perspective, Anderson‟s (1983) ACT-R (Adaptive
Control of Thought – Rational) theory, a hybrid theory for simulating and understanding
human cognition, combines symbolic, rule and fact knowledge with neural or mental
activity employed to make strategic decisions (Anderson &Schunn,2000). Anderson
(1991) describes that the accuracy of memory and rapidity of recall for task execution is
significantly improved though the application of categorization. Categorization is the
strategic application or skillful use of procedural knowledge to attain an outcome. These
20
strategic decisions can be mapped through IF-THEN situational or contextual steps of
goal structure which can be further sub-divided into sub goals. For example, IF the light
is green and there is no approaching traffic, and I wish to get to the other side, THEN it is
safe to proceed in crossing. This simple example illustrates that conditional knowledge is
not exclusively cognitive, but rather, combines ability and choice or “skill and will”
(Paris et al., 1983) to strategically complete a cognitive task. According to educational
psychologists, conditional knowledge is dependent on motives, choice or intent as they
relate to personal interest, perceived utility and efficiency of resource management (Paris
et al., 1983). Cognitive scientists however hold that conditional knowledge is deployed
from a purely logical conditional probability impetus, wherein choices are made to afford
an optimal outcome, given all possible outcomes. Anderson (1991) diverges slightly
from this purist view in his hybrid definition of this knowledge type. He argues for both
an internal and external trigger for the strategic deployment of conditional knowledge,
which incorporates contextual or environmental influences on choice. Educational
psychologists extend this premise further, and propose that conditional knowledge may
indeed be subject to manipulation and like declarative knowledge, may benefit from
carefully designed repetitious practice to improve mastery and rapidity of strategic
response (Forget & Gagné, 2003).
Conditional knowledge in medicine. A search of the current literature, using the
term “conditional knowledge and medicine” returned only a few relevant documents.
These writings primarily addressed the design of artificial intelligence, utilizing
conditional probability to facilitate medical decision making, clinical algorithms and
medical diagnoses (Shortliffe, 1975; 1986). The authors addressed phenomena in
21
familiar IF...THEN production rules of decision making steps as was seen in the
discussion above on Anderson‟s work. In his description of the Acquisition of Cognitive
Skills, though not specific to medicine, Anderson (1982) explains that during skill
acquisition, decisions generated by the transitions of propositions (facts) into productions
(procedures) are subject to rules. These rules include degrees of hierarchy and serial
deployment to improve discrimination, specificity and strength of production. The
factual, or declarative knowledge represents a decision step as represented by IF while
the production is represented by the THEN component. The THEN component
symbolizes an action, and as such illustrates the deployment of conditional knowledge.
This fact-to-action process described by Anderson, parallels the selective means of when
and when not to act, which in medicine is recognize as the pros and cons of action (Fox,
Johns, & Rahmanzadeh, 1998; Weed & Weed, 1999). This fact-to-action sequence is
also allied to situational awareness. Situational awareness is defined as “the perception
of the elements in the environment within a volume of time and space, the
comprehension of their meaning and the projection of their status in the near future‟‟
(Endsley, 1988 p.97). Using Anderson‟s (1982) IF...THEN model of processes, we see
that the THEN step represents a pro or an action and the IF component represents a non-
action (con) or simply a cue to make another decision (Shortliffe, 1986). As discussed
earlier in the section describing automation of procedural knowledge, we see that many
of these IF…THEN decisions escape conscious monitoring and occur rather via an
autopilot mode (Bargh & Chartrand, 1999) that allows for an attenuated cognitive
workload during complex mental functions (Anderson, 1983, 1993; Bransford et al.,
1999; Stefanidis, Scerbo, Korndorffer, Daniel, & Scott, 2007; Sweller, 2006).
22
Automaticity
Automaticity is the hallmark of routine (Smith et al., 2003) inasmuch as that
through repeated access and application, skill or knowledge becomes fluid and
unconscious. Once automated, skill deployment escapes conscious monitoring, is
remarkably rapid in execution and requires little in the way of cognitive expenditure
(Feldon, 2007; Mores & De Houwer, 2006; Stefanidis et al., 2007; Wegner, 1989, 1997).
An example of automaticity might be displayed by an expert pianist performing a well-
rehearsed masterpiece without conscious awareness of the execution of each keystroke.
This parsing of cognitive expenditure, characteristic of automaticity, facilitates the
availability of cognitive resources for other, more taxing demands, such as the unique
ability for complex problem solving that experts display (Bereiter & Scardamalia, 1993).
The conscious, metacognitive processes of conditional or strategic reasoning are
by conventional wisdom, the antithesis of automaticity. Automaticity epitomizes
knowledge fluidity, albeit this fluidity may be disrupted by purposeful conscious
engagement. Such disruption of fluidity might arise when cognitive load is increased as
one attempts to manage novel information, field multiple or conflicting streams of input
or during conscious and intentional self-monitoring (Wegner, 1989). Non conscious self-
monitoring may also disrupt the fluidity of automation. Wegner (1994, 1997) describes
an unconscious self-monitoring process which vigilantly scans during cognitive functions
for process errors. Under high cognitive load, emotional stress or time pressures, this
unconscious monitoring system, may ironically override conscious intentions. Such an
unconscious override may result in the execution of an action that is the opposite of that
which was intended. For example, a concert pianist might suffer a disruption of her fluid
23
performance if she suddenly becomes overly self-aware when an unexpected missed note
occurs in the string section.
In anesthesia practice, Smith et al. (2003) describe a comparable scenario which
may result when supervising faculty interrupt the knowledge flow of training anesthetists,
by disrupting the trainee‟s routines. Equally, faculty may experience disruptions in the
fluidity of automated knowledge from consciously deployed endeavors such as an
attempt to explain or instruct (Feldon& Clark, 2006; Feldon, 2007; Sullivan et al., 2008;
Weinger, Reddy, & Slagle, 2004) on procedures they typically execute unconsciously.
Automaticity and Expert Recall
During instruction in any given domain, subject matter experts are relied upon to
provide accounts and justification (Feldon& Clark, 2006; Feldon, 2007; Smith et al.,
2003) for the actions and processes of problem solving for the training of novices.
Exhaustive disclosure of strategies for problem solving is essential to the success of
effective instruction on problem solving (Taylor & Dionne, 2000). These efforts should
include exploring the scope of actions possible as well as the strategic employment
(Taylor & Dionne, 2000) of actions toward a desired end.
Research on experts‟ cognition, the accuracy of self-reports and free-recall
explanations to learners, indicates that expert recall is often fraught with erroneous
strategies and omissions (Clark et al., 2011; Feldon& Clark, 2006; Feldon, 2007).
Critical information omitted by experts may confound effective knowledge sharing. Such
critical information is defined as the procedural action (how to) and decision (IF...THEN)
steps of cognitive tasks. Employing expert instruction then presents challenges germane
to retrieving knowledge for training. These challenges arise because the automaticity of
24
knowledge occurs not only without effort but also without awareness of the process
(Bargh & Chartrand, 1999). The unconsciousness of automated knowledge
disadvantages the expert with regard to awareness and recall (Chao & Salvendy, 1994;
Crandall & Getchell-Reiter, 1993; Sullivan et al., 2008) of specific task details.
Following repeated practice, cognitive tasks become fluid and automatic and
subject matter experts are likely to become overconfident (Clark, 1999). This
overconfidence in ability to deploy strategies to solve problems is due to the ease with
which experts perceive task execution (Clark, 1999). This perception of task ease occurs
because the more often a task is executed, and the more often its deployment is perceived
as familiar and successful toward goal attainment, the less conscious awareness and effort
the individual is likely to assert during task execution (Clark, 1999). Hence, erroneous
processes are born of effortless processes that go unchallenged by the conscious mind.
What necessarily follows then is a precarious overconfidence, which may allow an
individual to miscalculate goals, employ faulty strategies and avert culpability or even
rebuff feedback (Clark, 1999). This scenario of overconfidence is particularly
troublesome in a high stakes, high cost setting such as healthcare delivery. There is
evidence to suggest that overconfidence may be moderated when feedback is accepted
(Clark, 1999). However, evidence suggests that errors in medicine are less likely to be
disclosed and are generally less well received when compared to admissions of error in
aviation (Hart & Owen, 2005; Sexton et al., 2000).
Expert recall in medicine. In a study examining the procedural instruction of
colonoscopy to second year post graduate residents, expert physician faculty neglected to
include 50% to 74% of procedural steps in the execution of the task and 57% to 75% of
25
the decision points during traditional teaching of the technique (Sullivan et al., 2008).
These omissions occurred despite faculty being informed that they would be observed
specifically for completeness of instructional content in these areas. Other recent studies
have examined the amount of critical information experts in medical education omit in
their descriptions of procedures. In a study examining the instruction of central venous
catheter (CVC) placement to surgical residents (Canillas, 2010), experts omitted an
average of 34% of the critical decision steps in this procedure and a further 73% of the
possible alternative decisions. Similarly, in their descriptions of open cricothyrotomy,
experts omitted a staggering 77% of the critical decisions in their narratives of this
procedure and omissions of the procedural steps totaled 61% (Crispen, 2010; Tolano-
Leveque, 2010). The omitted procedural steps included the information on “how” to
perform the task; those actions and decisions necessary for successful task execution.
The critical decisions omitted by these surgeons included information pertaining to
“when” steps should be taken. Such information is imperative for choosing from
alternatives as IF…THEN conditions arise. In yet another study examining expert
trauma surgeons‟ recall of critical information, Clark, Pugh, Yates, Early, and Sullivan
(2008) found that experts omitted 65% of the procedural steps necessary for femoral
artery shunt placement when describing this procedure. Results from yet another study
exploring expert surgeon recall on central venous catheter (CVC) placement were
significant for similar findings, albeit these were less compelling. This study (Canellas,
2010; Tolano-Leveque, 2010) demonstrated omissions of 30% of action steps and 35% of
decision steps during expert instruction on the procedure of CVC placement. These
significant, yet less vigorous findings of omission, for CVC procedural recall by experts
26
may reflect a higher degree of prior knowledge following recent requisite training on
CVC infection control or practice safety initiatives.
Expert recall in anesthesia practice. Anesthesiology is often regarded as the
quintessential medical discipline focused on patient safety and risk management
(Hardman & Moppett, 2010; Hart & Owen, 2005; Smith et al., 2003). Nonetheless, when
memory alone was relied upon during case preparation for non-emergency surgery,
experienced anesthesiologists in a simulation exercise demonstrated significant omissions
in procedural safety measures (Hart & Owen, 2005). These omissions occurred despite
level of expertise, an average of eight and a half years of experience, and despite the lack
of contextual exigency. Routine, non-emergency anesthesia practice is epitomized by the
concurrent processing of multiple streams of input and the deployment of cognitive tasks
in the monitoring and management of dynamic patient states. This cognitive workload is
significantly increased during non-routine (Byrne et al., 2010) or emergency states
(Weinger et al., 2002). Moreover, the significant cognitive demands of anesthesia
practice itself may confound situational awareness and knowledge activation, leading to
critical events in the operating room (Sowb & Loeb, 2002).
Clark (2010) makes a compelling argument for researchers and educators to
address the preponderance of tacit or implicit processes that reside outside of
consciousness, so as to adequately address a significant portion of learners needs.
Omissions in procedural knowledge, which are principally ignored in contemporary
education, are conspicuously overlooked in medical education (Smith et al., 2005). Tacit
elements of information are essential components for comprehensive knowledge
acquisition and as such must be accessed, identified, explicated and shared with trainees.
27
The imperative to utilize domain experts in the training of novices and the concomitant
challenges of accessing automated knowledge from these experts necessitates the use of
strategies that effectively capture the full spectrum of knowledge types that experts
employ when performing complex tasks.
Cognitive Task Analysis
Cognitive Task Analysis (CTA) techniques are employed to elicit knowledge in
order to delineate task rules and formulate highly accurate and exhaustive algorithmic
descriptions of challenging cognitive tasks (Clark et al., 2008). CTA endeavors are
typically intended to generate instructional materials, job aids, checklists or task
evaluation tools.
Cognitive task analysis arose as a necessary extension of early European task
analysis techniques employed for training industrial workers (Clark & Estes, 1996;
Schraagen, Chipman, &Shalin, 2000) in the 1800s. Such early task analysis formats
focused on what could be observed in task execution, largely omitting the cognitive or
decision processes of the unspoken or implied facets of task achievement. Moreover, as
organizational requirements evolved to include work that was more challenging, early
techniques proved insufficient (Clark & Estes, 1996; Gordon & Gill, 1997) for capturing
the complex nature of contemporary cognitive tasks (Wei &Salvendy, 2004). Thus a
broad umbrella of loosely defined knowledge elicitation techniques termed cognitive task
analysis evolved to meet the instructional demands of modern cognitive task
requirements. The following discussion is aimed at defining CTA and explaining its
application in effective and efficient instructional content design.

28
CTA Technique
Defining CTA. Cooke (1994) has defined many variations of contemporary CTA
techniques. These methods are employed to “...yield information about the knowledge,
thought processes and goal structures that underlie observable task performance,”
(Chipman et al., 2000, p. 3). In so doing, CTA allows for the identification, capture and
synthesis (Clark, Feldon, Van Merriënboer, Yates, & Early, 2006) of both the overt,
observable and covert cognitive functions (Chipman et al., 2000) associated with
performing a given task.
CTA methodology. CTA employs a variety of techniques which are targeted to
the specific type of knowledge being elicited (Clark et al., 2008). CTA techniques are
employed within a given domain to define gold-standards of performance which are ideal
for the instruction of novices. These techniques elicit knowledge and reveal psychomotor
actions of domain experts through methods perfected by cognitive psychologists (Cooke,
1999; Chipman et al., 2000). These methods define mental models and elucidate the
details of the intricate timing of decisions in complex cognitive tasks (Chipman et al.,
2000).
Various CTA methods include document review and analysis, observations of
performance and simulated performance, think aloud protocols, evaluations of the
disparity between novices and experts (Chipman et al., 2000) and various interviewing
formats. Interview formats include structured, semi-structured, unstructured individual,
group or panel interviews. Many CTA approaches employ multiple, overlapping or
sequential knowledge elicitation techniques to capture varied or rich perspective in a
given inquiry.
29
A CTA model proposed by Clark (2004, 2007), and the one employed for the
present study‟s instructional content, incorporates the concepts, processes and principles
(CPP) approach to capture the automated and tacit knowledge of experts involved in a
given cognitive task. The CPP model employs a series of semi-structured individual
interviews with a number of subject matter experts (SMEs) to capture the relevant
knowledge for accurate and efficient task execution. The interviews are intended to
capture all action and decision steps and to categorize all concepts, processes and
principles of the task and subtasks and to identify the initiating sequence for task
engagement and subtask hierarchies as well as to identify the cues, necessary equipment,
materials and sensory experiences preceding and occurring throughout subtask and task
execution. During the interviews, SMEs are asked to define or expose possible or likely
complications or problems. Such problems may range from simple to complex and
include the types of events that might arise frequently or only rarely during task
execution, but that should be mastered for accurate and efficient task execution.
Subsequently, the resulting captured data, including automated and tacit knowledge, is
revisited via repeated SME self and peer review analyses aimed at authenticating and
aggregating the elicited findings (Clark et al., 2008). Following these steps, a
comprehensive conceptual task outline or template for appropriate task execution is
generated from the combined and validated interview findings. The final task gold
standard, which also addresses all subtasks, reveals the spectrum of possible actions and
decisions (IF...THEN) necessary for accurate and efficient job completion. The gold
standard also includes crucial details about the conditions for and timing of decisions and
possible alternatives or considerations during task execution. The resulting synthesized
30
end product of the CTA process is then employed to underpin instructional content or
generate job aids, task performance or task evaluation criteria.
Effectiveness of CTA. Cognitive task analysis for the capture of expertise has
been successfully employed to guide effective instructional content in simulation training
and performance evaluation in the military (Hess, MacMillian & Serfaty, 1989) as well as
other disciplines (Chao &Salvendy, 1994; Clark, 2010; Feldon& Clark, 2008; Yates,
2007) including medicine, surgery (Clark et al., in press; Crispen, 2010; Tolano-Leveque,
2010; Sullivan et al., 2008; Velmahos et al., 2004) and nursing (Crandall & Getchell-
Reiter, 1993). CTA has also recently been employed to identify medical research
workflow and functional interactions employed in hypothesizing biomedical gene
product interactions (Mirel, Eichinger, Keller,&Kretzler, 2011) and to analyze key
cognitive activities and decision making processes in critical care medicine (Fackler et
al., 2009). CTA has also been employed in the discipline of anesthesiology to evaluate
the effects of clinical decision making processes on patient safety (Weinger& Slagle,
2002). Most recently, the effectiveness of employing a CTA guided curriculum in
medical training was demonstrated by Campbell et al., (2011), who employed a CTA
guided curriculum for medical students and second and third year post graduate surgical
residents performing a simulated cricothyrotomy procedure. The control group (n=14)
received conventional instruction on the procedure of open cricothyrotomy and the
experimental group (n=12) received a CTA guided curriculum on the same task. The two
groups were then evaluated using a 19 point checklist for skill performance and a 140
point self-appraisal tool. Both procedural performance and self-efficacy were
significantly improved in the group receiving the CTA guided instruction. The CTA
31
guided group produced a mean performance score of 17.75 (SD = 2.34) and a mean self-
appraisal score of 126.10 (SD = 16.90). These findings were compared to those of the
group who received standard instruction on open cricothyrotomy. The control group
produced a mean task performance score of 15.14 (SD = 2.48) and a mean self-appraisal
score of 110.67 (SD = 16.8). This study demonstrates that the CTA guided curriculum
was significantly more effective (p = 0.029) in increasing the performance and self-
efficacy of surgical residents and medical students performing the task of open
cricothyrotomy, when compared to conventional instruction for the task.
Efficiency of CTA for instructional content. CTA requires significant
resources, especially up-front time, effort and expertise; thus has been criticized as costly.
Instructional designers however must consider that “ by analogy, the more important the
training system one has to design, the more important becomes the up-front task analysis
on which it is based, no matter what its cost may be” (Schraagen, 2009, p. 169).
Chao and Salvendy (1994) found through knowledge eliciting techniques that the
acquisition of procedural knowledge could be doubled by interviewing one to six subject
matter experts with the optimal cost benefit ratio for knowledge elicitation being three
experts. The number three was defined as optimal with regard to effort-benefit ratio as it
was determined that subsequent SME interviews yielded less than 10% additional or new
data (Chao &Salvendy, 1994). Crispen (2010) demonstrated a knowledge gain from 56%
complete to 85% complete when he compared elicited knowledge from one CTA guided
interview to three CTA guided interviews with surgical experts describing the procedure
of cricothyrotomy. Moreover, the gains in knowledge from three CTA guided interviews
compared to one CTA guided interview, demonstrated improvements in information on
32
action steps from 66% to 93% and gains in decision step information increased from 28%
to 67%. More recently Clark et al., (2011) describe significant gains in knowledge
capture to improve instructional descriptions for the surgical task of femoral artery shunt
insertion following the use of a single CTA guided interview. The inquiry compared the
information elicited from one CTA guided expert interview to information elicited via
free recall and simulation aided recall from nine expert trauma surgeons. The single CTA
interview resulted in a more accurate and complete description of the procedure when
compared to the free recall of the nine other surgeons who omitted 68% of the necessary
information for task execution.
The efficiency of employing CTA in instructional content is evidenced though
time savings. Clark and Estes (1996) describe this savings following application of CTA
to inform instructional content for a mandatory training program for a large organization
with more than 10,000 employees. CTA so improved the instructional content in this
application that the employee training program was suitably condensed from a two day
program into a single day of training, yielding equal or greater performance scores on the
program posttest. For a company of this size, the time savings would no doubt translate
into significant financial savings.
Effectiveness of CTA in healthcare training. Research has demonstrated that
experts unintentionally omit up to 70% of the crucial knowledge necessary for effective
instruction of novices in nursing (Crandall & Getchell-Reiter, 1993) and medical skills
training (Clark et al., 2011; Sullivan et al., 2008; Yates, Sullivan,& Clark, 2011).
Cognitive task analysis is a promising knowledge elicitation technique that has
demonstrated amelioration of such critical knowledge omissions and instructional gaps in
33
medical (Campbell et al., 2011; Clark et al., 2008; Yates et al., 2011) and nursing training
(Crandall & Getchell-Reiter, 1993).
Sullivan et al., (2008) employed CTA semi-structured interviews with three
colorectal surgeons to determine if CTA could better elicit the knowledge gathered from
these experts regarding the steps and decision points in a colonoscopy procedure. The
percentage of included “how to” steps described by each of the three surgeons ranged
from 26% to 50% complete and the percentage of decision (IF...THEN) points described
by each of the surgeons ranged from only 25% to 43% complete. These study findings
demonstrate the scale of critical information unintentionally omitted by these experts.
Significant improvements were also demonstrated in the performance of medical
students and surgical residents following lecture and guided practice on a simulated open
cricothyrotomy procedure in a surgical skills lab (Campbell et al., 2011), when such
instruction was guided by CTA. In this study, surgical expertise was gathered through
CTA semi-structured interviews to generate a summary gold standard for the surgical
task. The gold standard was then employed to inform instructional content. Finally the
CTA guided ID was employed in a random experimental study comparing conventional
instruction on the task to the CTA guided ID. The trainees who received the CTA guided
ID demonstrated statistically significant improvements in performance outcomes
(Tirapelle, 2010) and self-efficacy (Campbell et al., 2011) when compared to their
counterparts who received conventional, instruction in the same procedural task.
Moreover, in similar studies, researchers (Maupin, 2003; Velmahos et al., 2004),
were able to demonstrate both quantitative improvements in procedural performance by
surgical residents carrying out CVC placement and very importantly, class I evidence
34
regarding the efficacy of the CTA guided surgical skills training to improve relatable
patient outcomes. In this inquiry, Velmahos et al., (2004) randomized 26 new surgical
interns into two groups, 12 into the experimental group who received CTA guided
instruction on CVC placement and 14 interns who underwent traditional instruction on
the procedure. In the months following the CVC insertion training, the interns were
evaluated using a 14 item checklist during actual CVC line placement on real patients.
The interns who had undergone the CTA guided curriculum in CVC line placement
demonstrated significant gains in knowledge as measured by posttest (11 ± 1.86 versus
8.64 ± 1.82, p=0.03) and performed significantly fewer needle insertions on the patients
to locate the central vein (3.3 ± 2.2, p=0.046) compared to their counterparts (6.4 ± 4.2).
The interns who had received the CTA guided instruction on CVC placement also
demonstrated a trend toward expeditious line placement (15.4± 9.5 minutes) as compared
to (20.6 ± 9.1 minutes, p=0.149) the control group.
In another inquiry involving a multi-institutional study aimed at reducing surgical
risk in routine laparoscopic surgery, Da Rosa et al., (2008) used a CTA technique known
as Critical Decision Method (CDM) to interview focus groups of surgical experts. The
purpose of the interviews was to capture the critical intraoperative decision processes
which occur during a surgical procedure, specifically laparoscopic cholecystectomy
(minimally invasive surgical removal of the gallbladder). The transcripts of the CTA
interviews were then used to develop an educational aid and an evaluation tool for
trainees learning this surgical procedure. The trainees were subsequently engaged in
“think aloud” protocols during their performance of the surgical procedure. The think
aloud protocols were aimed at facilitating evaluation of the trainees‟ previously tacit
35
decision processes and allowing expert instructional feedback during the operation.
Additionally, trainees were randomized into two groups, one receiving conventional
instruction on the surgical procedure and an experimental group which received CTA
guided training. Although there were no statistically significant differences during the
performance of the procedure in a porcine model, the experimental group, when
compared to the control group, demonstrated significant improvements on the written
posttest with regard to intraoperative judgments.
The CDM method of cognitive task analysis was also employed successfully in a
pair of studies by Crandall and Getchell-Reiter (1993) to recognize and record key
elements of nursing expertise. The studies were aimed at eliciting the tacit knowledge
employed by 19 highly experienced neonatal intensive care unit (NICU) nurses to expose
subtle cues of symptom recognition in early newborn sepsis (Crandall & Getchell-Reiter,
1993). The specific CTA technique employed, allowed the researchers to explicate and
clarify, with rigorous systemization, information that was otherwise represented by
unconscious perceptions and judgments. Such unconscious information is typically
difficult to access and articulate. The resulting comprehensive explanations of how the
nurses detected early signs of neonatal sepsis, through subtle cues, were then
incorporated into instructional aids for novice NICU nurses. The instructional aids
incorporated the cluster of previously covert but critically important cues which had
evolved unconsciously over many years in the expert nurses. These cues were
supplemented by exemplars and indicators of neonatal sepsis that typically eluded
discussion. Indeed, fully one third of the CTA elicited cues employed by the expert
nurses to recognize sepsis in neonates, were not reflected in the current literature. The
36
application of CTA to elicit both overt and tacit knowledge and to inform instructional
content, expedited knowledge transfer to the novices that otherwise might have taken
years to develop.
CTA in Anesthesiology. Owing to the dynamic and complex nature of the
workflow, it has been suggested that anesthesia practice is the ideal setting for the
application of CTA techniques (Segall, 2006). Such application of CTA may identify
and codify pre-event cues that preempt critical events and improve patient safety.
Moreover, application of CTA may improve instructional content and instructional
outcomes in anesthesia practice as it has in those studies previously described in surgery,
medicine and nursing practice.
In an effort to preempt and reduce practice risks, Sowb and Loeb (2002)
employed a CTA technique called critical decision method (CDM) to elucidate cues and
dynamics surrounding untoward ventilation related events (VREs) in anesthesia practice.
Results from practitioner debriefing interviews following VREs elucidated the complex
cognitive demands imposed on clinicians during the management of VREs. Study
findings were to be employed in efforts to improve anesthesia equipment design and to
guide anesthesia training in the management of VREs.
Weinger and Slagle (2002) also employed CDM during a cognitive task analysis
to elicit expertise about the decision making processes, from eight expert
anesthesiologists, surrounding postoperative tracheal extubation (removing the breathing
tube after general anesthesia). The study was part of a broader inquiry into issues of
patient safety and non routine events (NREs) in anesthesia practice. The inquiry
elucidated four critical factors necessary for safe tracheal extubation. These criteria were
37
1) the ability of the patient to maintain appropriate ventilation and oxygenation following
extubation, 2) the expectation that the patient could be successfully mask ventilated if
extubation failed, 3) the potential for reintubation if extubation failed and 4)
consideration of the ramifications for both the patient and anesthesia practitioner if the
extubation failed. The inquiry also revealed non clinical decisions such as deferring
extubation based on surgeon request or preference.
As the knowledge elicited through this CTA process reveals salient considerations
for the conditions influencing decisions about tracheal extubation, it might well be
employed to develop an instructional guide for the novice practitioner. Moreover, the
application of CTA techniques to elicit expertise in anesthesia practice might inform
clinical practice and improve knowledge sharing and patient safety by elucidating a
broader spectrum of information than is customarily shared in traditional recall-based
teaching methods. For example, a CTA technique was employed by Segall (2006) as one
of many methods to inform the development of a cognitive tool to aid anesthesia
practitioners during crisis management by eliciting the necessary goals, decisions and
information requirements of anesthetists. Using the CDM technique of CTA, Segall
(2006) developed a prototypical, cognitive model based decision tool aimed at supporting
anesthetists in the recognition and management of intraoperative myocardial infarction
(MI) or heart attack. The resulting decision tool could also be used by anesthesia faculty
to facilitate rapid assessment of patient status upon entering an operating room; where a
trainee was providing anesthesia care (Segall, 2006).

38
Summary
The application of CTA techniques has proven successful in improving training
and safety in high stakes; highly demanding domains like systems design, aviation,
military training and air traffic control (Hess, MacMillen, & Serfaty, 2005; Seamster,
Redding, Cannon, Ryder, & Purcell, 1993). Furthermore, demonstration that CTA
guided curricula in medical and surgical skills training have resulted in improved
instruction to trainees (Campbell et al., 2011; Maupin, 2003; Sullivan et al., 2008;
Velmahos et al., 2004; Yates, Sullivan, & Clark, 2011) as well as improved patient
outcomes (Maupin, 2003; Velmahos et al., 2004) is encouraging.
Postoperative tracheal extubation is a complex task in the domain of anesthesia
practice that requires the deployment of declarative, procedural and specifically
conditional knowledge, a strategic sub-type of procedural knowledge. Effective
instruction of this cognitive task must necessarily then incorporate the conscious,
conceptual and unconscious, procedural and strategic components of task execution. The
application of CTA techniques to elicit expertise in anesthesia practice, might inform
clinical practice and improve knowledge sharing and patient safety by elucidating a
broader spectrum of information than is customarily shared in traditional recall-based
teaching methods. A review of the education research literature suggests that the use of
CTA techniques may inform instructional content for novices in anesthesia care delivery
and thereby may improve patient outcomes. By explicating both the overt, observable
and covert cognitive functions associated with the highly complex and dynamic tasks in
anesthesia practice, CTA may reveal key elements connected to the conditions, decisions
and actions that experts employ during postoperative tracheal extubation.
39
The proposal for CTA supported instruction in anesthesia practice is a cogent
extension to prior research which demonstrates performance improvements in medical
and surgical education. Through a means of semi-structured interviews and peer and self
critiques that reveal the actions, decisions, concepts, processes and principles (Clark,
2004, 2007) necessary for efficient and accurate task execution, CTA may be employed
to capture the data that, owing to the unconsciousness of expert procedural knowledge,
would otherwise escape elucidation. Due to the high stakes, dynamic and complex nature
of anesthesia practice, this specialty is perhaps the quintessential platform for the
application of CTA techniques (Segall, 2006) to capture expertise. Application of CTA
techniques in anesthesia training could inform instructional content and thereby improve
patient outcomes, and in this study, specifically with regard to postoperative tracheal
extubation.
The Current Study
The purpose of the current study is to examine the generalizability of the results
of conducting and applying CTA in medical training to training in nurse anesthesia
practice. This inquiry was undertaken in an effort to provide support for instructional
content that ameliorates the limitations of the current methods of teaching anesthesia
tasks to trainees. This study replicates the methods used by Tirapelle (2010) to determine
if CTA based direct instruction is more effective than conventional clinical instruction to
teach the procedure of adult postoperative extubation to anesthesia trainees. The inquiry
is important as it adds to the body of existing evidence regarding the effectiveness of
using CTA to capture medical expertise for the purpose of improving instruction.
Moreover this work adds to the body of evidence comparing the effectiveness of CTA
40
based instructional methods to current, standard methods of instruction in medicine,
specifically anesthesiology and nurse anesthesia practice and training.
Research Questions. The following questions were the basis for this inquiry.
1. Do participants in the experimental group demonstrate greater declarative
knowledge on postoperative tracheal extubation than participants in the control
group as measured by pre and posttest?
2. Do participants in the experimental group demonstrate greater procedural
knowledge when performing postoperative tracheal extubation than participants in
the control group, as measured by procedural checklist? The second research
question was further divided to evaluate measures on accuracy for task execution,
timing for completion of the task and correct sequencing of subtasks.

41
CHAPTER 2: METHOD
This chapter will describe the research methodology employed in this random
experimental study to compare the results of standard instruction of postoperative
tracheal extubation to those of CTA guided instruction for the same anesthesia practice
task. The following discussion will include details on the application of CTA to inform
instructional content in the experimental branch of this study, the quantitative
experimental study design, the participants and the study procedures.
Pre Study Curricular Development
This quantitative inquiry compared the results of two teaching methodologies for
a single anesthesia task to anesthesia trainees. The independent variables in this study are
two instructional formats. The dependent variable is instructional outcome as measured
by declarative and procedural posttest performances by the trainees following either
control or experimental instruction. The control branch of this study was modeled after
the current standard method of teaching anesthesia tasks i.e., expert practitioner recall-
based instruction delivered during task execution in the operating room (OR). In this
inquiry the OR setting was substituted by a high fidelity simulation laboratory. The
experimental branch of this study consisted of instruction employing a CTA guided script
to aid the anesthesia practice expert with lesson delivery in the same high fidelity
simulated OR setting during task execution.
Expertise elicitation. To inform the instructional content of the experimental
branch of this study, a CTA technique modeled after Clark et al., (2008) was employed
prior to the current study to elicit expertise from three anesthesiology experts on the
action and decision steps, indications and contraindications, standards, and equipment for
42
the adult postoperative tracheal extubation task. A senior researcher, who is not an expert
in anesthesia, assisted the author in conducting the CTA interviews. The anesthesia
experts interviewed were selected based on years of practice in anesthesia delivery,
departmental standing and peer nomination. All three subject matter experts (SMEs)
were physician anesthesiologists with multiple years in anesthesia practice and resident
training. The Institutional Review Board (IRB) of the practice facility was consulted
regarding the CTA semi-structured interview phase of the inquiry. It was determined that
IRB approval was unnecessary for this portion of the study, as the SME interviews would
be employed only to inform curriculum design. What follows below is a discussion on
the CTA procedure employed to design the instructional platform for the experimental
instruction in this inquiry. Following this explanation is a discussion on the quantitative
study methodology.
CTA Instructional Content Procedure
The CTA procedure for knowledge elicitation followed the 5 steps suggested by
Clark et al., (2008) which include (a) collecting preliminary domain specific knowledge,
(b) identifying the types of knowledge associated with the task, (c) applying the
knowledge elicitation semi-structured interview technique and subsequently (d) verifying
and analyzing the results from the interviews and ultimately, (e) applying the findings to
curriculum design.
Phase 1: Collecting preliminary knowledge. Relevant literature from peer
reviewed journals and anesthesiology textbooks on the safe and appropriate execution of
postoperative tracheal extubation was reviewed. This “bootstrapping” was undertaken to
familiarize the senior researcher who would oversee the expert interviews, with the
43
language of anesthesia practice and to facilitate the gain of domain specific knowledge on
the anesthesia task in question.
Phase 2: Identifying knowledge representations. The types of knowledge
associated with the execution of postoperative tracheal extubation in the adult patient
were identified following a review of the anesthesia literature. These knowledge types
included the necessary concepts, processes, principles, and procedures in the form of the
action and decision steps necessary for task execution.
Phase 3: Application of knowledge elicitation methods. CTA guided semi-
structured interviews for knowledge elicitations were employed with three expert
anesthesiologists, experts A, B and C. The interviews were recorded and transcribed
verbatim for clarity, for subsequent coding of elicited knowledge type, for interview
content verification and later for supplemental feedback from two additional expert
anesthesiologists, experts D and E and one clinical faculty CRNA (KKE). These semi-
structured interviews were aimed at answering the following points below, using the
method adapted from Clark et al., (2008) to reveal:
1. The events or conditions (indications and contraindications) that determine
whether the tracheal extubation procedure should be performed;
2. The actions and decisions necessary to perform tracheal extubation;
3. The prior knowledge, in the form of concepts, processes and principles, necessary
to perform the task;
4. The necessary equipment, monitoring devices and materials needed for
appropriate task execution;
44
5. Any additional sensory information relevant to the task execution, such as smells,
sounds or tactile input that surround or cue the task or subtasks;
6. Indicators of appropriate task execution such as those which reveal accuracy,
speed, time or quality of task performance.
Each of the SME interviews was conducted independently and subsequently each
expert was provided with a transcribed copy of his or her interview. Sufficient time was
afforded to each of the experts to provided feedback, to clarify interview content and to
supplement interview content.
Phase 4: Data analysis and verification, CTA coding. The transcribed SME
interviews were then coded for type of knowledge content to reveal the elicited
conditional knowledge, specifically indications (I) and contraindications (CI) to actions
during the task execution. Transcript coding also catalogued equipment and materials
(EM) needed for task execution, sensory cues surrounding the task and subtasks such as
hearing (SH), seeing (SS) and touching (ST). The primary focus however of coding was
to identify the action steps (AS) and decision steps (DS) which indicate IF… points and
those steps indicating decision step alternatives (DSA) which elucidate the …THEN
points during task execution. A complete description of codes is available in Appendix
A.
Inter-rater reliability. The transcribed CTA interview for the first SME was
coded by two trained knowledge analysts. Data on agreements and disagreements in
coding to establish the rigor of inter-rater reliability (IRR) was collected. The percent of
consensus for each of the coded items was generated from the tallies of agreements and
disagreements between the coders. Any disagreements in coding not resolved by
45
discussion were reviewed by a third knowledge analyst for consensus. Inter rater
reliability was established at 96% agreement. Following the establishment of rigorous
IRR, a single researcher then coded the remaining CTA interview transcripts for the
purpose of knowledge type cataloguing.
Development of the CTA protocol. The information gathered during the semi-
structured CTA interviews from the anesthesia practice SMEs was employed to generate
a draft protocol for the task of postoperative tracheal extubation in the adult patient.
Additional feedback was solicited from the SMEs for the final task protocol.
Subsequently all feedback and the task protocol were synthesized to generate a summary
gold standard (GS) for the task of adult postoperative extubation. The GS was ultimately
employed in the design of instructional content for the experimental branch of the study
(Appendix B).
Phase 5. Formatting results. The current study included the capture of expertise
in an anesthesia practice task and employed this expertise in the training and evaluation
of knowledge and performance by anesthesia trainees in a high fidelity simulation lab.
Formatting results; developing materials and assessments. The GS formulated
from the CTA interviews was used (a) to develop a training outline and demonstration of
the procedure by the instructor of the experimental group, during instruction on the task
of extubation, (b) to design a procedural checklist that was employed to evaluate the
participants‟ performance of the procedure for both the standard method of teaching the
task of tracheal extubation as well as the CTA guided instructional session, and (c) to
generate the conceptual and procedural pre and posttests administered to both the control
and experimental groups. The evaluations of the trainees‟ procedural performances also
46
included assessments of timing for task completion, task accuracy and assessments on
correct sequencing for subtasks.
The Experimental Study Design
Figure 1: Study Flow and Timeline

Participants and Recruitment. Following IRB approval, volunteers were
sought during a scheduled educational presentation for graduate students in the Program
of Nurse Anesthesia (PNA). The PNA is housed within a major medical school in a large
research university in the western United States. Thirty-two potential student registered
nurse anesthetists (SRNAs) were invited to participate in the study. Twenty-five of the
potential 32 SRNAs volunteered to participate; these volunteers included 11 seniors and
14 juniors who were subsequently randomized into two stratified groups. The control
group was to undergo standard training in the extubation task, which consists of recall-
based instruction during task execution in the OR and the experimental group was to
undergo CTA guided instruction on the same anesthesia task.
consent
Study &
Simulation
Pre-brief
Pretest
Day 1
Control
Group
12
Participants
7 Juniors
5 Seniors
Day 2
Experimental
Group
13
Participants
7 Juniors
6 Seniors
Performance
Evaluation
Posttest
Study &
Simulation
Debrief
0700 0720-0735 0735-0800 0800 – 0825 0830-1045 1045-1115 1115-1130
Rough Timeline on Study Days
47
Sampling procedure. Because both first year and second year SRNAs were
enrolled in the study it was assumed there would be stratified levels of prior knowledge
regarding task execution. The senior students had experienced nine months of clinical
training, during which they had been regularly performing tracheal extubation under
faculty supervision. The junior students however had only observed clinical faculty
performing extubations during their very limited visits to the OR. To control for this
difference in prior knowledge between the junior and senior students, stratified
randomized sampling was employed to allow for equitable distribution of senior and
junior students in both the control and experimental groups. Some accommodation with
regard to availability for participation on a specific date was granted to five students who
had various preexisting commitments. These accommodations were made without regard
to control or experimental group assignment. The control group consisted of seven
juniors and five seniors for a total of 12 control participants. The experimental group
consisted of seven juniors and six seniors for a total of 13 experimental participants.
Expert instructor demographics. The instructors for the control and
experimental groups in the study were selected due to their similar experience in
anesthesia practice, exposure to SRNA clinical instruction and comparable familiarity
with the workings of the simulation laboratory. Neither instructor had participated in the
CTA interviews. The instructor for the control groups was blind to the purpose of the
study and was asked to conduct his customary method of instruction during the task of
extubation. The instructor for the experimental branch was briefed on the CTA generated
gold standard (GS) for task execution and agreed to conform to the lesson content
specified in the GS instructional aid, (Appendix C), during lesson delivery.
48
The Study Procedure
The study took place in “OR 13,” the simulation laboratory of the medical center
and was run during two days on consecutive weeks. As the control and experimental
groups were run on two separate days, each student was briefed on the facility‟s
simulation training confidentiality agreement. Students were admonished not to divulge
any information regarding their experiences during the training and evaluation process in
the OR with anyone other than the primary investigator. All students underwent
instruction on the “think aloud” protocol necessary for clarifying their actions and
explicating their decisions during the study procedure. Students were encouraged to
express verbally why and what they were doing as they executed each action of the task
and subtasks, during the procedural performance and evaluation. This protocol was
necessary to allow the data collectors, two trained evaluators, to code student actions and
decisions against the GS procedural checklist for completeness, timing, sequencing and
accuracy.
The study setting. The study lasted roughly four hours on each of the two days,
during which 12 control and 13 experimental students were respectively evaluated. All
study participants and investigators complied with requirements for standard OR attire
and conduct during the study process to maintain relevant environmental cues and
situational fidelity. The simulated OR employs the fully automated, fully automatic
model driven METI® high fidelity human patient simulator (see Appendix D). Model
driven refers to the simulator‟s ability to respond in real time to real events that parallel
human physiological responses for realistic clinical training. Students in both the control
and experimental groups had some level of experience using the simulation lab for
49
instruction. The level of experience with simulation was uniform between all seniors and
uniform between all junior students. The senior students however had considerably more
exposure to both the OR and the simulation environment over the prior year than did the
juniors. On or before the date of participation, all volunteers read and signed the study
consent, (Appendix E).
All participants filled out a demographic sheet describing their prior experience
with, or exposure to, the task of postoperative tracheal extubation. The demographic
questionnaire also captured information regarding the participants‟ levels of comfort and
familiarity with the task to be addressed during the study, (see Appendix F). Following
this preliminary data collection, all participants took the same proctored declarative
pretest (Appendix G) consisting of eight test questions surrounding a clinical scenario for
the task of postoperative extubation in the healthy adult patient. This pretest was
developed in the customary manner that simulation scenario, case based learning has
historically been prepared for, and presented to, students in the Program of Nurse
Anesthesia at this institution. The pretest and patient scenario focused on routine care for
a healthy patient.
Instruction and evaluation. Students in the control group observed the
performance of an anesthesia emergence and extubation in the simulated OR, during
which the clinical instructor interacted with the METI® high fidelity human patient
simulator. The instructor, who was blind to the study purpose, had been provided a
clinical case scenario surrounding the task of adult extubation (appendix H) and informed
that he was to teach novice anesthetists on the task of postoperative extubation in the
healthy patient, using his customary method of instruction. This clinical demonstration,
50
during which a think aloud approach was employed by the instructor, was viewed on a
single occasion by all of the control group students during task execution in the simulated
OR. The students were then afforded time to ask questions of the instructor regarding the
task.
During the experimental branch of the study, the same environment, the METI®
human patient simulator and patient care scenario were employed for task demonstration
and instruction by the experimental group teacher. However, during experimental
instruction, the educator was aided by the CTA generated gold standard, job aid and
lesson script for the task (Appendix B; C; I) and a think aloud protocol was used by the
instructor to explicate her actions and decisions. The CTA guided instruction included
detailed and thorough information on the action and decision steps, indications and
contraindications, standards, and equipment for the adult postoperative tracheal
extubation task. Following the lesson and demonstration by the instructor, the
experimental student group was afforded time to ask questions.
Following instruction, participants in both the experimental and control groups
underwent individual procedural performance evaluations for the task of adult extubation
in the simulated OR using the METI® human simulator. Each of the students was
supplied the student clinical scenario for procedural testing (Appendix J). The student
performances were videotaped during the evaluation for later analysis. All students
announced their coded student numbers at the start of evaluation and videotaping, and all
students were reminded to employ the think aloud technique during task execution to
explicate their intentions and clarify their actions. Evaluations for both groups of
students included measures on accuracy for task performance, timing for task execution
51
and correct sequencing of all subtasks. Task performances were evaluated using the CTA
generated checklist (Appendix K), which was employed by two trained observers during
the students‟ procedural executions.
Following the performance evaluations, each student completed a written
declarative posttest in a proctored environment. The posttest (Appendix L) consisted of
eight questions surrounding a clinical scenario for adult postoperative extubation. The
written posttest was developed in the manner that prior simulation scenario, case based
learning has historically been prepared for, and presented to students in the Program of
Nurse Anesthesia at this institution. The posttest focused on routine care for a healthy
patient. All students underwent a standard simulation center debriefing session during
which they were encouraged to discuss the simulation events, express any concerns about
their experiences and ask any questions regarding the instruction and evaluation process.
At the termination of the debriefing session all participants were again reminded of the
center‟s confidentially policy and the need to maintain clinical scenario and study
integrity by not discussing their study experiences with others.
Data Analysis
The purpose of this study was to determine if: CTA based instruction of
postoperative tracheal extubation is more effective than conventional clinical instruction
provided to anesthesia trainees, as measured by conceptual and procedural pre- and
posttests?
Study questions: The following questions were examined.1) Do participants in
the experimental group demonstrate greater declarative knowledge on postoperative
52
endotracheal extubation than participants in the control group, as measured by pre and
posttests?
2) Do participants in the experimental group demonstrate greater procedural knowledge
than participants in the control group when performing postoperative tracheal extubation,
as measured by procedural checklist? This second study question was further stratified to
explore three sub-questions.
2a) Do students in the experimental group demonstrate greater task accuracy for task
execution than students in the control group?
2b) Do students in the experimental group perform the extubation task more expediently
than students in the control group?
2c) Do students in the experimental group who have prior experience in extubation
(senior students) demonstrate improvements in sequencing for subtask execution when
compared to the experimental junior students (task novices).
Data collection. The data analysis of this inquiry involved comparing the
declarative and procedural posttest mean scores of the control group of students with
those of the experimental group, who received CTA informed instruction. Additional
measures on timing and accuracy for task execution were evaluated to explore differences
between the control and experimental groups. These two questions were also explored
within the subgroups and compared juniors to juniors and seniors to seniors within the
control and experimental groups.
Additionally, an assessment within the experimental group was performed to
explore differences in the correct sequencing of subtask execution for the senior students,
compared to the junior students, who were task novices. This assessment was undertaken
53
to evaluate the effects of prior knowledge on the task performance with regard to
obtaining the correct sequence for subtasks during task execution. All data was collected
with coded student numbers, no personal identifiers were employed during the study.
Videotaped data with correlates of student images and study codes has been maintained
in a secure location, accessible only to the primary investigator.
Inter rater reliability. The results of the conceptual pretest and posttest were
evaluated by two trained raters. Agreement between evaluators on the results of the
declarative pre and posttests was 100%. During procedural testing in the simulation lab,
concurrent observations of task performance were made by two independent evaluators
and the performances were videotaped for clarification or additional analysis as needed.
The goal between the trained raters for inter rater reliability (IRR) on analysis of the
procedural performances was 100%. Any discrepancies in performance assessment
between the raters were resolved, where possible, by revisiting the videotaped
performances. Evaluations produced an IRR of 96% for observations of the experimental
group and 93% for observations of the control group. These agreement rates produced an
overall IRR of 94% for the procedurals assessments.
Statistical analysis. See Table 1 below for a list of the analyses (Appendix M,
Table M-1 – M-11). The differences in declarative knowledge, as demonstrated by
written posttest and the differences in procedural knowledge, as assessed by the scores
from the procedural checklists, were examined. The raw data collected from the
declarative and procedural pre and posttests was entered into a Microsoft Excel
spreadsheet and analyzed using Statistical Package for the Social Sciences (SPSS) 15
(Release 15.0.0). For research Questions 1 and research Question 2, the dependent
54
variables were the results of the scored posttests and procedural checklists, and the
independent variables were instructional content. For Question 2a the dependent variable
was accuracy of task completion and the independent variable was instructional method.
For Question 2b the dependent variable was timing in minutes for task completion and
the independent variable was instructional content. For Question 2c the dependent
variable was correct sequencing for subtask execution and the independent variable was
either instructional content, for the assessment between groups, or prior or level of
experience, for the assessments within groups.
Table 1: Study Analyses

Research
Question
Assessments Groups Evaluated Means of
Analysis
Independent
Variable
Dependent
Variable
1 Declarative
Knowledge

All Students

Independent
Samples
T-Test
Instructional
Content
Mean Scores
Declarative Pre &
Posttests
1 Delta score
Declarative
Pre &
Posttest
Parity
All Students

Paired
Samples
T-Test
Test Parity Group
Homogeneity
2 Procedural
Performance

All Students

Junior C & E

Senior C & E
Independent
Samples
T-Test
Instructional
Content
Mean Scores
Procedural
Checklist
2a Procedural
Performance
Accuracy
Junior C & E Independent
Samples
T-Test
Instructional
Content
Mean Scores
Procedural
Checklist
2b Procedural
Performance
Expediency
Junior C & E

Senior C & E
Independent
Samples
T-Test
Instructional
Content
Mean Scores
Procedural
Checklist
2c Procedural
Performance
Correct
Sequencing
All Students

Control
Seniors & Juniors

Experimental
Seniors & Juniors
Test
Chi Square
Instructional
Content

Level of Prior
Knowledge
Improved
Procedural
Performance
Sequencing
Note: All students = both control & experimental groups, includes all seniors & all junior students;
C = control group, E = experimental group; juniors = first year SRNA, seniors = second year SRNA

For all statistical analyses in this study a 95% confidence level (p < 0.05) was
employed. Using an independent t-test, a comparison was made of the differences
55
between the control and experimental groups‟ performances for both declarative and
procedural knowledge. Using a paired sample t-test the differences between the means of
the pretest and posttest within each group were assessed to establish homogeneity
between groups. Assessments of procedural knowledge included accuracy and timing of
task performance as well as measures on correct sequencing for the execution of
subtasks. Independent samples t-test analyses were employed to evaluate the differences
in accuracy and timing for task completion between the control and experimental groups.
To examine the effects of prior knowledge on procedural performance for correct
subtask sequencing, chi square values were calculated using the raw data from the
assessments of the experimental senior and junior students and the control senior and
junior students. These chi square values were then tested for significance.

56
CHAPTER 3: RESULTS
The present study examined both the declarative knowledge and procedural
performances of nurse anesthesia trainees following experimental and control methods of
instruction on an anesthesia task, adult postoperative tracheal extubation. The control
group of students received traditional recall-based instruction on the task while the
experimental group received instruction for the same task, informed by the results of
CTA elicited expertise. The study was conducted to determine whether the CTA guided
instruction was more effective than traditional expert led instruction for this anesthesia
task. The anticipated result in this inquiry was that the CTA guided instruction would
result in statistically significant improvements in both declarative knowledge and
procedural performance for the task when employing a 95% confidence level (P < 0.05).
As seen below in Table 2, students had varying levels of prior experience with the task of
postoperative extubation; the effects of these differences on task performance were also
examined.
Table 2: Demographics on Students’ Prior Extubation Experience
Study Cohort Mean Number of
Extubations Observed
Mean Number
Extubation Assisted
Mean Number of
Extubations Performed

Junior Control Students 2 0 0

Junior Experimental Students 4 0 0

Senior Control Students 36 33 105

Senior Experimental Students 12 60 143

Below, the results of the analyses of data are organized by research question.
57
Question 1: Do participants in the experimental group demonstrate greater declarative
knowledge on postoperative tracheal extubation than participants in the control group as
measured by pre and posttest?
Pretest of declarative knowledge. The 25 study participants took an eight
question written pretest surrounding a clinical scenario for adult postoperative extubation
in a healthy patient. One test question required participants to correctly sequence six
extubation subtasks into their appropriately safe order of execution. The remaining seven
test questions called for participants to write in the correct answer(s). As seen below in
Table 3, (Appendix M; Table M-1) an independent samples t-test demonstrates no
significant differences in baseline knowledge on extubation between the control and
experimental groups: t (23) = -.843 p= .408.
Table 3: Question 1, Declarative Pretest, Means Comparisons

Group Mean Score Standard Deviation Statistical Significance
Control 73.33 9.267
p = .408 Experimental 76.46 9.270
All Students 74.96 9.213

Posttest of declarative knowledge. Following instruction and procedural
evaluation, the study participants took an eight question written posttest that again was
based on a clinical scenario surrounding postoperative extubation in a healthy adult. One
test question required participants to correctly sequence 10 subtasks into their
appropriately safe order of execution. The remaining seven questions called for
participants to write in the correct answer(s). As seen below in Table 4, employing an
independent samples t-test, there were no significant differences in declarative
58
knowledge between the control group and the experimental students, who had received
CTA based instruction: t (23) = -.183 (p= .856), (Appendix M; Table M-2).
Table 4: Question 1, Declarative Posttest, Means Comparison

Group Mean Score Standard Deviation Statistical Significance
Control 68.00 9.105
p = .856 Experimental 68.62 7.709
All Students

68.32 8.235

A paired samples t-test was then employed to assess for differences between the
means of pretest and posttest scores within each of the study groups. This deltascore
indicated that there were no significant differences between the pretest and posttest scores
for each of the two groups, indicating parity between the pre and posttests outcomes
within each of the groups.
Procedural Performance
Question 2: Do participants in the experimental group demonstrate greater
procedural knowledge in performing postoperative tracheal extubation than participants
in the control group, as measured by procedural checklist? This question was subdivided
to explore differences between the control and experimental groups’ and subgroups’
performances with regard to 2a) task accuracy 2b) task expediency and 2c) correct order
of subtask sequencing.
Question 2a: Procedural performance, task accuracy. Procedural checklists
were used to assess the participants‟ performances of tracheal extubation in the
simulation lab. A percent for task execution accuracy was tallied from each performance
evaluation. The checklist evaluations (Appendix K) included measures on task and
59
subtask executions that were rated by trained evaluators as “done correctly, done
incorrectly or not done.” The evaluators could also note if a subtask became “not
applicable” depending on the METI® high fidelity human patient simulator‟s response to
an action performed by the study participant.
Independent t-test analyses were employed to assess the differences between the
mean procedural performance scores of the overall control and experimental groups as
well as between the senior students in both groups and the juniors in both groups, as seen
in table 5. The overall control group‟s (seniors and juniors) mean score was calculated at
70.92 (SD = 14.10) while the experimental group‟s mean was 79.46 (SD = 12.434). The
grand overall mean for the performances was 75.36 (SD = 13.693), p = .121, (Appendix
M; Table M-3). These findings demonstrate a trend toward performance improvement in
the group of students that received CTA guided instruction, though no significance
differences between the control and experimental group performances were found. When
comparing just the scores of the control seniors to the experimental seniors, again a trend
toward improved accuracy on performance for the experimental seniors was observed.
As seen in Table 5 however, no statistically significant differences were observed
between these groups. However, there was a statistically significant difference in the
performance of juniors, who had received CTA guided instruction, compared to the
control group juniors, (Appendix M; Table M-4).
Table 5: Question 2a, Procedural Performance, Task Accuracy

Groups
Compared
Control Mean
Score
Standard
Deviation
Experimental
Mean Score
Standard
Deviation
Statistical
Significance
All Students
(juniors & seniors)
70.92 14.10 76.46 12.434 p = .121
Senior Students

85.2 90 p = .167
Junior Students

60.71 6.993 70.43 9.253 p = .047*
* p < .05
60
Question 2b: Procedural performance, task expediency. All performances
were timed from start to finish of the simulated extubation procedure. An independent
t-test was used to assess the differences in time for task completion between the control
and experimental groups and again between the subgroups, juniors only and seniors only.
Timing information was available for 24 of 25 participants.
A significant level of expediency was found for the overall experimental group
(seniors and juniors) when compared to their control counterparts, (see Table 6). The
mean time for task completion among the experimental group was 8.83 minutes (± 1.337)
this was compared to the mean time for the control group 10.75 (± 2.340) (p = .022).
When comparing the times for task completion among the junior experimental and
control students, again a significant improvement was noted in the performance of the
experimental group. Juniors in the experimental group outperformed their control
counterparts with a mean time of 9.00 minutes (± 1.291) versus 11.43 minutes (± 2.637)
(p = .049), (Appendix M; Table M-5). When comparing just the senior students‟
performances, a trend toward expediency was seen in the experimental group (8.6 ±
1.517 minutes) versus the control group (9.80 ± 1.643 minutes), though these differences
were not as significant as those of the overall (all juniors and seniors together), groups‟
performances on this measure, (Appendix M; Table M-6).
Table 6: Question 2b, Procedural Performance, Task Expediency

Groups
Compared
Control Mean
Time
Standard
Deviation
Experimental
Mean Time
Standard
Deviation
Statistical
Significance

All Students
(juniors & seniors)
10.75 2.340 8.83 1.337 p = .022*
Senior Students

9.80 1.643 8.6 1.517 p = .264
Junior Students

11.43 2.637 9.00 1.291 p = .049*
* p < .05
61
Question 2c: Procedural performance, correct subtask sequencing. The
procedural checklists used for assessing performances in the simulation lab, included
notations indicating whether or not the participants performed the subtasks, within the
main task of extubation, in their correct sequence or out of order. For example, did the
student suction the trachea before deflating the tracheal cuff balloon, or did the student
reverse the neuromuscular blocking agent before observing the patient for spontaneous
ventilation. In the experimental group one of seven juniors correctly sequenced the
subtasks, as did five of six senior students. In the control group of students, no junior
student correctly sequenced the subtasks and only three of five senior students correctly
sequenced the subtasks. When the results of the overall (junior and senior students)
performances between the experimental and control groups were analyzed for subtask
sequencing, there were no significant findings (X
2
=.427, p = .513). There were also no
significant findings when comparing the performances of the control and experimental
junior students for this assessment, as seen in Table 7.
Table 7: Question 2c, Procedural Performance, Subtask Sequencing

Groups Compared X
2
Significance

Corresponding Appendix
All Students
(juniors & seniors)
.427 .513 Appendix M; Table M-7
Junior Students

0000 1.00 Appendix M; Table M-8
Senior Students

.749 .387 Appendix M; Table M-9
How level of experience
(prior knowledge) effects
performance on this
measure

Experimental
Seniors versus Juniors

6.198

.013*

Appendix M; Table M-10
Control
Seniors versus Juniors
2.743 .098 Appendix M; Table M-11
All Seniors versus
All Juniors
* p = .05
8.766 .003*

Appendix M, Table M-12
62
However, as Table 7 shows, assessing correct sequencing of the subtasks between
the experimental junior and senior students, in order to evaluate the effects of prior
knowledge on this measure produced a significant finding (X
2
=6.198, p = .013). This
sizable difference in performance was anticipated, as the senior students possessed
considerably higher levels of prior knowledge on the task of extubation than their junior
counterparts, as seen in the demographic assessment in Table 2. The current findings
may reflect expected knowledge gains following instruction, when building on a
foundation of prior knowledge. An overall comparison, on correct sequencing for
subtask execution, between all junior and all senior students was performed, and
demonstrated statistically significant findings X
2
(1, N = 25) = 8.766, p = .003.

63
CHAPTER 4: DISCUSSION
The results from this quantitative inquiry evaluating declarative and procedural
knowledge gains, following the application of CTA guided instruction in an anesthesia
practice task, are positive. The study is the first of its kind in nurse anesthesia training
and the findings are favorable for the future application of CTA guided instruction for
anesthesia skills. The results from the current study are in keeping with expectations
based on similar prior studies that explored the training of medical students and surgical
residents. The present study was modeled after Tirapelle‟s (2010) inquiry, which
demonstrated significant improvements in the procedural performances of surgical
trainees learning an open cricothyrotomy procedure, following CTA guided instruction.
The present study‟s findings suggest that CTA based instruction significantly
improved the expediency in task execution in the overall experimental (seniors and
juniors) group. Significant improvements were also noted in the procedural
performances of junior nurse anesthetists who had received CTA guided instruction on
the task of postoperative tracheal extubation. Junior students, anesthesia novices in this
inquiry, demonstrated significant improvements in both task accuracy and expediency
following CTA guided instruction compared to control junior students, who received
traditional recall-based instruction on extubation. These results are congruent with those
of other studies that demonstrate significant knowledge gains for the novice following
CTA based instruction. Such gains from expert informed CTA instruction allow the
novice to transfer knowledge on decision-making points for problem solving and
assimilate automated skills from experts into their own procedural performances (Luker,
Sullivan, Peyre, Sherman, & Grunwald, 2007). These gains following CTA guided
64
instruction were also evident in the students with higher levels of prior knowledge in the
current study, and are discussed below in the section on senior students. As a whole, the
junior students participating in the current study possessed minimal prior exposure to the
task of extubation, as they had only observed the skill performed on rare occasion, by
other practitioners during observational visits to the OR. No junior student had actually
performed the task of postoperative tracheal extubation in the OR prior to participating in
the study. Senior students however had all performed over a hundred extubations during
their clinical training.
Senior students, who received CTA guided instruction, demonstrated a trend
toward improvements in task accuracy, expediency and correct subtask sequencing when
compared to their control counterparts. This trend toward improvement may reflect the
ability of CTA guided instruction to facilitate more effective skill acquisition, even for
the more experienced student, in whom the task has become automated after repeated
execution. The automation of skill execution in the experienced individual allows for
conscious effort to be applied to problem solving or novel encounters. Feldon (2007)
refers to this ability as the “adaptive nature of expertise.” In the experienced individual,
this adaptive ability allows for one to capitalize on the automaticity of already learned
behavior and thus more easily take in new information. Senior students in this study
naturally possessed higher levels of prior knowledge on extubation, as they had been
performing the task with supervision for a period of nine months before participating in
the study. The trend toward improved procedural performance in this group of anesthesia
students with higher levels of prior knowledge is also encouraging and portends well for
the application of CTA guided instruction in the more experienced practitioner.
65
Declarative knowledge gains for the anesthesia task in the current study were not
significantly different overall following either the traditional expert guided or the CTA
guided instruction. What follows is a discussion on the findings for each of the research
questions, information on the study‟s limitations and suggestions for future research.
Question 1: Do participants in the experimental group demonstrate greater
declarative knowledge on postoperative tracheal extubation than participants in the
control group as demonstrated by pre and posttests?
No significant improvements were found in declarative knowledge gains between
the experimental and control groups as measured by the written posttest. Although all
participants responded to the test items completely, the junior students, those with less
clinical experience, and ostensibly less declarative knowledge on extubation, tended to
list many more creative answers on the declarative tests than the experienced senior
students. In general, senior students offered fewer but more accurate answers to
declarative test questions than their junior counterparts. The more circumscribed answers
of the senior students may reflect automation of the skill or a “functional fixedness”
which Chi (2006) describes as a lack of flexibility associated with those more
knowledgeable in a given domain. Similarly, more knowledgeable individuals may also
tend to “gloss over” information and miss details (Chi, 2006). A propensity in the senior
students toward constrained answers might also reflect the application of appropriate
strategies for problem solving typical of the experienced individual (Chi, 2006). Junior
students lacking both functional fixedness and the appropriate strategies, experience, or
conceptual framework (Feldon, 2007) for problem solving in the domain, appeared to
have put in considerable effort toward creative answers to test questions. There was no
66
indication of skipped, rushed or perfunctory answers on either the declarative pre or
posttests.
Question 2: Do participants in the experimental group demonstrate greater
procedural knowledge in performing postoperative tracheal extubation than participants
in the control group, as measured by procedural checklist? This question was subdivided
to explore differences between the control and experimental groups’ and subgroups’
performances with regard to 2a) task accuracy 2b) task expediency and 2c) correct order
of subtask sequencing.
Significant improvements were observed in both the procedural performance
accuracy and the time for task execution in the experimental junior students when
compared to their control group peers. This improvement was expected in the junior
students exposed to CTA guided instruction, as novice practitioners constitute the ideal
target population for CTA guided instruction that elucidates the tacit knowledge of expert
practitioners (Feldon& Clark, 2006). There were no significant differences between the
control and experimental juniors for the correct sequencing of the subtasks during task
execution. This finding may reflect the lower levels of prior knowledge on postoperative
tracheal extubation in this population of students and the concomitant lack of experience
and conceptual framework (Feldon, 2007) necessary to facilitate appropriate sequencing
in the subtasks. Task execution was also significantly more expedient in the overall
experimental group (seniors and juniors) when compared to their control counterparts,
perhaps reflecting the coherent organization of task execution following CTA guided
instruction.
67
There was a trend toward improved performance in the experimental senior
students‟ accuracy, timing and sequencing of subtasks when compared to the control
seniors‟ performances. As expected a significant improvement was observed in all of the
senior students‟ sequencing performances when compared to all of the junior students‟
performances following instruction. These gains may reflect the “learning by contiguity”
(Anderson, 1987) that occurs in students with higher levels of prior knowledge in the
domain. The prior knowledge of the senior students may also have been responsible for
the lack of significant findings between the senior control and experimental groups with
respect to overall task performance. All of the senior students, having completed
hundreds of extubations in their clinical training, have to some degree, automated the task
and subtask sequences for postoperative extubation. Such automation of the procedure
may confer resistance to instructional input by way of the added challenges associated
with “unlearning” (Shriffin & Schneider, 1977) an already established routine.
Limitations
The main limitation of this study was the small number of eligible participants.
The program of nurse anesthesia currently houses 32 graduate student registered nurse
anesthetists (SRNAs); this was the targeted population for the inquiry. Of these 32
potential participants, 25 volunteers were recruited (78% participation). While the
minimal number of participants for robust parametric statistical analyses such as
comparisons between means using at-test is roughly 30 individuals (Salkind, 2008),
additional eligible participants were unavailable. This small study population may pose a
challenge to statistical rigor for parametric testing which is employed to reflect
expectations in the general population. Therefore, appropriate nonparametric testing, chi
68
square, was included in analyses to evaluate differences within the subpopulations of the
groups where possible. Future similar studies involving the comparisons of means
between groups may expand the target audience to SRNAs in other graduate programs as
well as anesthesia residents and medical students, to increase the number of participants.
The promising findings in both novices and students with higher levels of prior
knowledge in the present study, following CTA guided instruction, portend well for the
recruitment and inclusion of seasoned practitioners in future similar studies.
The current study focused only on the simplest iteration of postoperative
extubation for instruction of the novice anesthetists and examined extubation in the
healthy adult model. The other more complex extubation tasks listed in the gold standard
that were not addressed in the current inquiry, such as performing deep extubation or
managing the traumatized airway during extubation would be ideal for future similar
studies, when the participant pool can be increased or when evaluating the performances
of individuals with higher levels of prior knowledge.
Other limitations to the current study included challenges for the trained observers
in gaining and documenting accurate observations of student activities during the
videotaping of procedural evaluations in the simulation lab. Anesthesia tasks
surrounding emergence and extubation occur during a very dynamic time in case
management, during which the care provider must field and process multiple
simultaneous streams of input. It was for this reason that the procedural testing was
videotaped; to supply supportive documentation on observations for the trained raters, in
the case of disagreements on observations. While the videotaping did allow for review
and consensus for many of the student actions and verbalizations during task
69
performance, this medium did not clearly evidence all of the gas flow and vital sign
parameters visible to the observer on the screens of the anesthesia delivery unit (ADU).
This shortcoming of the videotaping process did impose some limitations on reanalysis of
student actions and decisions. This lack of visualization however was not an issue during
direct observation in the simulation lab, where the screen displays were easily viewed by
the raters. Therefore this lack of information was an issue only for the reanalysis of data
or the settling of observer disagreements. Future similar research in the simulation lab
utilizing the ADU might employ additional videotaping specifically to capture the screen
displays for added clarity. Alternatively, recordings of electronic parameters may be
captured directly through the METI® software and these might be used to supplement the
videotaped actions of the participants and the direct observations of the raters.
Participant Performance Anxiety
Additional limitations for this study may surround student anxiety during
performances in the simulation lab. This training and testing facility is a setting in which
a strict code of conduct has historically been imposed with regard to maintaining serious
demeanor and situational fidelity. Furthermore, expectations for high levels of
performance are a general tenet of training and practice in nurse anesthesia, where
vigilance and patient safety are paramount. Additional stressors surrounding clinical
faculty observing procedural testing and the videotaping of performances may have
altered student behavior or verbalizations of intentions or decisions. These proposed
student anxieties might differ in degree, depending on the individual‟s level of prior
knowledge on the task or the student‟s familiarity with the simulation lab or the ADU or
level of trust in the clinical faculty. To ameliorate some of these performance anxieties
70
the students were pre-briefed about study procedures and expectations for conduct during
simulation. Post simulation debriefing was carried out to allow for participant questions
and concerns to be addressed by the primary researcher following the simulated
procedures. Many of the control group junior students were quite verbal about their
anxieties surrounding their performances in the lab during the debriefing period. The
experimental junior students appeared less anxious about their performances during
debriefing and did not express the same concerns regarding their performances as was
observed with the control group of juniors. This apparent variance in observed anxiety
between the control and experimental juniors may reflect the clearer organization of the
CTA guided instruction. The CTA guided lesson script comprehensively listed the
conditions, processes, steps, standards, equipment, concepts and reasons for the adult
postoperative tracheal extubation task. Such organization of the lesson may have allowed
for easier student recall of subtasks or provided cues for execution. Alternately, fewer
expressed anxieties among the CTA guided juniors may reflect increased levels of self-
efficacy for task execution. Though the current study did not examine student self-
efficacy after CTA guided instruction, Campbell et al., (2011) demonstrated significant
improvements in medical student and surgical resident self-efficacy following similar
CTA guided instruction on cricothyrotomy. Future studies examining the efficacy of
CTA guided instruction in anesthesia training might easily incorporate assessments on
student self-efficacy for task execution.
Simulation Laboratory
While the simulation laboratory does offer a safe alternative to direct patient
interaction for training and testing purposes, it does have its limitations with regard to
71
situational fidelity and unconscious task cues. The METI® high fidelity human patient
simulator‟s responses can be programmed to fit the planned training or testing scenario
and any number of possible alternative responses to actions made by the student. These
simulated responses mirror those of human physiological reactions but necessarily also
require additional active programming by the METI® operator who must interact
dynamically with the unfolding clinical scenario, the student‟s actions or verbalized
intentions and the expected reactions from the METI® to these actions. Because of
limitations imposed by the simulation process, it was not possible to exactly duplicate the
testing scenario for each of the students. There was some slight nuanced individuality to
each of the testing scenarios in response to student actions; however all of the
performances followed an algorithm for extubation by the novice anesthetist in the awake
postoperative adult. While individual scenario nuances were extremely subtle, they did
result in some students needing to perform one or two extra steps for task execution. For
example, if a student extubated the patient without first suctioning the oropharynx
appropriately the patient, having full return of reflexes, might have coughed on
extubation. Whereas this coughing did not occur if the student appropriately suctioned
the oropharynx or stated that she or he had done this before extubating the trachea. These
simulated individualized patient reactions were necessary to maintain physiologic fidelity
in response to the unfolding clinical scenario. More importantly, any simulated adverse
patient responses to student actions or omissions during care delivery represent ethical
imperatives in both the code of situational awareness and the obligation to above all,
ensure safe practice in nurse anesthesia clinical education.
72
The current study demonstrates positive trends and statistically significant
improvements in the performances of graduate student nurse anesthetists learning the task
of adult postoperative tracheal extubation through CTA guided instruction. Specifically,
performance improvements were significant for task accuracy, task expediency and
subtask sequencing following CTA guided instruction. The experimental group of
students significantly outpaced their control counterparts on the measure of task
expediency. Junior students, task novices demonstrated significant improvements on task
accuracy as well as task expediency following CTA guided instruction. This finding
illustrates the benefits of CTA guided instruction for the task novice. Senior students in
the experimental group showed a trend toward improvements in task accuracy and
expediency when compared to control group seniors. Improvements in correct
sequencing for the subtasks of extubation were significant in the experimental senior
students. This finding additionally illustrates the benefits of CTA guided instruction for
students with higher levels of prior knowledge, in which it can be assumed, task
automation is already established. The current study did not demonstrate any significant
gains in declarative knowledge for trainees following either standard or CTA guided
instruction on this anesthesia task. While similar studies with larger participant pools
may be required to more thoroughly evaluate the efficacy of CTA guided instruction in
graduate nurse anesthesia training, the findings from this study are nonetheless positive.
The procedural performances of student anesthetists, both novices and students with
higher levels of prior knowledge, were significantly improved following CTA guided
instruction on adult postoperative tracheal extubation.

73
CONCLUSION
The purpose of this study was to compare the efficacy of CTA guided instruction
on an anesthesia practice task, adult postoperative tracheal extubation, to standard recall-
based clinical instruction in the training of graduate student nurse anesthetists. The
current standard method of teaching clinical skills is limited with regard to conveying
overt and tacit information for task execution. The CTA method employed in this study,
to inform instructional content, elicited expertise from anesthesiology experts to reveal
the necessary equipment, performance objectives, conceptual knowledge, procedural
knowledge and performance standards essential for safe extubation. Trainees exposed to
CTA guided instruction based on this expertise, demonstrated positive trends and
statistically significant improvements over students who received traditional recall-based
instruction on postoperative extubation. The junior participants, novices in anesthesia
care, and the target population for most instructional improvements in nurse anesthesia
training, demonstrated the most significant gains in procedural knowledge following
CTA guided instruction. These gains included improved task accuracy and expediency
over control group performances. An additional key finding in this study was the
statistically significant improvement in the performances of students with higher levels of
prior knowledge. Following CTA guided instruction; the senior students demonstrated
significant performance improvements for correct sequencing of the extubation subtasks
when compared to the junior students. These finding illustrate the benefits of CTA
guided instruction for both the novice anesthetist and the student with higher levels of
prior knowledge.

74
GLOSSARY OF TERMS
Anesthesia Care Team (ACT)
A group of professional anesthesia care providers, working together to deliver
anesthesia services. An ACT may consist of a physician anesthesiologist, a certified
registered nurse anesthetist (CRNA), an anesthesiology assistant (AA) or a trainee such
as an anesthesia residents or a student registered nurse anesthetist (SRNA).

Automaticity
An unconscious fluidity of engagement in activity ensuing in the expert following
sustained and repeated execution (Anderson, 1996; Clark & Estes, 1996) of tasks. This
repetition results in an automated or “auto-pilot” mode of functioning. As a result of this
automaticity, experts may not purposefully or consciously access their knowledge
(Ericsson, 2004b).

Central Venous Catheter (CVC)
Intravenous access placed in a central vein such as the internal jugular, femoral or
sub clavian vein to facilitate the delivery of intravenous fluids or medications or for the
purpose of measuring central venous blood pressure.

Certified Registered Nurse Anesthetist (CRNA)
An advanced practice professional nurse, trained at the graduate level in
anesthesiology, who works with surgeons, dentists or podiatrists to provide anesthesia
services during and surrounding the time of surgery or labor, and who might also work
with an anesthesiologist (physician anesthetist) on an anesthesia care team.

Cognitive Load
Cognitive load refers to the simultaneous demands on working memory during
information processing that can present challenges to learners; hence cognitive load is
often the target for interventions by instructional designers. Cognitive load includes
intrinsic load, germane load and extraneous load (Chandler & Sweller, 1991). Intrinsic
cognitive load, that which is inevitable in task execution, germane cognitive load, the
load on cognitive resources associated with the utilization of constructed schema or
access to stored memories, which facilitate task execution, and extraneous cognitive load,
which is non contributory or distracting during cognitive task execution.

Cognitive Tasks
These are tasks that require mental engagement and effort. Both declarative and
procedural knowledge are necessary for the execution of most cognitive tasks (Clark,
2008).

Cognitive Task Analysis
(CTA) is a knowledge elicitation technique employed for acquiring expertise from
domain specialists. The goals of CTA are to capture and catalogue, from multiple subject
matter experts (SME), the necessary equipment, performance objectives, conceptual
knowledge, procedural knowledge and performance standards employed when experts
75
execute a particular task, to define the “gold standard” of practice in a particular skill set
(Clark et al., 2008).

Conditional Knowledge
This sub type of procedural knowledge (Paris et al., 1983) facilitates strategic
application of declarative and procedural knowledge, for successful task execution.
Conditional knowledge is knowledge about why and when something is (Schraw, 1998)
or should be. Conditional knowledge guides decisions on when and when not to act or
execute a possible task consideration (Paris, et al., 1983).

Critical Decision Method (CDM)
CDM is a method of cognitive task analysis developed by Klein, Calderwood and
MacGregor (1989) that has been employed to capture decision making in real world
contexts and that has been employed to explore decisions surrounding untoward or
adverse events for later analysis, discussion, instruction, product design or the institution
of safety measures.

Declarative Knowledge
Declarative knowledge is overt comprehension of facts, events and objects and is
represented by knowledge about why or that something is.

Expertise
Expertise develops after a minimum of ten years in a specific domain, during
which an expert acquires skills and knowledge essential for consistently superior
performance and complex problem solving in that domain (Bransford, Brown, &
Cocking, 1999; Chi, 2006; Ericsson, Krampe, & Tesch-Römer, 1993; Feldon& Clark,
2006; Kirschner, Sweller,& Clark, 2006). Experts excel in solution generation, cue and
pattern recognition and routinely spend significant time considering problems
qualitatively (Chi, 2006). Experts typically possess superior self-monitoring skills and
are able to gauge their own understanding and comprehension as well as select
appropriate strategies for problem solving, while outperforming others in domain relevant
knowledge retrieval (Chi, 2006).

Explicit Knowledge
Explicit knowledge represents facts that are unambiguous (Dienes & Perner,
1999); this type of knowledge is overt and easily accessed, codified and communicated.

Extubation
Extubation is the removal of any tube in situ.

Gold Standard (GS)
An aggregate of the expertise elicited from the CTA guided interviews with
subject matter experts, which includes the necessary equipment, performance objectives,
conceptual knowledge, procedural knowledge and performance standards employed
when experts execute a particular task (Clark et al., 2008).

76
Junior Student
A first year graduate Student Registered Nurse Anesthetist in the Program of
Nurse Anesthesia.

Procedural Knowledge
Knowledge about how and when something occurs (Clark & Estes, 1996).
Procedural knowledge can be acquired though instruction or generated through repeated
encounters (Paris et al., 1983) and this type of knowledge is goal specific and production
oriented (Corbett & Anderson, 1995). Procedural knowledge is employed to execute
procedures or possible behaviors that an individual can select from when performing
tasks (Paris et al., 1983). During knowledge compilation, procedural knowledge
develops from the merger of performance and domain specific declarative knowledge, or
facts that support the new procedural process (Anderson, 1982).
Program of Nurse Anesthesia (PNA)
A graduate anesthesiology training program, responsible for the education of
advanced practice student registered nurse anesthetists (SRNAs).

Self-Efficacy
This construct, operationalized by Bandura as a key concept in his Social
Cognitive Theory of motivation in the achievement motivation literature (Bandura, 1997;
Schunk et al., 2008), is defined as an individual„s beliefs about her performance
capabilities in a specific task or domain (Bandura, 1997). Beliefs in abilities are twofold
and include expectancy beliefs: which are outcome expectations, addressing one„s belief
that a particular behavior will lead to particular outcome, and efficacy expectations,
beliefs about whether one can effectively perform the behaviors required to produce the
outcomes (Eccles & Wigfield, 2002).

Senior Student
A second year graduate Student Registered Nurse Anesthetist (SRNA) in the
Program of Nurse Anesthesia.

Student Registered Nurse Anesthetist (SRNA)
A graduate student in an approved Program of Nurse Anesthesia with a minimum
of one year of prior experience in an intensive care unit (ICU), but typically having
several years of prior ICU experience before entering training in anesthesiology.

Strategic Knowledge
See Conditional Knowledge.

Subject Matter Expert (SME)
An individual determined as an expert in a given domain, based on years of
service, hours of training, consistently superior performance or ability to solve complex
and unique problems, or based on departmental standing or peer nomination.

77
Tacit Knowledge
Polanyi (1962) first described this term and held that this type of knowledge,
which is difficult to articulate, is subsidiary to, as well as integrated with, and supportive
of, the explicit knowledge needed for task performance. Polanyi used the term in the
context of medical skill acquisition and expressly conveyed that tacit knowledge is
subsidiary to skill acquisition and not the main object of attention (Polanyi, 1962).

Trachea
The “wind pipe” or a portion of the normal anatomical airway, supported by
cartilaginous rings and including the larynx, which connects the pharynx and bronchi.

78
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APPENDIX A
CTA CODING SCHEME AND PROCEDURE
Conditions:
Indications = I
Contraindication = CI
Standard for Accuracy = SA
Standard for Time = ST
Equipment and Materials = EM
New (to the learners) declarative knowledge required to perform the steps:
Concepts = DC
Processes = DPR
Principles = DPN
Procedure:
Classification = PDC
Modification = PDM
Sensory Cues:
Hearing = SH
Seeing = SS
Touching = ST
Steps:
Action Step = AS – definitive and measurable activities that would yield
measurable and definable results-
Decision Step = DS
Decision step criteria for deciding = DSC (“IF” statement)
Decision step alternatives = DSA (“THEN” statement)
Reason for a step = r (small r)
Uncertain =  (Delta triangle)
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APPENDIX B
CTA GOLD STANDARD FOR POSTOPERATIVE TRACHEAL EXTUBATION
Procedure Title: Postoperative Tracheal Extubation in the Healthy Adult Patient
1. Objective
Safe and efficient removal of the endotracheal tube from the healthy adult
postoperative patient (A51-58; A64-65; A68-79; A81-96; B22-28; C15-30)
2. Reasons
 When intubation is no longer required; to facilitate the resumption of
respiratory homeostasis via the natural airway in the adult postoperative
patient (A94-96; B22-24; C34; C58-59)
 The risks of not performing extubation safely or efficiently may include:
o Laryngospasm/ Bronchospasm (A132-133; B437; B698-700; B886-
893; B1006-1009; C814-816)
o Aspiration/ Regurgitation/ Aspiration Pneumonia (A172-176; B336-
337; B342 - 346; B554-555; B583-593; C569)
o Airway obstruction/Hypoventilation/ Hypoxia (A109-113; A172;
A185-186; B210; B1038-1039; B864-871; C 394-397; C814)
o Negative pressure pulmonary edema (A116-120; B135-137)
o Trauma to oropharynx, teeth, airway / Airway compromise (A98-105;
A245; B983-985; C77-80)
o Increased intracranial pressure/Increased intraocular pressure/ Cerebral
hemorrhage/ Aneurysm rupture (A72-74; A1393; B384)
o Hypertension/ Bleeding (A69-72; A98; B384; B349-353; B960;
B977-982; C579-581)
o Surgical site disruption(A74-75; B380-382; C575-577)
o Unnecessary delay of extubation(A1302-1303; C106-108)
o Reintubation (A290-292; B981-982; C158-161)
o Death (A113)

91
3. Conditions
Indications: (A149-158; B22-24; C58-64)
 Patient condition supports postoperative extubation (A151-152; A187; B38-39;
C59-63) and reliable equipment is available to support patient respiration and
ventilation if extubation fails (A254-257; A265-296) and immediate access to
anesthesia faculty is available (C147)
 Absence of contraindications to extubation after surgery (A216-218; A702-704;
B32-34; C34; C58-59)
Contraindications: (A163-177; B35-36; B42-46; B50-55; C80-83)
 Indications for intubation remain (A163-164; B42-50; C66-83)
o Suboptimal oxygenation (A166; A884; C70; C331-371)
o Suboptimal ventilation (A168; A884; B44-46; C70)
o Absence of protective airway reflexes (A172-173; A884; C68)
o Hemodynamic instability massive trauma/ blood loss/ chest
trauma/hypothermia/sepsis (A172-177; B34-38; C70-72)
o Inability to meet pain control needs without intubation (B46-49)
o Long cancer surgery (B46-47)
o Intubation was difficult and associated with airway trauma (B50-55)
o Airway edema/ trauma/ impending airway edema (C77-80)
o Possibility of return to the OR in the immediate future (A735; C84-87)
o Absence of reliable equipment to re-intubate if extubation fails (A254-
257; A265-296)
4. Standards
 Time
Approximately 10 – 15 minutes of preparation in the last 30- 45 min of
surgery, task of extubation takes approximately 1 – 2 minutes (A501-510;
B63-64; B82-86;C98-101)
 Accuracy
Greater than 95 % accuracy (C120-124; C133)

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5. Equipment
 Mandatory
o Back up emergency airways including LMA (A273-274; B117-118; C155)
o Breathing circuit/ reservoir bag/ PPV mask (A227; B107; C621)
o Emergency medications/ succinylcholine (B124-126)
o ETT tube same size or one size smaller (A269-271, B117-118; C157-160)
o Laryngoscope handles and blades (A271-272; B118; C148)
o Neuromuscular twitch monitor (B662; C191; C190)
o Oral and nasal airways (A1007; A1011; A1421; B101; B105; C154-155)
o Protective eyewear/ goggles (B786)
o Reliable positive pressure ventilation equipment (A277; B916; C620)
o Reliable source of oxygen (A277; B130; B921;B 924; B1037; C147)
o Resuscitation equipment/ defibrillator (C148; C164)
o Standard ASA monitors including ECG, BP, SaO2, ET CO2 detector,
temperature (A259-262; A267-268; B123; B138-140; C170-179)
o Suction / suction catheters, 2 types (A 218; A276; B92; B102-103; C198)
o Universal precaution barriers (KKE)
o Working ventilator/ anesthesia machine/ gas monitor (A256; B97; C171 )
 Recommended
o BIS monitor (B299; C172)
o Blood gas analysis equipment (C331)
o Boujie (A274)
o Esmolol (B979)
o Fiberscope (A296; C156)
o Glidescope (A295)
o Humidifier (B1079)
o Level one/ Hotline (B1080)
o Lidocaine gel (B834) lidocaine IV/ ETT (KKE)
o Lightwand (A274)
o Patient Restraints (KKE)
o Reversal drugs for NMB (A233-234; A847; B173; B214-215; B320;
B330; B425-427)
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o Reversal drugs for opioids & benzodiazepines (A629-636; A847)
o Stethoscope (A291)
o Syringe (A946; B93; C680)
o Tape to secure the ETT (A219; B767; C618)
o Tongue blade (B879-880)
o Transport mask (B1044)
o Transport O2 (B895)
6. Task List
1. Monitor surgical completion and begin tapering anesthesia(A182-188; A206-208;
A231-235; A343-344; A399-407; A457-458; A460-465; A474-477; A630-642;
A700-704; A735; A1391; B43-47; B53-55; B263-265; B140-141; B273-274;
B1059-1062; B1069-1081; C71-73; C77-80; C84-87; C99-108; C212-218; C246-
264; C324-332;C440-446; A182-188; A231-235; A493-495; A630-642; A688-
690; B161-175; B219-225; B253-256; B286-291; B302-311; B745-749; C96-
101; C403-405; C427-430; C459-463; C486-494; C799-808; KKE)
2. Task 2: Position the patient for safe extubation (A189; A286-288; A493-494;
A688-690; B92-93; B243-252; B286-290; B387-392; B459-460; B464-469;
B575-596; B736-737; B799-808; B818-822; B1006-1009; C275-279; C390-393;
C431-436; C525-537; C639-643)
3. Task 3: Emerge the patient and extubate the trachea(A691-692; A771; A810;
B619-624; C275-279; C636-662; C808-815; B448-451; B724-737; B799-808;
C453-454; C489-495; A189-A191; A219; A277-280; A367; A944-947; A953-
955; A960-964; B763-792; B771-774; B791-793; B1000-1003; B1006-1011;
C219; C618-626; C679-680; C685-688)
4. Task 4: Monitor and confirm post extubation respiratory homeostasis(A98-120;
A132-134; A214-216; A290-292; A368; A375; A978-985; A1108; A1025-1027;
A1028-1031; B25-28; B126-133; B133-135; B913; B 917-924; C220-221; B864-
869; B799-800; B854-858; B866-877; B844-903; B864-869, B860-862; B880-
884; B885-887; B892-899; B914-917; B926-928; B1056-1060; B799; B854-855;
C211; C393-397; C621-622; C702-703; C724-726; C723-726)
7. Procedure Steps
Task 1: Monitor surgical completion and begin tapering anesthesia
(A182-188; A206-208; A231-235; A343-344; A399-407; A457-458; A460-465;
A474-477; A630-642; A700-704; A735; A1391; B43-47; B53-55; B263-265;
B140-141; B273-274; B1059-1062; B1069-1081; C71-73; C77-80; C84-87; C99-
108; C212-218; C246-264; C324-332; C440-446; A182-188; A206-208; A231-
94
235; A493-495; A630-642; A688-690; B161-175; B219-225; B253-256; B286-
291; B302-311; B745-749; C96-101; C403-405; C427-430; C459-463; C486-494;
C799-808; KKE;A189; A286-288; A493-494; A688-690; B92-93; B243-252;
B286-290; B387-392; B459-460; B464-469; B575-596; B736-737; B799-808;
B818-822; B1006-1009; C275-279; C390-393; C431-436; C525-537; C639-643)
Step: Actions and Decisions
1.1 Monitor the patient and the surgical culmination, and begin to taper anesthetics.
a. IF the surgical case was long THEN begin to taper anesthetics about 30
minutes before you plan to emerge and extubate the patient (A346) and go
to Step 1.2
b. IF the surgical case was short THEN begin to taper anesthetics about 15
minutes before surgery completion (C99-108); go to Step 1.2
c. IF surgery end is imminent and you have not tapered anesthetics
appropriately or have over medicated THEN plan to reverse medications
as needed to facilitate emergence and monitor the patient for return of
respiratory homeostasis (A182-188; A206-208; A231-235; A630-642) and
go to Step 1.2
d. IF the patient is not fully paralyzed THEN do not give additional
neuromuscular blocking (NMB) agents unless paralysis is essential
(KKE), and switch from controlled ventilation mode to SIMV or
spontaneous mode (SV) to build CO2 and further encourage spontaneous
ventilation (C459-463) without causing the patient to buck against the
ventilator or move excessively while the surgeons finish their procedure
(KKE) go to step go to Step 1.2
1.2 During tapering of anesthesia, continue to monitor the patient‟s depth of
anesthesia:
a. IF the surgical procedure is nearing completion and post surgical
respiratory homeostasis is anticipated THEN begin preparing for
emergence and extubation to follow the remaining surgical stimulation
(A399-407; A460-465; A457-458; A474-477; A493-495;B251-255;
B263-265; B273-274; C71-73; C99-108; C214-218; C249-253)by
beginning to reduce the level of anesthesia delivered to allow for a BIS
level of about 40 to 50 (KKE) go to Step 1.3
b. IF the patient has experienced a change in condition or excessive blood
loss THEN assess an arterial blood gas (ABG) (C324-332; C363-371);
consult anesthesia faculty and refer to the Procedure for Determining
Extubation Potential in the Unstable Postoperative Patient (KKE)

95
c. IF airway edema or trauma has resulted or is anticipated following a
difficult intubation, THEN defer extubation (C77-80); consult anesthesia
faculty and refer to the Procedure for the Management of Postoperative
Airway Edema (KKE)
d. IF airway edema, trauma or dysfunction is present or anticipated from the
surgical intervention THEN defer extubation, consult the surgeons and
anesthesia faculty (C77-80) and refer to the Procedure for the
Postoperative Management of Iatrogenic Airway Trauma (KKE)
e. IF the surgeons are finishing the current surgical intervention but plan to
bring the patient back to the OR in the immediate future THEN defer
extubation (A735; C84-87) and refer to the Procedure on Transporting the
Intubated Postoperative Patient to the Intensive Care Unit (KKE)
1.3 Reverse the neuromuscular blocking agent (NMB) only when patient movement
is no longer contraindicated by patient condition or the surgical procedure (B161-
175; C96-101; C403-405; C799-808) go to step 1.4
a) IF open abdominal case THEN reverse the NMB only when the peritoneal
fascia is closed (B219-225; B253-256) go to step 1.4
b) IF the surgeons are on skin closure THEN reverse the NMB if not
previously performed and monitor for spontaneous ventilation (C427-430)
go to step 1.4
1.4 Suction the oropharynx after reversal of NMB and while the patient is still asleep
enough to tolerate the stimulation of suctioning without bucking or moving
excessively (A452-454; C801-805) go to step 1.5
1.5 When the patient is breathing spontaneously but not coughing or moving,
maintain this level of anesthesia; keeping the BIS around 55-60 for the surgery
completion (B286-291; B302-311) and go to step 1.6
1.6 Monitor spontaneous ventilation during surgical closure and assess the patient for
return of respiratory homeostasis i.e., respiratory rate (RR) 8 -30/min, tidal
volume (TV) > 5cc/kg, ETC02< 45 cmH2O (C479-483)
a) IF the ETCO2 level is above 60 cmH2O (B748-749) THEN assist
ventilation by hand or with the ventilator in SIMV or pressure support
mode (KKE) until the patient is able to sustain appropriate minute
ventilation (C486-494) go to step 2.1

96
Task 2: Position the patient for safe extubation
(A189; A286-288; A493-494; A688-690; B92-93; B243-252; B286-290; B387-392;
B459-460; B464-469; B575-596; B736-737; B799-808; B818-822; B1006-1009;
C275-279; C390-393; C431-436; C525-537; C639-643)
Step Actions and Decisions
2.1 Employ Universal precautions, put on gloves and protective eyewear before
beginning extubation procedure (KKE) go to 2.2
2.2 IF the patient is not in a supine position at the top of the table at the end of
surgery THEN place the patient in this position to facilitate optimal/ safe
access to the airway during emergence and extubation (C525-537) go to step
2.3
2.3 IF the patient is at increased risk for aspiration or is obese then raise the head
of the bed 30 to 40 degrees or place the patient in reverse Trendelenberg
position for extubation (B387-392; B575-596) go to step 2.4
2.4 IF the OR table is turned away from the anesthesia practitioner THEN place
the patient on 100% O2 and return the table to its optimal position with the
patient‟s head in proximity to the ventilator and anesthesia practitioner (KKE)
go to step 2.5
2.5 Place an oral airway (OA) before the patient wakes up (A1011; B799-808;
C393) go to step 2.6
a) IF the patient underwent oropharyngeal surgery or is edentulous
THEN place a nasal pharyngeal airway (NA) instead of an OA (B818-
822) go to step 2.6
b) IF the patient has obstructive sleep apnea (OSA) THEN place a nasal
(B818-822) and oral airway before wakeup (KKE) and go to step 2.6
2.6 Suction the oropharynx thoroughly and the ETT if necessary (A189; A286-
290; B92-93; C390-393) go to step 2.7
a) IF the secretions or blood in the oropharynx is thick or the patient is a
“full stomach” THEN use the Yankauer suction tip to suction (B459-
460) go to step 2.7
b) IF the secretions are thin or you may cause trauma/ bleeding to the
mucosa THEN use the soft suction catheter and get deep into the
oropharynx about 5 – 6 inches to get pooled secretions (B464-469) go
to step 2.7

97
c) IF a gastric tube (GT) is in place THEN thoroughly suction this also
(A286-288) and remove the GT if the surgeons are in agreement
(KKE) go to step 2.7
2.7 IF the patient is at increased risk for laryngospasm or bronchospasm during
extubation THEN administer an appropriate dose of lidocaine (B1006-1009)
2% IV or 4% via ETT one to two minutes before extubation and discuss
performing a deep extubation with anesthesia faculty (KKE) or go to step 2.8
a) IF the patient is to be extubated while asleep/ deep extubation THEN
refer to the Procedure for Deep Extubation in the Postoperative
Healthy Adult
2.8 Three to 5 minutes before surgical stimulation is expected to finish, place the
patient on 100% O2 (C431-436) and taper remaining anesthetic agents to
facilitate the patient transitioning from Guedel‟s Stage III of anesthesia to
Stage I when surgery has finished (A493-494) go to step 2.9
a) IF the surgical case was long THEN plan for a longer wait to reach
Guedel‟s Stage I from stage III of anesthesia if agents were not tapered
early (A688-690) go to step 2.9
b) IF the case was short THEN anticipate a more rapid (B243-252)
transition from Stage III toward Stage I if the patient is not over
narcotized (KKE) go to step 2.9
c) IF regional anesthesia was used in conjunction with GAETT THEN be
prepared for a more rapid transition from Stage III toward Stage I than
if GA and IV opioids were use (B243-252) go to step 2.9
2.9 Ensure that the patient is safely restrained with a safety-belt and that both
arms are gently but securely restrained before the patient passes into Stage II
from Stage III (KKE) go to step 2.10
2.10 Remove the eye tape/ and or protective goggles from the patient‟s eyes
(KKE) go to step 2.11
2.11 Turn up the O2 flows to >10 LPM and monitor the level of MAC (minimal
alveolar concentration) remaining and allow the patient to emerge
undisturbed/ without stimulation (C639-643) go to step 2.12
2.12 Continue monitoring for respiratory homeostasis (B736-737; C275-279) as
the patient passes from stage II toward stage I of anesthesia go to step 3.1

98
Task 3: Emerge the patient and extubate the trachea
(A691-692; A771; A810; B619-624; C275-279; C636-662; C808-815): B448-451;
B724-737; B799-808; C453-454; C489-495; A189-A191; A219; A277-280; A367;
A944-947; A953-955; A960-964; B763-792; B771-774; B791-793; B1000-1003;
B1006-1011; C219; C618-626; C679-680; C685-688)
Step Actions and Decisions
3.1 Assess the patient during emergence for signs of waking up, i.e. reaching stage I of
anesthesia, by observing for the return of reflexes such as coughing, swallowing,
increased muscle tone, pupils returning to conjugate/ midline position and
appropriate response to noxious stimuli (A771; A810; B619-624) go to step 3.2
a) IF the patient remains in Stage II or you are not sure if the patient is in Stage
II THEN do not extubate(A691-692; B 619-624; C808-815) and go to step 3.1
3.2 During emergence, continue monitoring the patient for maintenance of respiratory
homeostasis i.e., RR remains regular, the TV is appropriate and the ECO2 is < 45
cmH20 as the patient passes from stage II to stage I of anesthesia (B736-737;
C275-279) go to step 3.3
a) IF the RR is < 8 THEN gently assist the patient with bag assisted ventilation
and go to step 3.1
b) IF the RR is > 30/ minute THEN titrate opioids for pain control (C489-495)
using the RR as an indication of patient pain unless the high RR may reflect
patient anemia, hypovolemia, hypoventilation, fever or excessive CO2 levels
(KKE) and go to step 3.2
c) IF the RR is irregular THEN continue monitoring for return of a regular
pattern (KKE) and go to step 3.2
3.3 When the patient meets the Stage I criteria listed in Step 3.1 and the requirements in
Step 3.2 for respiratory homeostasis, suction the oropharynx again if necessary
(B448-451; C453-454) and then loosen the tape edges on the patient‟s face (A219;
A944-946; B767-768; C618) and go to step 3.4
3.4 Place your positive pressure ventilation (PPV) mask next to the patient‟s head (A191;
A277-280) on the left side of the OR table and place your Yankauer suction catheter
to the right of the patient‟s head tucked under the mattress corner (C678-681) and go
to step 3.5

99
3.5 Reassess end tidal level of anesthetic gasses for MAC awake level (< 0.3 MAC);
observe BIS level > 80 and patient eye opening in response to name calling or patient
making motions to self-extubate, assess for ability to squeeze a hand or lift head off
of bed for > 5 seconds or to appropriately follow commands (B332-335; C636-662)
and double check that pupils are midline/ conjugate (A563; C646), and that the
patient is able to stick out his/ her tongue (D) and go to step 3.6
3.6 When the patient is awake and responding appropriately, give a breath by gently
squeezing the bag or turning up the APL valve slightly to apply a little positive
pressure (A189 – 190; A953-955; A960-964; C619-626) while deflating the ETT cuff
(A946-947; B771-772) with a syringe and go to step 3.7
3.7 Pull out the ETT with one hand (B772-774; C618-621), you can do this with (C685-
687) or without (B791-793) disconnecting from the circuit, then place the ETT on a
towel on the patient‟s chest (C687-688) go to step 4.1
Task 4: Monitor and confirm post extubation respiratory homeostasis
(A98-120; A132-134; A214-216; A290-292; A368; A375; A978-985; A1108; A1025-
1027; A1028-1031; B25-28; B126-133; B133-135; B913; B 917-924; C220-221; B864-
869; B799-800; B854-858; B866-877; B844-903; B864-869, B860-862; B880-884;
B885-887; B892-899; B914-917; B926-928; B1056-1060; B799; B854-855; C211;
C393-397; C621-622; C702-703; C724-726; C723-726)
Step Actions and Decisions
4.1 Immediately following extubation place the PPV mask on the patient‟s face to
confirm that the patient is safe from obstruction (A214-216; B25-28; B913; C220-
221) by monitoring for exhaled CO2 in the absence of the ETT (A978-985; B799;
B854-855; C621-622; C724-726) go to step 4.2
a) IF no ETC02 is seen THEN check to see that you are holding the mask on the
face correctly with a good seal, you should see the bag moving up and down with
respiration (B854-858) go to step 4.2
4.2 Assess for and monitor chest rising, misting in the mask and movement of the
ventilator bag (B866-877; C723-726) coinciding with patient respiratory effort then
go to step 4.3
a) IF after readjusting your mask placement there is no ETC02 and the bag is not
moving THEN the patient might be holding his/ her breath (B860-862) or might
be obstructing (B864-869) go to 4.2d
b) IF the patient is holding his/her breath, THEN continue holding the PPV mask in
place and go to Step 4.2
c) IF you see paradoxical movement of the chest or throat, suppressed lung
expansions(B864-869) or you suspect airway obstruction THEN provide a chin
lift and monitor for improved air exchange (KKE) go to 4.2
d) IF no improvement in air exchange after chin lift THEN go to 2.4e)
100
e) IF airway obstruction is suspected and no oral airway is in place THEN place oral
airway (A1025-1027; C393-397) using a tongue blade to avoid putting your
fingers in the patient‟s mouth (B878-881) and reassess for chest rising, misting in
the mask and movement of the ventilator bag (B866-877; C723-726) coinciding
with patient respiratory effort then go to 4.2h
f) IF you can‟t get the mouth open to place an OA after extubation THEN lubricate
and place a nasal trumpet (B880-883) and reassess for chest rising, misting in the
mask and movement of the ventilator bag (B866-877; C723-726) coinciding with
patient respiratory effort and when you see this go to step 4.3
g) IF after placing an OA or NA the patient is still not breathing THEN give the
patient a couple of breaths with the mask and bag (B885-887) and go to step 4.2
h) IF the patient requires suctioning after the ETT is removed THEN suction again
using the Yankauer tip (C702-703) go to step 4.3
i) IF trauma, bleeding or vocal cord palsy noted THEN anticipate airway
compromise (A98-120); maintain the airway with chin lift or airway adjunct, call
for help, consult anesthesia faculty and prepare to re-intubate (KKE)
j) IF the patient is not ventilating and the oxygen saturation is dropping or the
patient‟s color is turning blue or laryngospasm occurs THEN immediately apply
positive pressure ventilation (PPV) (B914-917) by setting the APL valve to 20
cmH20 and providing PPV to facemask for 10 to 15 seconds (A1028-1031) go to
step 4.2
k) IF you need to use 2 hands to hold the mask to the jaw THEN have someone help
you and use two hands to hold the mask to supply oxygen (B882-884) or PPV
with the ventilation bag go to step 4.2
l) IF PPV does not break laryngospasm THEN give a small dose of succinylcholine
so that you will be able to ventilate the patient with 100% oxygen and call for
expert anesthesia help (A132-134; B126-133; B 917-924), continue to assist
ventilations with PPV (KKE) and go to step 4.2
m) IF after succinylcholine and ventilation with 100% O2 the patient does not
improve (A290-292; B133-135) or the pulse starts to drop THEN re-intubate
(B926-928)
4.3 IF the patient is awake and demonstrating respiratory homeostasis following
extubation THEN place the patient on the transport mask with at least 6 liters per
minute (LPM) flow of O2 and move the patient to the transport gurney (B892-899) go
to step 4.4
a) If the patient does not appear awake or is not demonstrating respiratory
homeostasis THEN maintain your PPV mask in place and keep the patient in
position on the OR table (KKE) and go to 4.2

101
4.4 Raise the head of the transport bed 45degrees if this is not contraindicated by the
surgical procedure (KKE) and continue monitoring the patient for signs of respiratory
homeostasis during transport to the recovery room (B892-899) by observing for chest
rise and misting in the transport mask and refer to the Procedure for Recovery Room
Transfer of Care for the Healthy Postoperative Adult
a) IF the patient can‟t tolerate the face mask for transport(A1108), then place it
in close proximity to the patient‟s face without strapping it on (B892-899) and
turn the O2 flow up to 10 LPM (KKE), observe the patient for chest rise
during transport and refer to the Procedure for Recovery Room Transfer of
Care for the Healthy Postoperative Adult
b) If the patient does not appear to be awake or in respiratory homeostasis THEN
remain in the OR, place the PPV mask back onto the patient, consult with
anesthesia faculty (KKE) and go to step 4.2
4.5 STOP
Other Information:
8. Conditions & Cues
 Usually performed in the OR but can be performed in the PACU or ICU if the
patient is not ready for extubation in the OR (A 39; B45-46; C769-770)
 Patients may require adequate warming, especially elderly patients, before they
are ready for extubation (B1060-1062)
9. Prerequisite Skills / Knowledge
 Standard knowledge of Nurse Anesthesia trainees including concepts of patients
at risk for aspiration, reversal of neuromuscular agents, pharmacokinetics and
pharmacodynamics of injected and inhaled agents as well as physics of anesthesia
and understanding of physiology and pathophysiology and the Stages of
anesthesia and basic airway management and masking skills (A107; A1266-1267;
B77; C458; C791-794)
10. Concepts
Advanced Cardiac Life Support (ACLS) (KKE)
Backup intubation equipment, standard and emergency drugs, oxygen and positive
pressure ventilation equipment, suction and standard monitors must be available as well
as emergency airway adjuncts and expert faculty (A252-274; B92-144; C144-180)

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Full Stomach or increased aspiration risk; patient who is not fasted for > 8 hours, or who
is otherwise an increased aspiration risk due to advanced pregnancy (> 20 weeks),
trauma, emergency surgery, patients with GERD, gastro-paresis or uncontrolled DM,
patients on chronic opioids or with GI bleed (A53; B549; C569; KKE) or obesity, (A436-
443), incompetent sphincters, hiatal hernia, Zenker‟s diverticulum, difficult intubation or
mask (B387-392; B575-596)
Patients at increased risk for aspiration should be extubated in the head up position, 30 –
40 degrees, or reverse Trendelenberg position if this is not contraindicated by the surgical
procedure (A436-443; B387-392; B575-596)
Reversal of NMB; administer reversal agents only when at least ¼ twitches present on
the twitch monitor or when the patient begins breathing spontaneously (B313-321; B423-
427; C409-423). After reversal agents are administered and twitches 4/4 and equal in
amplitude and tetanus is sustained for > 5 seconds at 50 Hz without any fade, we can
estimate that 90% of neuromuscular receptors are free of blockade (B646-658; B665-
683) and this is an acceptable parameter for this test (B 744-745)
Respiratory homeostasis: when respiratory parameters are roughly RR12 – 15 per minute,
TV 5cc/kg and ETC02 40-45cmH2O these likely reflect (B745-747) appropriate minute
ventilation ( ) to facilitate respiratory homeostasis (A313-316; KKE)
Minute Ventilation: Tidal volume (cc) x breaths per minute (RR x TV) = (A313-316)
11. Process Knowledge
 How to manage the airway, mask ventilate and re-intubate (KKE)
 How to check, use and troubleshoot the anesthesia machine (KKE)
 Reading eye signs and gauging the stages of anesthesia depth (A107; A1266-
1267; B77; C458; C791-794)
 Assessing NMB reversal, use of the train of four monitor (B646-658; B665-683;
C410-416)
 How to read and use the monitoring equipment (A259-264; B307-320; C216-221)
 How to suction appropriately (A286-287; B102-116; C423)
 Universal precautions (A53; B779; KKE)
12. Principles
Novice extubations or extubations at night should be performed only when the patient is
fully awake (B1014-1016) and when expert help is available (KKE)

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13. Sensory Mode Information
Touch
 Assess hand squeeze for patient strength (A573; C665)
 Keep a hand on the reservoir bag while the patient is breathing spontaneously to
monitor respiratory effort and rate (C692-693)
 Feel the patient‟s strength of response to the train of four and sustained tetanus
delivery when assessing NMB level or reversal (B646-658; B665-683)
 Feel the breath of the patient on exhalation on your wrist during chin lift and
transport (C751-753)
Visual
 Watch what the surgeons are doing and how the surgery is progressing (A343;
B68-72; C214; C251)
 Visually scan all monitors periodically looking for BIS level and signs that the
patient is returning to respiratory homeostasis (A259-264; B307-320; C216-221)
 Watch for CO2 waveform reflecting ventilation (A292-293; B720-721; C724-
726)
 Watch the patient skin color to make sure they are oxygenating properly (B914-
915)
 Watch for chest rise, respiratory effort and mist with spontaneous ventilation
(A995;A1121; B864-867; C723)
 Watch for paradoxical chest movement signally obstruction (B846-869)
 Observe that you have a good mask fit on the patient‟s face and that the reservoir
bag is moving in synchrony with patient breathing (B854-858)
Sound
 Listen for the tone and rate of the oxygen saturation monitor to judge heart rate
and oxygen level (A556; C697)
 Listen for sounds of airway obstruction like croaking after you have extubated
(B913-915)
 Listen constantly for any equipment alarms (KKE)
 Listen to what the surgeons are communicating to themselves or to you with
regard to surgery end (A344; B264-267; C251)

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14. Safety Factors
Novice extubations or extubations at night should be performed only when the patient is
fully awake (B1014-1016) and when expert help is available (KKE)
Employ barrier precautions (B779; KKE)
Maintain oxygen saturation monitoring up until the last minute before leaving the OR to
go to the PACU (KKE)
Keep the patient gently but securely restrained during emergence and extubation (KKE)
Perform anesthesia machine and emergency equipment check between each case (KKE)
Leave emergency airway equipment in plain sight at all times, never cover up equipment
with towels, or disable alarms (KKE)
15. Environmental Considerations
Ensure the OR is free of extraneous noise during emergence and extubation (KKE)
Develop a routine for placement of your equipment where you will find it immediately
when needed (KKE)
Make every effort to keep the patient warm (> 36 ° C) (A848-850; B140; C40)
16. References
P. Lumb (personal communication, September 19, 2011)
17. Problems
 Incorrectly determining the patient to be in Stage I when the patient remains in
Stage II i.e. pulling the ETT too soon (A110; B609-610; B644; C636-639)
 Not ensuring that proper oropharyngeal suctioning is performed (A189; B92-93;
C390-393)
 Laryngospasm/Bronchospasm (A132-133; B437; B698-700; B886-893; B1006-
1009; C814-816)
 Aspiration/ Aspiration Pneumonia (A172-176; B336-337; B362-346; B554-555;
B583-593; C569)
 Hypertension/Surgical site disruption (A67-72; A74-75; B380-384; C579-581)
 Patient hypothermia during surgery (< 35°C): allow additional time to warm the
patient before extubation (B1069-1081) or anticipate keeping the patient intubated
(B140-141; B1072-1073; C71-75; B1059-1062; B1069-1081)

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 Intubation or extubation related vocal cord, airway or pulmonary trauma or
bleeding (A89-99; B135;C77-80)
 Causing untoward patient movement during surgical closure by suctioning the
patient or placing an oral airway too early (C800-805)
 Over medicating the patient before extubation which requires reversal of
respiratory depressing medications (A182-188; A206-208; A231-235)
 Not having backup intubation equipment ready (A269-271; B117-118; C157-160)
 Surgical complications of the airway (C77-80)

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APPENDIX C
JOB AID FOR EXPERIMENTAL INSTRUCTION FACULTY
Objective: The safe and efficient removal of the endotracheal tube from the healthy adult
postoperative patient.
Figure C-1: Adult Postoperative Extubation Task List

Monitor surgical
completion and
begin tapering
anesthesia

Position the patient
for safe extubation
Emerge the patient
and extubate the
trachea
Monitor and
confirm post
extubation
respiratory
homeostasis
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Equipment:
 Mandatory
o Back up emergency airways including LMA
o Breathing circuit/ reservoir bag/ PPV mask
o Emergency medications/ succinylcholine
o ETT tube same size or one size smaller
o Laryngoscope handles and blades
o Neuromuscular twitch monitor
o Oral and nasal airways
o Protective eyewear/ goggles
o Reliable positive pressure ventilation equipment
o Reliable source of oxygen
o Resuscitation equipment/ defibrillator
o Standard ASA monitors including ECG, BP, SaO2, ET CO2 detector,
temperature, suction & suction catheters, 2 types
o Universal precaution barriers (gloves/ goggles)
o Working ventilator/ anesthesia machine/ gas monitor
 Recommended
o BIS monitor
o Blood gas analysis equipment
o Boujie
o Esmolol
o Fiberscope
o Glidescope
o Humidifier
o Level one/ Hotline
o Lidocaine gel &lidocaine IV/ ETT
o Lightwand
o Patient Restraints
o Reversal agents for NMB
o Reversal agents for opioids & benzodiazepines
o Stethoscope
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o Syringe
o Tape to secure the ETT
o Tongue blade
o Transport mask
o Transport O2

Task 1: Monitor surgical completion and begin tapering anesthesia
Step Actions and Decisions
1.1 Monitor the patient and the surgical culmination, and begin to taper anesthetics.
o IF the surgical case was long THEN begin to taper anesthetics
about 30 minutes before you plan to emerge and extubate the
patient
 Go to Step 1.2
o IF the surgical case was short THEN begin to taper anesthetics
about 15 minutes before surgery completion
 Go to Step 1.2
o IF surgery end is imminent and you have not tapered anesthetics
appropriately or have over medicated THEN plan to reverse
medications as needed to facilitate emergence and monitor the
patient for return of respiratory homeostasis
 Go to Step 1.2

 IF the patient is not fully paralyzed THEN do not give additional
neuromuscular blocking (NMB) agents unless paralysis is essential and
switch from controlled ventilation mode to SIMV or spontaneous mode
(SV) to build CO2 and further encourage spontaneous ventilation without
causing the patient to buck against the ventilator or move excessively
while the surgeons finish their procedure
 Go to Step 1.2

1.2 During tapering of anesthesia, continue to monitor the patient‟s depth of
anesthesia
o IF the surgical procedure is nearing completion and post surgical
respiratory homeostasis is anticipated THEN begin preparing for
emergence and extubation to follow the remaining surgical
stimulation by beginning to reduce the level of anesthesia
delivered to allow for a BIS level of about 40 to 50

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 Go to Step 1.3
o IF the patient has experienced a change in condition or excessive
blood loss THEN assess an arterial blood gas (ABG) consult
anesthesia faculty
 Go to the Procedure for Determining Extubation
Potential in the Unstable Postoperative Patient

o IF airway edema or trauma has resulted or is anticipated following
a difficult intubation, THEN defer extubation; consult anesthesia
faculty
 Go to the Procedure for the Management of
Postoperative Airway Edema

o IF airway edema, trauma or dysfunction is present or anticipated
from the surgical intervention THEN defer extubation, consult the
surgeons and anesthesia faculty
 Go to the Procedure for the Postoperative Management
of Iatrogenic Airway Trauma

o IF the surgeons are finishing the current surgical intervention but
plan to bring the patient back to the OR in the immediate future THEN
defer extubation
 Go to the Procedure on Transporting the Intubated
Postoperative Patient to the Intensive Care Unit

1.3 Reverse the neuromuscular blocking agent (NMB) only when patient movement
is no longer contraindicated by patient condition or the surgical procedure
 Go to Step 1.4
o IF open abdominal case THEN reverse the NMB only when the
peritoneal fascia is closed
 Go to Step 1.4
o IF the surgeons are on skin closure THEN reverse the NMB if not
previously performed and monitor for spontaneous ventilation
 Go to Step 1.4

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1.4 Suction the oropharynx after reversal of NMB and while the patient is still asleep
enough to tolerate the stimulation of suctioning without bucking or moving
excessively
 Go to Step 1.5

1.5 When the patient is breathing spontaneously but not coughing or moving,
maintain this level of anesthesia; keeping the BIS around 55-60 for the surgery
completion
 Go to Step 1.6
1.6 Monitor spontaneous ventilation during surgical closure and assess the patient for
return of respiratory homeostasis i.e., respiratory rate (RR) 8 -30/min, tidal
volume (TV) > 5cc/kg, ETC02< 45 cmH2O
o IF the ETCO2 level is above 60 cmH2O THEN assist ventilation
by hand or with the ventilator in SIMV or pressure support mode
until the patient is able to sustain appropriate minute ventilation
 Go to Step 2.1
Task 2: Position the patient for safe extubation
Step Actions and Decisions

2.1 Employ Universal Precautions, put on gloves and protective eyewear before
beginning the extubation procedure
 Go to Step 2.2
2.2 IF the patient is not in a supine position at the top of the table at the end of
surgery THEN place the patient in this position to facilitate optimal/ safe access to
the airway during emergence and extubation
 Go to Step 2.3
2.3 IF the patient is at increased risk for aspiration or is obese then raise the head of
the bed 30 to 40 degrees or place the patient in reverse Trendelenberg position for
extubation
 Go to Step 2.4
2.4 IF the OR table is turned away from the anesthesia practitioner THEN place the
patient on 100% O2 and return the table to its optimal position with the patient‟s
head in proximity to the ventilator and anesthesia practitioner
 Go to Step 2.5

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2.5 Place an oral airway (OA) before the patient wakes up
 Go to Step 2.6
o IF the patient underwent oropharyngeal surgery or is edentulous THEN
place a nasal pharyngeal airway (NA) instead of an OA
 Go to Step 2.6
o IF the patient has obstructive sleep apnea (OSA) THEN place a nasal and
oral airway before wakeup
 Go to Step 2.6

2.6 Suction the oropharynx thoroughly and the ETT if necessary
 Go to Step 2.7
o IF the secretions or the blood in the oropharynx is thick or the patient is a
“full stomach” THEN use the Yankauer suction tip to suction
 Go to Step 2.7

o IF the secretions are thin or you may cause trauma/ bleeding to the mucosa
THEN use the soft suction catheter and get deep into the oropharynx
about 5 – 6 inches to get pooled secretions
 Go to Step 2.7

o IF a gastric tube (GT) is in place THEN thoroughly suction this also and
remove the GT if the surgeons are in agreement
 Go to Step 2.7

2.7 IF the patient is at increased risk for laryngospasm or bronchospasm during
extubation THEN administer an appropriate dose of lidocaine 2% IV or 4% via
ETT one to two minutes before extubation and discuss performing a deep
extubation with anesthesia faculty
o IF the patient is to be extubated while asleep/ deep extubation THEN
 Go to the Procedure for Deep Extubation in the
Postoperative Healthy Adult

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2.8 Three to 5 minutes before surgical stimulation is expected to finish, place the
patient on 100% O2 and taper remaining anesthetic agents to facilitate the patient
transitioning from Guedel‟s Stage III of anesthesia to Stage I when surgery has
finished
 Go to Step 2.9

o IF the surgical case was long THEN plan for a longer wait to reach Stage I
from stage III of anesthesia if agents were not tapered early
 Go to Step 2.9
o IF the case was short THEN anticipate a more rapid transition from Stage
III toward Stage I if the patient is not over narcotized
 Go to Step 2.9

o IF regional anesthesia was used in conjunction with GAETT THEN be
prepared for a more rapid transition from Stage III toward Stage I than if
GA and IV opioids were use
 Go to Step 2.9

2.9 Ensure that the patient is restrained with a safety-belt and that both arms are
gently but securely restrained before the patient passes into Stage II from Stage III
 Go to Step 2.10

2.10 Remove the eye tape and/ or protective goggles from the patient‟s eyes
 Go to Step 2.11

2.11 Turn up the O2 flows to >10 LPM and monitor the level of MAC remaining and
allow the patient to emerge undisturbed/ without stimulation
 Go to Step 2.12

2.12 Continue monitoring for respiratory homeostasis as the patient passes from stage
II toward stage I of anesthesia
 Go to Step 3.1

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Task 3: Emerge the patient and extubate the trachea
Step Actions and Decisions

3.1 Assess the patient during emergence for signs of waking up, i.e. reaching Stage I
of anesthesia, by observing for the return of reflexes such as coughing,
swallowing, increased muscle tone, pupils returning to conjugate or midline
position and appropriate response to noxious stimuli
 Go to Step 3.2

o IF the patient remains in Stage II or you are not sure if the patient is in
Stage II THEN do not extubate
 Go to Step 3.1

3.2 During emergence, continue monitoring the patient for maintenance of respiratory
homeostasis i.e., RR remains regular, the TV is appropriate and the ECO2 is < 45
cmH20 as the patient passes from stage II to stage I of anesthesia
 Go to Step 3.3

o IF the RR is < 8 THEN gently assist the patient with bag ventilation
 Go to Step 3.1

o IF the RR is > 30/ minute THEN titrate opioids for pain control using the
RR as an indication of patient pain unless the high RR may reflect patient
anemia, hypovolemia, hypoventilation, fever or excessive CO2 levels
 Go to Step 3.2

o IF the RR is irregular THEN continue monitoring for return of a regular
pattern
 Go to Step 3.2

3.3 When the patient meets the Stage I criteria listed in Step 3.1 and the requirements
in Step 3.2 for respiratory homeostasis, suction the oropharynx again if necessary
and then loosen the tape edges on the patient‟s face
 Go to Step 3.4

3.4 Place your positive pressure ventilation (PPV) mask next to the patient‟s head on
the left side of the OR table and place your Yankauer suction catheter to the right
of the patient‟s head tucked under the mattress corner
 Go to Step 3.5

114
3.5 Reassess end tidal level of anesthetic gasses for MAC awake level (< 0.3 MAC);
observe BIS level > 80 and patient eye opening in response to name calling or
patient making motions to self-extubate, assess for ability to squeeze a hand or lift
head off of bed for > 5 seconds or to appropriately follow commands and double
check that pupils are midline/ conjugate and that the patient is able to stick out
his/ her tongue
 Go to Step 3.6

3.6 When the patient is awake and responding appropriately, give a breath by gently
squeezing the bag or turning up the APL valve slightly go apply a little positive
pressure while deflating the ETT cuff with a 10cc syringe
 Go to Step 3.7

3.7 Pull out the ETT with one hand, you can do this with or without disconnecting
from the circuit, then place the ETT on a towel on the patient‟s chest
 Go to Step 4.1

Task 4: Monitor and confirm post extubation respiratory homeostasis
Step Actions and Decisions

4.1 Immediately following extubation place the PPV mask on the patient‟s face to
confirm that the patient is safe from obstruction by monitoring for exhaled CO2
in the absence of the ETT
 Go to Step 4.2
o IF no ETCO2 is seen THEN check to see that you are holding the mask
on the face correctly with a good seal, you should see the bag moving up
and down with respiration
 Go to Step 4.2

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4.2 Assess for and monitor chest rising, misting in the mask and movement of the
ventilator bag coinciding with patient respiratory effort
 Go to Step 4.3

a) IF after readjusting your mask placement there is still no ETCO2
and the bag is not moving THEN the patient might be holding his/ her
breath or might be obstructing
Go to 4.2d

b) IF the patient is holding his/her breath, THEN continue holding the PPV
mask in place
Go to Step 4.2

c) IF you see paradoxical movement of the chest or throat, suppressed lung
expansions or you suspect airway obstruction THEN provide a chin lift
and monitor for improved air exchange
Go to Step 4.2

d) IF no improvement in air exchange after chin lift THEN
Go to Step 2.4e

e) IF airway obstruction is suspected and no oral airway is in place THEN
place oral airway using a tongue blade to avoid putting your fingers in the
patient‟s mouth and reassess for chest rising, misting in the mask and
movement of the ventilator bag coinciding with patient respiratory effort
Go to Step 4.2h

f) If you can‟t get the mouth open to place an OA after extubation THEN
lubricate and place a NA and reassess for chest rise, misting in the mask
and movement of the reservoir bag coinciding with the patient‟s
respiratory effort and when you see this
Go to Step 4.3

g) IF after placing an OA or NA the patient is still not breathing THEN give
the patient a couple of breaths with the mask and bag
Go to Step 4.2

h) IF the patient requires suctioning after the ETT is removed THEN suction
again using the Yankauer tip
Go to Step 4.3

116
i) IF trauma, bleeding or vocal cord palsy noted THEN anticipate airway
compromise; maintain the airway with chin lift or airway adjunct, call for
help, consult anesthesia faculty and prepare to re-intubate

j) IF the patient is not ventilating and the oxygen saturation is dropping or
the patient‟s color is turning blue or laryngospasm occurs THEN
immediately apply positive pressure ventilation (PPV) by setting the APL
valve to 20 cmH2O and providing PPV to facemask for 10 to 15 seconds
Go to Step 4.2

k) IF you need to use 2 hands to hold the mask to the jaw THEN have
someone help you and use two hands to hold the mask to supply oxygen or
PPV with the ventilation bag
Go to step 4.2

l) IF PPV does not break laryngospasm THEN give a small dose of
succinylcholine so that you will be able to ventilate the patient with 100%
oxygen and call for expert anesthesia help, continue to assist ventilations
with PPV
Go to Step 4.2

m) IF after succinylcholine and ventilation with 100% O2 the patient does not
improve or the pulse starts to drop THEN re-intubate

4.3 IF the patient is awake and demonstrating respiratory homeostasis following
extubation THEN place the patient on the transport mask with at least 6 liters per
minute (LPM) flow of O2 and move the patient to the transport gurney
 Go to step 4.4

o If the patient does not appear awake or is not demonstrating respiratory
homeostasis THEN maintain your PPV mask with 100% O2 in place and keep the
patient in position on the OR table
 Go to step 4.2

117
4.4 Raise the head of the transport bed 45degrees if this is not contraindicated by the
surgical procedure and continue monitoring the patient for signs of respiratory
homeostasis during transport to the recovery room by observing for chest rise
and misting in the transport mask
 Go to the Procedure for Recovery Room Transfer of
Care for the Healthy Postoperative Adult

o IF the patient can‟t tolerate the face mask for transport, then place
it in close proximity to the patient‟s face without strapping it on
and turn the O2 flow up to 10 LPM, observe the patient for chest
rise during transport
 Go to the Procedure for Recovery Room Transfer of
Care for the Healthy Postoperative Adult

o If the patient does not appear to be awake or in respiratory
homeostasis THEN remain in the OR, place the PPV mask back
onto the patient, consult with anesthesia faculty
 Go to step 4.2

4.5 STOP

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APPENDIX D
METI® HIGH FIDELITY HUMAN PATIENT SIMULATOR

METI® (Medical Education Technologies Incorporated)

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APPENDIX E
STUDY CONSENT
University of Southern California
Department of Anesthesiology, KSOM & Rossier School of Education
INFORMED CONSENT FOR NON-MEDICAL RESEARCH
The Use of Cognitive Task Analysis to Capture Expertise in Anesthesiology for the
Instruction of the Novice Practitioner
You are invited to participate in a research study conducted by Kären Kim Embrey
CRNA, Ed.D(c) and Kenneth Yates Ed.D at the University of Southern California,
because you are a graduate student in the Program of Nurse Anesthesia at USC. Your
participation is voluntary. You should read the information below, and ask questions
about anything you do not understand, before deciding whether to participate. Please take
as much time as you need to read the consent form. You may also decide to discuss
participation with your family or friends. If you decide to participate, you will be asked to
sign this form. You will be given a copy of this form.
PURPOSE OF THE STUDY
This study is designed to assess the effectiveness of an innovative instructional content
for teaching complex cognitive skills in a manner that facilitates accelerated learning
when compared to the customary methods of teaching clinical skills. The purpose of this
study is to evaluate whether expertise gained through Cognitive Task Analysis can guide
instruction in anesthesia skills as well as it has for similar studies on the instruction of
surgical skills.
STUDY PROCEDURES
If you volunteer to participate in this study, you will be randomized to control or study
group by a coin toss. The study will be conducted at LAC+USC on the 5
th
floor in the
department of Anesthesiology simulation lab room A5C 113. We will first meet in the
conference room on the 5
th
floor. You will be asked to answer a questionnaire about your
previous experience with the task being evaluated and take a short pretest to assess your
prior knowledge on the anesthesia task to be taught. There will be less than 10 questions
on the pre-test, some of them are fill in the blank and in some, you will list the correct
answers in order of priority 1 - 6. You will place a code rather than your name on both
the pre and post-test. Your names will not appear on any study materials at any time.
You will be taught the specific anesthesia task through one of two methods, the standard
instructional method whereby a) an instructor tells you how to perform the task while
he/she performs the task in the simulation lab b) or you will receive instruction designed
120
with the help of expertise gained through cognitive task analysis and which provides a
job aid designed from a Gold Standard for instruction. You will then perform the
Anesthesia task in the simulation lab during the study and describe aloud what you are
doing as you do it. This performance will be videotaped for analysis. No one will have
access to the videotapes besides the principal investigator and the research Chair.
The study should take about 4 hours and will run from 7 AM to around 11 AM on a
Friday morning in October – you will participate either on Friday, October 21
st
or Friday,
October 28
th
. This experience will be in lieu of other clinical assignments if you are a
senior student or will supplement a clinical shadow day at LAC+USC if you are a junior
student and you are scheduled for a shadow experience on a study day.
At the end of your instruction session in the simulation lab, you will be videotaped
performing the anesthesia task while you describe what you are doing by “thinking
aloud”. Your videotape will be coded with the same code on your pre and posttests –
your names will not be used. Following this, you will take a short posttest of less than 10
questions to assess your learning and then spend about 5 to 10 minutes debriefing after
the simulation experience, as is customary following all simulation training.
If you do not wish to be videotaped during the evaluation, we can facilitate this
request by simply observing your performance.
The experimental instruction by the faculty member will be videotaped and available for
all students in the program of Nurse Anesthesia to view at their convenience following
the completion of the study. Therefore, all students and all participants will have access
to the experimental instruction material immediately following the study.
POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated or foreseeable risks associated with participation in this study
other than any minor test/ performance anxiety by the participants or the customary risks
associated in educational delivery.
POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
The potential benefits to participants are 1) improved instruction and learning on this
important anesthesia skill 2) improved safety in practice delivery following improved
instructional content and 3) additional exposure to the simulation lab environment and
improved comfort with the lab equipment.
CONFIDENTIALITY
Any identifiable information obtained in connection with this study will remain
confidential and will be disclosed only with your permission or as required by law. The
members of the research team and the University of Southern California‟s Institutional
121
Review Board (IRB) may access the data. The IRB reviews and monitors research studies
to protect the rights and welfare of research subjects.
The study data will be stored in a password-protected file on the principal investigator‟s
PC and in a locked cabinet in the offices of the Program of Nurse Anesthesia at USC. No
one besides the principal investigator and research Chair will have access to the data. All
data will be coded and no participant‟s names will be used. Videotapes will be coded and
then stored securely for the required 3 years and then destroyed. No identifying or
personal data will be maintained. Study participants will place a designated code on their
pre and post-tests for correlation of results and this same code will be used to label
videotaped performances – no personal identifiers will be used for labeling or storage.
When the results of the research are published or discussed in conferences, no identifiable
information will be used.
PARTICIPATION AND WITHDRAWAL
Your participation is entirely voluntary. Your refusal to participate will involve no
penalty or loss of benefits to which you are otherwise entitled. You may withdraw your
consent at any time and discontinue participation without penalty. You are not waiving
any legal claims, rights or remedies because of your participation in this research study.
ALTERNATIVES TO PARTICIPATION
If you elect not to participate in the study, you will fulfill your previously scheduled
clinical objectives for the day. For senior students, this will mean that you attend your
normal scheduled day in the OR at your current rotation. For juniors, you will be
scheduled to observe / shadow a CRNA for the day as is customary on Fridays in
October.
EMERGENCY CARE AND COMPENSATION FOR INJURY
If you are injured as a direct result of research procedures not done primarily for your
own benefit, you will receive medical treatment; however, you or your insurance will be
responsible for the cost. The University of Southern California does not provide any
other form of compensation for injury.
INVESTIGATOR’S CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact the
principal investigator Kären Embrey at 323 409 3518 or 323 442 1641, or mobile at 805
377 3573 or at Embrey@usc.edu or Dr. Kenneth Yates at kennetay@usc.edu .
RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant
you may contact the IRB directly at the information provided below. If you have
questions about the research and are unable to contact the research team, or if you want to
talk to someone independent of the research team, please contact the Institutional Review
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Board (IRB) Office at 323-223-2340 between the hours of 8:00 AM and 4:00 PM,
Monday to Friday. (Fax: 323-224-8389 or email at irb@usc.edu) or write to the Health
Sciences Institutional Review Board at LAC+USC Medical Center, General Hospital
Suite 4700, 1200 North State Street, Los Angeles, CA 90033.
SIGNATURE OF RESEARCH PARTICIPANT

I have read the information provided above. I have been given a chance to ask questions.
My questions have been answered to my satisfaction, and I agree to participate in this
study. I have been given a copy of this form.
□ I agree to be audio/video-recorded /photographed
□ I do not want to be audio/video-recorded /photographed

Name of Participant

Signature of Participant Date

SIGNATURE OF INVESTIGATOR

I have explained the research to the participant and answered all of his/her questions. I
believe that he/she understands the information described in this document and freely
consents to participate.

Name of Person Obtaining Consent

Signature of Person Obtaining Consent Date
123
APPENDIX F
PARTICIPANT DEMOGRAPHIC DATA SURVEY
Student Code: _________
Student Group: A B
Cognitive Task Analysis Survey for Postoperative Tracheal Extubation
Current year of Nurse Anesthesia Training 1 2
Gender: Female Male
Years in ICU Nursing before entering Program of Nurse Anesthesia ___________
Years of ER Nursing before entering Program of Nurse Anesthesia ____________
CCRN Certification Yes_______ No_________
Have you ever performed a postoperative extubation in the OR?
Performed? No Yes If yes how many during training? _____________
Assisted? No Yes If yes how many during training? _____________
Observed? No Yes If yes how many during training? _____________
Have you ever performed an adult extubation in the ICU/ ER?
Performed? No Yes If yes how many during training? _____________
Assisted? No Yes If yes how many during training? _____________
Observed? No Yes If yes how many during training? _____________
Rate your prior experience with postoperative extubation: (circle your answer)
None Some Fair amount Good amount

What is your confidence level with performing this task? (Circle your answer)
No confidence Little confidence Somewhat
confident
Quite confident

124
APPENDIX G
DECLARATIVE PRETEST
Pretest Scenario Student Code_____________

Ms S is a 30 y/o ASA I, 60 kg patient who has just undergone a laparoscopic
cholecystectomy during which she receive pre induction midazolam 2 mg and famotadine
20mg. During induction of anesthesia an hour ago she received fentanyl 50 mcg,
lidocaine 50 mg, propofol 100mg and rocuronim 40 mg. The surgeons have been liberal
with local anesthetics and intraoperatively it was only necessary for you to administer
another 75 mcg of fentanyl making the total dose of opioids 125 mcg. Case maintenance
has been managed with sevoflurane at MAC 1.2. The surgeons have just removed the
specimen and their laparoscopic ports. The scrub tech has been asked to provide suture
for closing. The patient has 2/4 twitches, mechanical ventilation is TV 475 x 12 min,
ETCO2 = 42 mmHg. Your faculty CRNA has suggested a dose of toradol 30mg IV
which you have just administered.
The surgeons are now closing their surgical ports.
Answer the following questions to the best of your ability:
1) Your next actions should be? Label the activities 1 – 6 in the order they are best
performed for patient safety.
Task Order
performed
Remove the eye tape 6
Reverse the remainder of the neuromuscular blocking agent 2
Take your patient off of the ventilator to evaluate if the patient is
capable of effective spontaneously ventilation
5
Place an oral airway 1
Suction the oropharynx 3
Check for train of four and sustained tetanus 4

2) Your patient‟s neuromuscular blocker is now fully reversed and your twitch
monitor shows 4/4 with sustained tetanus for > 5 seconds. The surgeons are
taking down the drapes; the circulator is getting the patient some warm blankets
for the trip to the recovery room. Your patient is breathing spontaneously at a TV
of 150cc to 350cc with a respiratory rate of 8/ min but she is still very much
125
asleep and does not respond to your suctioning of her oropharynx. The patient is
on 100 % O2 at 10 LPM and the ET% of sevoflurane is 0.7.

a) At this point in case management to be on an appropriate schedule for
extubation what are 4 things you would evaluate about your patient/
patient management while you wait for her to wake up?

b) What physical assessment findings might indicate that your patient is out
of Stage II and safe to extubate? Name as many as you can.

c) Name 6 pieces of equipment you need for a safe patient extubation

d) When you lift your patient‟s eyelids her pupils are disconjugate. Your
assessment has stimulated her and she begins gagging heavily and she
appears to be struggling against the noxious stimulus of the ETT.
Name 4 things you should do or assess before extubating this patient

e) Your patient appeared to be awake and you have just extubated her by
deflating the ETT cuff and pulling the ETT out. What is the first thing
you would do to ensure your patient is safe from airway obstruction or
laryngospasm?

f) Name three assessments you might make to evaluate that your patient is
tolerating the removal of the ETT without untoward airway events.

126
APPENDIX H
INSTRUCTOR SCENARIO
Patient:
Mr. P is a 32 y/o ASA II 80 kg patient undergoing laparoscopic cholecystectomy. He has
a history of active GERD. Preoperative medications were midazolam 3mg and
famotadine 20mg. Intraoperatively the patient received lidocaine 100 mg, propofol
250mg and rocuronium 50 mg for induction. Total opioid dose intraoperative is 200 mcg
of fentanyl and the procedure has taken about 45 minutes. The surgeons have just
announced that the specimen is out. He is still in the left tilt, head up position. The ET
sevoflurane is 2.7 and FiO2 is 40%. Total IV intake is 1200cc LR, EBL is 50cc, there
was no urinary catheter placed. The OG tube has drained about 50 cc of bile to low
intermittent suction. TOF = 3/4.
You have a novice SRNA with you who has not extubated before.

127
APPENDIX I
EXPERIMENTAL LESSON SCRIPT
Table I-1: Experimental Lesson Overview
Instructor Activities Student Activities Estimated
Time
 Discuss Simulation Lab
confidentiality
agreement
 Agree not to share your
knowledge of simulation
scenarios with other
participants/ students
5 min
 Provide pretest  Take pretest 20 minutes
 Present Scenario and
Demonstrate Simulated
Extubation
 Think aloud during
actions
 Observe & ask questions 20 minutes
 Review Potential
Problems
 Observe & ask questions 15 minutes
 Evaluate trainee task
performances
 Receive evaluation while
you perform the task: think
aloud so we know what you
are doing or deciding
60 – 90 minutes
(8 - 16 students)
 Handout posttest  Receive & take posttest 20minutes
 Facilitate Simulation
Lab debriefing Session:

 Debrief the Simulation Lab
session
15 minutes

128
Adult Postoperative Extubation Lesson Script
Introduction
Demonstration scenario for adult postoperative extubation shared with the students.
Course Objectives
 Introduce the Lesson Goal:
o You will learn the key cues and indications for safe postoperative tracheal
extubation.
o We will review the decision processes of anesthesia tapering to facilitate
emergence and safe extubation.
o The procedure will be demonstrated in the Simulation Lab for you with
the instructor explaining the rationale for his/her actions and decisions.
o After you have had time ask questions your performance on the task will
be evaluated in the Simulation Lab while you explain your decisions and
actions.
Indications for Extubation:
o Patient condition supports extubation and emergency airway equipment and
expertise is immediately available to support the patient if extubation
fails.
o Absence of contraindications to resumption of normal respiratory
homeostasis and respiration via the patient‟s natural airway.
Contraindications to Extubation:
o Suboptimal oxygenation
o Suboptimal ventilation
o Reasons for intubation remain
o Absence of protective airway reflexes
o Hemodynamic instability massive trauma/ blood loss/ chest
trauma/hypothermia/sepsis
o Inability to meet pain control needs without intubation
o Long cancer surgery
o Intubation was difficult and associated with airway trauma
o Airway edema/ trauma/ impending airway edema
129
o Possibility of return to the OR in the immediate future
o Absence of reliable equipment to re-intubate if extubation fails
Necessary Equipment:
o Mandatory
o Recommended
Procedure Overview:
 The 4 Major Tasks for Postoperative Tracheal Extubation are:
1. Monitor for surgical completion and begin tapering anesthesia
2. Position the patient for safe extubation
3. Emerge the patient and extubate the trachea
4. Monitor and confirm postoperative respiratory homeostasis
 Planning for extubation should occur about30 minutes before extubation;
preparation might take about 15 minutes; while the extubation task itself will
require approximately 1 to 2 minutes.
Teaching Scenario
 Explanation: Instructor describes he/she is going to run through a scenario in the
simulation lab depicting a typical adult postoperative extubation for a healthy
individual and that she/he will review the necessary steps for the procedure along
with the students.
Scenario: Instructor explains his/ her actions as she works through the simulation
scenario of an extubation on a healthy adult describing how the following steps
are employed:
1. Monitor for surgical completion and begin tapering anesthesia
2. Position the patient for safe extubation
3. Emerge the patient and extubate the trachea
4. Monitor and confirm postoperative respiratory homeostasis

130
Task 1- Monitor for surgical completion and begin tapering anesthesia
Monitor the patient and the surgical culmination and begin to taper anesthetics.
 IF the surgical case was long THEN begin to taper anesthetics about
30 minutes before you plan to emerge and extubate the patient
o IF the surgical case was short THEN begin to taper anesthetics about
15 minutes before surgery completion
o IF surgery end is imminent and you have not tapered anesthetics
appropriately or have over medicated THEN plan to reverse
medications as needed to facilitate emergence and monitor the patient
for return of respiratory homeostasis
 IF the patient is not fully paralyzed THEN do not give additional
neuromuscular blocking (NMB) agents unless paralysis is essential,
and switch from controlled ventilation mode to SIMV or spontaneous
mode (SV) to build CO2 and further encourage spontaneous
ventilation, without causing the patient to buck against the ventilator
or move excessively while the surgeons finish their procedure
Task 1-During tapering of anesthesia continue to monitor the patient’s depth of
anesthesia:
 IF the surgical procedure is nearing completion and post surgical respiratory
homeostasis is anticipated THEN begin preparing for emergence and
extubation to follow the remaining surgical stimulation by beginning to
reduce the level of anesthesia delivered to allow for a BIS level of about 40 to
50

o IF the patient has experienced a change in condition or excessive blood
loss THEN assess an arterial blood gas (ABG) consult anesthesia faculty
and refer to the Procedure for Determining Extubation Potential in the
Unstable Postoperative Patient

o IF airway edema or trauma has resulted or is anticipated following a
difficult intubation, THEN defer extubation consult anesthesia faculty and
refer to the Procedure for the Management of Postoperative Airway
Edema

o IF airway edema, trauma or dysfunction is present or anticipated from the
surgical intervention THEN defer extubation, consult the surgeons and
anesthesia faculty and refer to the Procedure for the Postoperative
Management of Iatrogenic Airway Trauma
131
 IF the surgeons are finishing the current surgical intervention but plan to bring the
patient back to the OR in the immediate future THEN defer extubation and refer
to the Procedure on Transporting the Intubated Postoperative Patient to the
Intensive Care Unit

Task 1-Reverse the NMB agent only when patient movement is no longer
contraindicated by patient condition or the surgical procedure:
 IF open abdominal case THEN reverse the NMB only when the peritoneal fascia
is closed
 IF the surgeons are on skin closure THEN reverse the NMB if not previously
performed and monitor for spontaneous ventilation
Task1-Suction the oropharynx after reversal of NMB and while the patient is still
deep enough to tolerate the stimulation of suctioning without bucking or moving
excessively
 When the patient is breathing spontaneously but not coughing or moving,
maintain this level of anesthesia; keeping the BIS around 55 – 60 for the
surgery completion
 Monitor spontaneous ventilation during surgical closure and assess the
patient for return of respiratory homeostasis i.e. RR 8- 30/min, TV > 5cc/kg,
ETCO2 < 45 cmH2O
o IF the ETCO2 level is above 60 cmH2O, THEN assist ventilation by hand
or with the ventilator in SIMV or pressure support mode until the patient
is able to sustain appropriate minute ventilation
Task 2- Position the patient for safe extubation
 Employ Universal precautions, put on gloves and protective eyewear before
beginning extubation procedure
 IF the patient is not in a supine position at the top of the table at the end of
surgery THEN place the patient in this position to facilitate optimal/ safe
access to the airway during emergence and extubation
o IF the patient is at increased risk for aspiration or is obese then raise the
head of the bed 30 to 40 degrees or place the patient in reverse
Trendelenberg position for extubation

132
o IF the OR table is turned away from the anesthesia practitioner THEN
place the patient on 100% O2 and return the table to its optimal position
with the patient‟s head in proximity to the ventilator and anesthesia
practitioner
Task 2- Place an oral airway (OA) before the patient wakes up
 IF the patient underwent oropharyngeal surgery or is edentulous THEN
place a nasal pharyngeal airway (NA) instead of an OA

 IF the patient has obstructive sleep apnea (OSA) THEN place a nasal and
oral airway before wakeup
Task 2-Suction the oropharynx thoroughly and the ETT if necessary
o IF the secretions or the blood in the oropharynx is thick or the patient is a
“full stomach” THEN use the Yankauer suction tip to suction

o IF the secretions are thin or you may cause trauma/ bleeding to the mucosa
THEN use the soft suction catheter and get deep into the oropharynx
about 5 – 6 inches to get pooled secretions

o IF a gastric tube (GT) is in place THEN thoroughly suction this also and
remove the GT if the surgeons are in agreement

Task 2- IF the patient is at increased risk for laryngospasm or bronchospasm
during extubation THEN administer an appropriate does of lidocaine 2% IV or 4%
ETT one to two minutes before extubation and discuss performing a deep
extubation with anesthesia faculty
 IF the patient is to be extubated while asleep/ deep extubation THEN refer to
the Procedure for Deep Extubation in the Postoperative Healthy Adult
Task 2- Three to 5 minutes before surgical stimulation is expected to finish, place
the patient on 100% O2 and taper the remaining anesthetic agents to facilitate the
patient transitioning from Stage III of anesthesia to Stage I when surgery has
finished
o IF the surgical case was long THEN plan for a longer wait to reach
Guedel‟s Stage I from stage III of anesthesia if agents were not tapered
early

o IF the case was short THEN anticipate a more rapid transition from
Stage III toward Stage I if the patient is not over narcotized

133
o If regional anesthesia was used in conjunction with GAETT THEN be
prepared for a more rapid transition from Stage III toward Stage I than
if GA and IV opioids were use

Task 2- Ensure that the patient is safely restrained with a safety-belt and that both
arms are gently but securely restrained before the patient passes into Stage II from
Stage III

 Remove the eye tape/ and or protective goggles from the patient’s eyes

 Turn up the O2 flows to >10 LPM and monitor the level of MAC (minimal
alveolar concentration) remaining and allow the patient to emerge
undisturbed/ without stimulation
 Continue monitoring for respiratory homeostasis as the patient passes from
stage II toward stage I of anesthesia

Task 3- Emerge the patient and extubate the trachea
 Assess the patient during emergence for signs of waking up, i.e. reaching
stage I of anesthesia, by observing for the return of reflexes such as coughing,
swallowing, increased muscle tone, pupils returning to conjugate/ midline
position and appropriate response to noxious stimuli
o IF the patient remains in Stage II or you are not sure if the patient is in Stage II
THEN do not extubate

Task 3-During emergence, continue monitoring the patient for maintenance of
respiratory homeostasis i.e., RR remains regular, the TV is appropriate and the
ECO2 is < 45 cmH20 as the patient passes from stage II to stage I of anesthesia

 IF the RR is irregular THEN continue monitoring for return of a regular
pattern

o IF the RR is < 8 THEN gently assist the patient with bag assisted ventilation

o IF the RR is > 30/ minute THEN titrate opioids for pain control using the RR
as an indication of patient pain unless the high RR may reflect patient anemia,
hypovolemia, hypoventilation, fever or excessive CO2 levels

134
Task 3- When the patient meets the Stage I criteria and respiratory homeostasis
criteria, suction the oropharynx again if necessary and then loosen the tape edges on
the patient’s face
 Place your positive pressure ventilation (PPV) mask next to the patient’s
head on the left side of the OR table and place your Yankauer suction
catheter to the right of the patient’s head tucked under the mattress corner
 Reassess end tidal level of anesthetic gasses for MAC awake level (< 0.3
MAC); observe BIS level > 80 and patient eye opening in response to name
calling or patient making motions to self-extubate, assess for ability to
squeeze a hand or lift head off of bed for > 5 seconds or to appropriately
follow commands and double check that pupils are midline/ conjugate and
that the patient is able to stick out his/ her tongue

 When the patient is awake and responding appropriately, give a breath by
gently squeezing the bag or turning the APL valve up slightly to apply a
little positive pressure while you deflate the ETT cuff with a 10 cc syringe

 Pull out the ETT with one hand, you can disconnect or not from the circuit,
and place the ETT on the patient’s chest on a towel.

Task 4- Monitor and confirm post extubation respiratory homeostasis
Slide 21: Task 4- Immediately following extubation place the PPV mask on the
patient’s face to confirm that the patient is safe from obstruction by monitoring for
exhaled CO2 in the absence of the ETT
 IF no ETCO2 is seen THEN check to see that you are holding the mask on the
face correctly with a good seal, you should see the bag moving up and down with
respiration, readjust your mask fit if you need to
Task 4- Assess for and monitor chest rising, misting in the mask and movement of
the ventilator bag coinciding with patient respiratory effort
 IF after readjusting your mask placement there is no ETCO2 and the bag
is not moving THEN the patient might be holding his/ her breath or
might be obstructing
IF the patient is holding his/her breath, THEN continue holding the PPV
mask in place
IF you see paradoxical movement of the chest or throat, suppressed lung
expansions or you suspect airway obstruction THEN provide a chin lift
and monitor for improved air exchange
IF airway obstruction is suspected provide a chin lift – if this does not
relieve obstruction and no oral airway is in place THEN place oral
135
airway using a tongue blade to avoid putting your fingers in the
patient‟s mouth and reassess for chest rising, misting in the mask and
movement of the ventilator bag coinciding with patient respiratory
effort
IF you can‟t get the mouth open to place an OA after extubation THEN
lubricate and place a nasal trumpet and reassess for chest rising,
misting in the mask and movement of the ventilator bag coinciding
with patient respiratory effort and when you see this
IF after placing an OA or NA, the patient is still not breathing, THEN give
the patient a couple of breaths with the mask and bag
IF the patient requires suctioning after the ETT is removed THEN suction
again using the Yankauer tip
IF trauma, bleeding or vocal cord palsy noted THEN anticipate airway
compromise maintain the airway with chin lift or airway adjunct, call
for help, consult anesthesia faculty and prepare to re-intubate
IF the patient is not ventilating and the oxygen saturation is dropping or
the patient‟s color is turning blue or laryngospasm occurs THEN
immediately apply positive pressure ventilation (PPV) by setting the
APL valve to 20 cmH2O and providing PPV to facemask for 10 to 15
seconds
IF you need to use 2 hands to hold the mask to the jaw THEN have
someone help you and use two hands to hold the mask to supply
oxygen or PPV with the ventilation bag
IF PPV does not break laryngospasm THEN give a small dose of
succinylcholine so that you will be able to ventilate the patient with
100% oxygen and call for expert anesthesia help, continue to assist
ventilations with PPV
IF after succinylcholine and ventilation with 100% O2 the patient does not
improve or the pulse starts to drop THEN re-intubate
Task 4-IF the patient is awake and demonstrating respiratory homeostasis following
extubation THEN place the patient on the transport mask with at least 6 liters of O2
per min (LPM) and move the patient to the transport gurney
If the patient does not appear awake or is not demonstrating respiratory
homeostasis THEN maintain your PPV mask in place and keep the
patient in position on the OR table

136
Task 4-Raise the head of the transport bed 45 degrees if this is not contraindicated
by the surgical procedure and continue monitoring the patient for signs of
respiratory homeostasis during transport to the recovery room by observing for
chest rise and misting in the transport mask and refer to the Procedure for
Recovery Room Transfer of Care for the Healthy Postoperative Adult
o IF the patient can‟t tolerate the face mask for transport then place it in
close proximity to the patient‟s face without strapping it on and turn the
O2 flow up to 10 LPM, observe the patient for chest rise during transport
and refer to the Procedure for Recovery Room Transfer of Care for the
Healthy Postoperative Adult

o If the patient does not appear to be awake or in respiratory homeostasis
THEN remain in the OR, place the PPV mask with 100% O2 back onto
the patient and consult with anesthesia faculty
Preparation for Student Evaluation
 Explain some of the problems/ complications associated with extubation
following demonstration of extubation in the context of a simulated scenario
and before the student‟s performances are evaluated.
Problems/Complications
 Explain some of the potential problems and complications associated with
postoperative tracheal extubation in the adult.
o Not paying attention to the surgical progress/ culmination or the patient‟s
responses to the surgery or environment/ forgetting to keep the patient warm
o Over medicating the patient too close to extubation or when a peripheral nerve
block has been placed
o Inaccurately assessing the effectiveness of the patient‟s NMB reversal
o Not suctioning appropriately, either performing suctioning when the patient is
light and causing bucking, or not suctioning thoroughly enough and predisposing
the patient to laryngospasm or aspiration
o Not placing an oral airway before the patient begins to emerge predisposing the
patient to an obstructed ETT and the potential for negative pressure pulmonary
edema
o Failing to place a nasal trumpet before emergence on obese patients or patients
with obstructive sleep apnea (OSA)
o Not having expert help immediately available for extubation
o Not having a backup ETT and emergency drugs and equipment immediately
available
o Lack of experience reading patient‟s depth of anesthesia or responsiveness
o Lack of experience with equipment and reading monitor cues
137
o Pulling the ETT too soon when the patient is still in stage II
o Forgetting to let down the cuff before removing the ETT
o Forgetting to practice barrier precautions
o Trauma/bleeding/edema to the airways/ surgical site disruption
o Failing to recognize airway obstruction post extubation
o Failing to raise the head of the bed on patients at higher risk for aspiration
Evaluation
 Explain: Let the students know that following their observation they will perform
the anesthesia skill while their performance is evaluated during a “think aloud”
protocol which allows the student to explain their decisions and actions while they
perform the task in the simulation lab. They will also take a short written posttest.
Debrief
 Facilitate: Guide a debriefing session wherein the students can discuss their
performances and the simulation experience and have their questions answered.
Remind students not to discuss the simulation scenarios with others once they
leave the room.

138
APPENDIX J
STUDENT EVALUATION SCENARIO
Student Performance Evaluation of Extubation Scenario:
Ms C is 37 y/s ASA I 60 kg woman undergoing laparoscopic assisted vaginal
hysterectomy. The patient has received 2500 cc of LR, EBL was 150cc, urine output is
200cc clear yellow urine, and the OG tube has produced minimal drainage.
Preoperatively the patient received 2mg of midazolam, and for induction she received
50mg of lidocaine, 120 mg of propofol and 50mg of rocuronium. You have re-dosed the
rocuronium twice for a total of 70 mg of rocuronium for the case. The opioid total for the
case has been 300mcg of fentanyl.
The patient is in the lithotomy position at the end of the OR table and the surgeons have
just announced they will be finished closing in 15 minutes.
Emerge and extubate the patient while you think out loud so that we have an idea of what
you are doing and your decisions during this process
Relax and do the best you can – there are no wrong answers – we just want to see
what you have learned from today’s simulation experience.

139
APPENDIX K
SKILLS PERFORMANCE CHECKLIST
Student Code: _________
Student Group: A B

Evaluation Scenario:
Ms C is 37 y/s ASA I 60 kg woman undergoing laparoscopic assisted vaginal
hysterectomy. The patient has received 2500 cc of LR, EBL was 150cc, urine output is
200cc clear yellow urine, and the OG tube has produced minimal drainage.
Preoperatively the patient received 2mg of midazolam, and for induction she received
50mg of lidocaine, 120 mg of propofol and 50mg of rocuronium. You have re-dosed the
rocuronium twice for a total of 70 mg of rocuronium for the case. The opioid total for the
case has been 300 mcg of fentanyl.
The patient is in the lithotomy position at the end of the OR table and the surgeons have
just announced they will be finished closing in 15 minutes.
Emerge and extubate the patient while you think out loud so that we have an idea of what
you are doing and your decisions during this process
Relax and do the best you can – there are no wrong answers – we just want to see
what you have learned from today’s simulation experience.

140
Table K-1: Evaluation Simulation Lab Scenario Checklist Student Code______
Task Not Done
(ND)
Done
Incorrectly
(DI)
Done
Correctly
Comments
1. Begins tapering anesthesia in response to
cues from surgeons
a) Checks TOF
b) Administers NMB reversal
c) Suctions OP
d) Monitors for spontaneous ventilation
ND DI 1
ND DI 1
ND DI 1
ND DI 1
ND DI 1
2. Positions patient for safe emergence
&extubation
a) Employs universal precautions

b) Places oral airway

c) Returns patient to HOB supine
d) Ensures patient is restrained
e) Removes eye tape
f) Turns O2 to 100%
g) Monitors MAC

ND DI

1

ND DI 1

ND DI

1
ND DI 1
ND DI 1
ND DI 1
ND DI 1
3. Emerge the patient and extubate the
trachea
a) Assess the patient for
emergence; observes for return
of reflexes

b) Does not extubate when pt
remains in Stage II

c) Check RR is 8- 30, TV
appropriate (5cc/kg) & ETCO2
< 45cmH2O

d) Assists ventilation by hand when
MV not appropriate

e) Reassesses respiratory status for
RR is 8- 30, TV appropriate
&ETCO2 < 45cmH2O

ND DI

1

ND DI

1

ND DI

ND DI

ND DI

1

1

1

141
f) Looks for regular respiratory
rate.

g) Confirms patient is in Stage I
using specific criteria (eye
opening, hand squeeze, head lift,
tongue projection)

h) Places PPV mask & suction in
appropriate reach

i) Loosens tape on face

j) Deflates ETT cuff

k) Increases PPV squeezes bag or
sets APL valve to 20cmH2O
pressure and pulls ETT

ND DI

ND DI

ND DI

ND DI

ND DI

ND DI

1

1

1

1

1

1
Comments
4. Monitor and confirm post extubation
respiratory homeostasis
a) Immediately following extubation
places the PPV on the patient‟s face
and confirms CO2/ mist (pt is free of
obstruction)
b) if not reposition the mask / check for
breath holding/ provide chin lift

c) If obstruction is suspected place
OA(use tongue blade or NA as
needed)
d) Suction again post extubation if
needed
e) Confirm respiratory homeostasis &
place pt on transport mask at >
6LPM
f) Raise the HOB, keep O2 Sat
monitor in place until leaving the
OR
g) Monitor patient during transport to
PACU – watch for mist in the mask/
chest rise/ pt color listen for
obstruction

ND DI

ND DI

ND DI

ND DI

ND DI

ND DI

ND DI

1

1

1

1

1

1

1

Table K-1 Continued
142
Were all tasks performed in correct sequence? Yes No
If not in the correct sequence then which were performed out of order?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Total time to complete the task: ___________________
Percent accuracy of task: _________________________

143
APPENDIX L
DECLARATIVE POSTTEST
Posttest Scenario Student Code__________

Mr. B is a 43 y/o ASAII, 75 kg patient who is undergoing an ORIF of the ankle
after a work related injury. He is generally in good health but smokes ½ packs
per day and drinks alcohol occasionally. He refused a peripheral nerve block and
his GAETT was managed with midazolam 3 mg preop, and intraoperatively he
was maintained with 750 mcg of fentanyl, ketamine 30 mg and sevoflurane. You
gave an intubating dose of rocuronium 50 mg with 300 mg of propofol an hour
and a half ago. Mr. B appeared to have a minor bronchospasm following
induction. This was easily managed with 3 albuterol puffs, a small dose of
ketamine and sevoflurane. He has been placed in a lateral position with a
beanbag for the surgery. The surgeons are closing skin, after which they plan to
take 2 X-rays and then cast the ankle before emergence. Judging from their work
pace you expect to be waking your patient up in 25 minutes.
Answer the following questions to the best of your ability:

1) List the order of your actions as you prepare for the safest possible extubation.
Task Order
performed
Remove the eye tape 5
Reverse the remainder of the neuromuscular blocking agent 3
Take your patient off of the ventilator to evaluate if the patient is
capable of effective spontaneously ventilation
6
Return Mr. B to the supine position 1
Place an oral airway 2
Suction the oropharynx 4
Check for train of four and sustained tetanus 7
Place Mr. B on 100% O2 8
Administer lidocaine 4% down the ETT 9
Evaluate the patient‟s minute ventilation and ETCO2 level 10

1) What are 4 signs that your patient is not ready for extubation?

144

2) What are some signs that your patient is ready for extubation? Name as many
as you can.

3) What are 2 actions you might consider during the extubation phase of this
case to avoid a repeat of the bronchospasm you witnessed on induction?

4) Name 6 pieces of equipment necessary for a safe extubation.

5) What will be your first action following the removal of the ETT? Justify your
decision with an explanation of why this is the best first step.

6) What backup equipment should be available to you at the time of extubation?

7) List 4 things you would do during transport to ensure that your patient
continues to maintain a patent airway and appropriate ventilation on the way
to the PACU.

145

146

147
148
Table M-4: Procedural Performance, Junior Students

group

N

Mean

Std. Deviation
Std. Error
Mean
Procedural test control
experimental
7
7
60.71
70.43
6.993
9.253
2.643
3.497

t-test for Equality of Means

t

df

Sig. (2-tailed)

Mean
Difference
Procedrual test Equal variances
assumed
Equal variances
not assumed
-2.216

-2.216
12

11.168
.047

.048
-9.714

-9.714

Levene's Test for
Equality of Variances

F

Sig.
Procedural test Equal variances
assumed
Equal variances
not assumed
1.480 .247
149
Table M-5: Procedural Performance, Expediency, Junior Students

group

N

Mean

Std. Deviation
Std. Error
Mean
Time control
experimental
7
7
11.43
9.00
2.637
1.291
.997
.488

t-test for Equality of Means

t

df

Sig. (2-tailed)

Mean
Difference
Time Equal variances
assumed
Equal variances
not assumed
2.189

2.189
12

8.720
.049

.057
2.429

2.429

Levene's Test for
Equality of Variances

F

Sig.
Time Equal variances
assumed
Equal variances
not assumed
6.064 .030
150

151
Table M-7: Procedural Performance, Correct Sequence, Experimental
Students

Cases
Valid Missing Total
N Percent N Percent N Percent
class * correctseq 13 100.0% 0 .0% 13 100.0%

correctseq

Total yes no
class junior
senior
Total
1
5
6
6
1
7
7
6
13

Chi-Square Tests

Value

df
Asymp. Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Pearson Chi-Square
Continuity Correction
a
Likelihood Ratio
Fisher's Exact Test
Linear-by-Linear
Association
N of Valid Cases
6.198
b

3.731
6.796

5.721

13
1
1
1

1
.013
.053
.009

.017

.029

.025

152
Table M-8: Procedural Performance, Correct Sequence, Control Students

Cases
Valid Missing Total
N Percent N Percent N Percent
class * correctseq
12 48.0% 13 52.0% 25 100.0%

correctseq Total
1 2 1
class juniors
1 6 7
seniors
3 2 5
Total
4 8 12

Chi-Square Tests

Value df
Asymp. Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Pearson Chi-Square
2.743(b) 1 .098
Continuity
Correction(a)
1.071 1 .301
Likelihood Ratio
2.805 1 .094
Fisher's Exact Test
.222 .152
Linear-by-Linear
Association
2.514 1 .113
N of Valid Cases
12

153
Table M-9: Procedural Performance, Correct Sequence, All Students

correctseq

Total yes no
group control
experimenatl
Total
4
6
10
8
7
15
12
13
25

Chi Square

Cases
Valid Missing Total
N Percent N Percent N Percent
group * correctseq
class * correctseq
25
25
100.0%
100.0%
0
0
.0%
.0%
25
25
100.0%
100.0%

Value

df
Asymp. Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Pearson Chi-Square
Continuity Correction
a
Likelihood Ratio
Fisher's Exact Test
Linear-by-Linear
Association
N of Valid Cases
.427
b

.060
.429

.410

25
1
1
1

1
.513
.806
.512

.522

.688

.404
154

155
Table M-11, Procedural Performance, Correct Sequence, All Senior Students

correctseq

Total yes no
group control
experimental
Total
3
5
8
2
1
3
5
6
11

Chi Square Test

Value

df
Asymp. Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Pearson Chi-Square
Continuity Correction
a
Likelihood Ratio
Fisher's Exact Test
Linear-by-Linear
Association
N of Valid Cases
.749
b

.034
.754

.681

11
1
1
1

1
.387
.853
.385

.409

.545

.424

Cases
Valid Missing Total
N Percent N Percent N Percent
group * correctseq 11 100.0% 0 .0% 11 100.0%
156
Table M-12, Correct Sequence, All Seniors versus All Juniors

Chi Square Test

Correct seq

Total yes no
class junior
senior
Total
2
8
10
12
3
15
14
11
25

Value

df
Asymp. Sig.
(2-sided)
Exact Sig.
(2-sided)
Exact Sig.
(1-sided)
Pearson Chi-Square
Continuity Correction
a
Likelihood Ratio
Fisher's Exact Test
Linear-by-Linear
Association
N of Valid Cases
8.766
b

6.500
9.276

8.416

25
1
1
1

1
.003
.011
.002

.004

.005

.005

Abstract (if available)

Abstract Cognitive task analysis (CTA) is a knowledge elicitation technique employed for acquiring expertise from domain specialists to support the effective instruction of novices. CTA guided instruction has proven effective in improving surgical skills training for medical students and surgical residents. The standard, current method of teaching clinical skills to novices in medical and nursing specialties, including anesthesiology, relies on recall-based instruction from domain experts. This method of instruction is limited by task automation in the expert practitioner. Automated knowledge eludes conscious access and impedes explication of comprehensive essentials for task execution. CTA guided instruction maximizes declarative and procedural knowledge gains in the novice by explicating the necessary equipment, performance objectives, conceptual knowledge, procedural knowledge and performance standards employed when experts execute a particular task. This study employs CTA elicited expertise in the instructional content of an anesthesia practice task, adult postoperative tracheal extubation to 13 junior and senior nurse anesthesia trainees. The declarative and procedural knowledge gains of these students were compared to those of 12 junior and senior nurse anesthesia trainees who received standard recall-based instruction on the same anesthesia task. The study results indicate that CTA-based instruction has a positive and significant effect on procedural knowledge gains in the novice anesthetist as well as the trainee with higher levels of prior knowledge. There were no significant gains in declarative knowledge following either CTA or conventional recall-based instruction on this task for either junior or senior students. Implications for future CTA guided instruction in anesthesia training and the study limitations are discussed.

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Asset Metadata

Creator Embrey, Kären K. (author)

Core Title The use of cognitive task analysis to capture exterptise for tracheal extubation training in anesthesiology

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Publication Date 03/27/2012

Defense Date 01/12/2012

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anesthesiology,cognitive task analysis,nurse anesthesia,OAI-PMH Harvest,simulation,skills,Training

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Yates, Kenneth A (committee chair), Hirabayashi, Kimberly (committee member), Sullivan, Maura E. (committee member)

Creator Email embrey@usc.edu,karynembrey@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c127-678652

Unique identifier UC1363621

Identifier usctheses-c127-678652 (legacy record id)

Legacy Identifier etd-EmbreyKren-553.pdf

Dmrecord 678652

Document Type Dissertation

Rights Embrey, Kären K.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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