Introduction
Point of care ultrasound (POCUS) is quickly becoming the standard in assessment and management of patients in the Emergency Department and Critical Care settings and has the potential to radically improve the delivery of care in all aspects of healthcare, particularly in resource-limited environments. Advanced Practice Nurses lag behind our physician colleagues in implementation of POCUS training. There are a number of challenges to adding POCUS training to advanced practice nursing programs including an already full curriculum, lack of qualified advanced practice nursing POCUS instructors, and the additional challenges that an increasingly hybrid/distance learning format presents to teaching a hands-on skill.
Objectives
- Understand the benefits of integrating POCUS training into advanced practice nursing education
- Understand the challenges to POCUS integration into advanced practice nursing education
- Describe some basic strategies to overcome challenges of integrating POCUS education into advanced practice nursing education
Benefits
Point of care ultrasound (POCUS) is an increasingly used diagnostic tool in acute care. It allows for rapid radiological examination of a patient without exposure to ionizing radiation and does not require patients to be transported to the radiology department or to outside facilities in the case of clinic-based practices. POCUS is used by clinicians at the bedside to make diagnoses, direct resuscitation efforts, and assist with invasive procedures. POCUS also offers a significant cost advantage when compared to traditional radiological imaging modalities. As the cost of handheld ultrasound devices continues to decrease, POCUS is likely to become even more common, becoming as ubiquitous as the stethoscope (Frankel, et al., 2015; Lee & DeCara, 2020; Martin, et al., 2023; Russel et al., 2022).
Studies have shown that implementing POCUS training into the curriculum improves students’ knowledge, comfort, confidence and performance using POCUS (Bhargave, et al., 2022; Ferre, et al., 2022; Martin, et al, 2023; Mellor, et al. 2019; & Russel, et al., 2021). In addition, POCUS has been shown to improve physical examination skills, knowledge of anatomy and performance in clinical rotations (Martin, et al., 2023).
Challenges
In addition to the challenge of how to add material covering POCUS to an already full curriculum, many advanced practice nursing programs face the additional task of training students in an advanced, hands-on skill while operating in a hybrid, distance-learning model of education. Advance practice nursing education has shifted in recent years to this hybrid model, which allows students to live and work in their hometowns while attending class virtually at a university which may be hundreds of miles away. This model is beneficial as many advanced practice nursing students are working adults and are unable to relocate to complete graduate education.
Unique among radiographic studies, POCUS not only requires the ability to interpret images but also the skill in performing the exams. Studies have shown that the use of repetitive, deliberate practice with instructor feedback improves acquisition of procedural skills (Bosse, et al., 2015). Given the limitations of online or hybrid learning, it is difficult to teach these hands-on skills to students.
Strategies
Because of the limitations in teaching POCUS in a distance-learning format, we have focused on adding intensive POCUS training to the Objective Clinical Intensives (OCIs), when all students come to campus for face-to-face training.
These occur three times during the course of the program. In order to maximize the time we have with students on campus, prerecorded lectures covering topics ranging from introduction to ultrasound to advanced clinical applications are made available online for students to watch prior to arriving on campus (fig 1). This flipped classroom model eliminates the need for face-to-face lectures, freeing precious time that can be better used for hands-on training.
When on campus, students receive 4-6 hours of hands-on time with instructors. This time may be spent practicing scanning on classmates, faculty, or professional models (figs 2-3). In addition, this gives students the opportunity to discuss clinical application of ultrasound with faculty experts.
Conclusions
POCUS training offers significant benefits to advanced practice nurses and our patients. It can improve speed of diagnosis, assist with management of complex patients, and offer more rapid and less invasive diagnostic studies to patients in resource-limited environments. There are a number of challenges to incorporation of POCUS instruction in advanced practice training programs, but there are also innovative ways to overcome these challenges.
References
Bhargava, V., Hailescelassie, B., Rosenblatt, S., Baker, M., Kuo, K., & Su, E. (2022). A point of care ultrasound education curriculum for pediatric critical care medicine. Ultrasound Journal, 14(44), 2-8.
Bosse, H. M., Mohr, J., Buss, B., Krautter, M., Weyrich, P., Herzog, W., Jünger, J., & Nikendei, C. (2015). The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills. BMC medical education, 15, 22. https://doi.org/10.1186/s12909-015-0286-5
Ferre, R.M., Russell, R. M., Peterson, D., Zakeri, B., Herbert, A., Nti, B., Goldman, M., Wilcox, J., & Wallach, P.M. (2022). Piloting a graduate’s medical education point-of-care ultrasound currciculum. Open Access Original Article.
Frankel, H.L., Kirkpatrick, A.W., Eldarbary, M., Blaivas, Ml, Desai, H., Evans, D., Summerfield, D.T., Slonin, A., Breitkreutz, R., Price, S., Marik, P., E., Talmor, S., Levitov, A. (2015). Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients- part 1: general ultrasonography. Critical Care Medicine, 43(11), 2479-2502.
Lee, L. & DeCara, J.M. (2020). Point of care ultrasound. Current Cardiology Reports, 22, 149.
Martin, R., Do, HAL., Morrison, R., Bhargava, P., & Deiling, K. (2023). The rising tide of point-of-care ultrasound (POCUS) in medical education: an essential skillset for undergraduate medical education. Current Problems in Diagnostic Radiology 52(6), 482-484.
Mellor, T.E., Junga, S., Ordway, S., Hunter, T., Shimeall W.T., Krajnik, S., Tibbs, L., Mikita, J., Zeman, J., & Clark, P. (2019). Not just hocus pocus: implementation of a point of care ultrasound curriculum for internal medicine trainees at a large residency program. Military Medicine, 184, 901-906.
Russell. F.M., Herbert, A., Ferre, R.M. Zakeri, B., Echeverria, V., Peterson, D., & Wallach, P. (2021). Development and implementation of a point of care ultrasound curriculum at a multi-site institution. The Ultrasound Journal, 13(9), 2-7.
Russell, R.M., Zakeri, B., Herbert, A., Ferre, R.M., Leiser, A., & Wallach, P.M. (2022). The state of point-of-care ultrasound training in undergraduate medical education: findings from a national survey. Academic Medicine, 97(5), 723-727.
critical care notes 