et al., 2016; Cosford et al., 2019), dentistry (Thomson et al., 2019), or theriogenology (Root Kustritz et al., 2006). Additional resources may include those skills required by accrediting agencies (e.g. the AVMA COE's 9 clinical competencies), internal surveys of faculty, and Day‐One skills lists shared by other colleges (Morin et al., 2020). For veterinary nursing students, Day‐One competencies lists have been published by the Royal College of Veterinary Surgeons, the Veterinary Nursing Council of Australia, and the South African Veterinary Council (RCVS 2015; VNCA 2019; SAVC 2020).
Care must be taken to prioritize these lists, as they can quickly become exhaustive, and thereby both unattainable and confusing for the student. For example, an informal survey of eight US veterinary colleges in 2009 generated a list of over 900 different, individual clinical skills, of which approximately three quarters were considered core by college faculty, but only 105 were shared by half or more of the colleges (Lizette Hardie, personal communication). Consideration, therefore, should be given to those skills considered essential for a Day‐One veterinarian versus those that may be better learnt or mastered by a subset of students, or after graduation, for example in clinical practice or in continuing education programs (Malone, 2019; Duijn et al., 2020). This consideration should also take into account those skills that may be life‐saving if done correctly, and those that might be life‐endangering if done incorrectly (Malone, 2019). In this context, a short list of crucial skills could be valuable and could ensure we are “teaching to the common uncommonly well” (Henry J. Heinz), rather than providing exposure but not necessarily competence (Malone, 2019).
Finally, consideration should be given not only to the skills that should be included in this list, but also to the opportunities for students to master these skills. For example, the skills on a school's prioritized list of clinical skills may not be the set of skills they are exposed to in a high‐level referral teaching hospital. It is essential students are given time to learn and practice these skills in the curriculum, and that this is structured to prepare them for the next stage, for example progressing from learning basic skills to more complex procedures, or in readiness for the clinical year or work placements such as extra‐mural studies. Monitoring both students' confidence and competence in these skills would help ensure graduates are meeting the minimum standards expected.
Backward Curricular Design
One methodology that may help with generation of an appropriate list of core clinical skills that should be included in a curriculum is “backward design.” This emerging theme in medical education has been driven by the thought that curricular design should begin at the end, rather than at the beginning (Harden, 2014). With this technique, the outcomes of the educational process are specifically determined first, then the curriculum is designed to achieve these outcomes. This is in contrast to historical approaches where the content that faculty believed should be taught was often developed at the front of the curriculum and arranged without regard for a student's ability to perform the required activities of veterinarians or veterinary nurses as a result of the teaching. A shift to competency‐based education helps address this problem as this model is based on clearly defined and measurable competencies, together with student demonstration that these have been achieved. A number of competency frameworks have been developed for veterinary education, which have helped define the expected outcomes of veterinary curricula (Bok et al., 2011; Shung and Osburn, 2011; AVMA, 2017; Matthew et al., 2020; RCVS, 2020).
Entrustable Professional Activities (EPAs), Nested EPAs, and Clinical Skills
Although a focus on competencies has assisted backward curricular design, some critics of competency‐based education believe that competency frameworks are too theoretical to be useful for teaching and assessment in daily clinical practice. In response to these concerns, EPAs were developed to work in tandem with competencies to produce a more “holistic” basis for curricular design (Prideaux, 2016).
An EPA is a core task which a learner can be entrusted to perform independently at a certain stage of their training when they seem ready. The EPA should be carried out within a given time frame, be observable and measurable, and allow for focused entrustment decisions (ten Cate et al. 2015), or where multiple methods exist for entrustment decisions (Duijn et al., 2019b) include the use of entrustment scales, mini‐clinical evaluation exercise (mini‐CEX), and direct observation of procedural skills (DOPS). In this way, EPAs operationalize observable competencies in a practical setting, because several competencies within multiple domains must be integrated simultaneously to execute the EPA (Englander et al., 2017).
Since EPAs are the routine activities that learners should be expected to perform in a clinical or workplace‐based setting without direct supervision at graduation, it could be argued that these should drive curricular design for a clinical skills curriculum in the same way competencies drive curricular design and content for the entire veterinary curriculum. Recently, a number of sets of EPAs have been developed in veterinary education that focus on either core activities of graduates (Molgaard et al., 2019), those that focus on farm animals (Duijn et al., 2019a), and those that focus on surgical skills for companion animal practice (Favier et al., 2020). Additional sets of EPAs have been created for postgraduate students, such as the ones developed by Graves et al. (2020) for large animal interns.
Theoretically, an EPA can be small or simple (e.g. measuring and reporting blood pressure) or large and more complex (e.g. performing anesthesia). However, similar to the concern regarding long lists of required clinical skills, it does not make sense to develop hundreds of small EPAs resulting in long and unmanageable skills lists with no possible endpoint application. To this end, it has been suggested that smaller EPAs could be identified, which can be subsequently clustered into a large (or endpoint) EPA, where these have been called nested EPAs or sub‐EPAs (ten Cate et al., 2015; Duijn et al., 2019b). In order to recognize that there are small, simple tasks or skills that need to first be mastered so that a student can be competent at the more complex EPAs, Warm et al. (2014) called these smaller units “observable practice activities” (which we call “clinical skills”), and these, in turn, can be clustered or nested into an EPA. In this way, clinical skills followed by nested EPAs can be taught and assessed in earlier years of the curriculum, allowing logical progression of skills development, as well as appropriate preparation for students to execute the larger, more complex core EPAs during their final clinical year (ten Cate, 2018). A diagrammatic representation of these relationships is outlined in Figure 2.2.
Lastly, regardless of whether competency frameworks or EPAs in tandem with competencies are used in curricular design, it is important that the required competencies (rather than individual faculty expectations) drive curricular content and the choice of logical priorities for inclusion.
Step 3: Writing Goals and Objectives
Goals are a broad overview of the content to be covered and the knowledge or skill to be obtained, while objectives are specific, measurable statements that identify the who, the what, and the when of the goal. Evidently, in a clinical skills curriculum, the focus is more on the objectives, where it is important to indicate to students the expected level of competence and how it is achieved.
As stated earlier, acquiring clinical skills includes three components: learning how to perform certain movements (procedural knowledge and abilities), why one should do these (underlying basic and clinical science knowledge), and what the findings might mean (clinical reasoning). As such, clinical skills involve more than simply performing a procedure, but clinicians are often not consciously aware of the complex interplay of different parts of a clinical skill (including knowledge and decision points) that they are practicing and accordingly do not teach all these aspects to students (see Chapter 3 for more detail) (Michels et al., 2012). When designing a clinical skills curriculum, the underpinning knowledge and the interpretation
