By Kelly M. Pyrek
One of the most critical roles of the infection preventionist is instructing healthcare workers about the proper principles and practices relating to infection prevention and control -- especially as an increasing number of healthcare institutions and accreditation agencies are examining more closely the competencies of healthcare professionals. Experts Marguerite M. Jackson, RN, MS and Patricia Lynch, RN, BSN, in a 1986 paper in AJIC, asserted that although infection control practitioners are expected to be capable and effective educators, few individuals have had formal training in preparing, presenting and evaluating education programs for healthcare personnel from different disciplines, educational backgrounds and comprehension levels.
Ann Marie Pettis, RN, BSN, CIC, director of infection prevention at the University of Rochester Medical Center in Rochester, N.Y., points to the anonymous quotation that "Teaching can occur without learning and learning can occur without teaching," and emphasizes that as the content expert, infection preventionists must capture and hold the attention of adult learners -- no small task in the busy, demanding, chaotic healthcare environment.
Pettis explains that a crucial part of infection preventionists' role is to develop, facilitate and evaluate teaching and learning at the institutional level while simultaneously creating an environment for participation and interaction and stimulating reflective and critical thinking to promote good practice. This task is known as "andragogy," the science of lifelong learning for adults. Andragogy is used to describe the scholarly approach to what is more commonly known as the practice of adult education; in other words, teachers facilitating and supporting the active learning process of adults.
What may be helpful is a quick review of the basics of learning and teaching theory. Pettis explains that the basic theory of learning boils down to the learner receiving a stimulus, which may either be the act of experiencing (concrete) or thinking (abstract). Then, the learner must process the information gained through experimentation (active) or reflection (passive). As for teaching styles, they can be Authoritarian (traditional); Socratic (using questions to elicit answers); Heuristic (relies on the student's curiosity level; and Counseling (concentrates on the emotional impact of the lesson). When it comes to learning styles, there are Activists (those who enjoy hands-on learning or role playing/games) Reflectors (those who enjoy watching audio/visual presentations or engaging in discussion); Theorists (those who enjoy complex problem-solving); and Pragmatists (those who enjoy exploring practical situations with the formulation of goals as the end result).
It may also be helpful to remember the various adult learning styles, which include Visual, Auditory and Kinesthetic, which all require different approaches to presenting information so that maximum retention is achieved. Pettis explains that retention varies by learning method and that individuals retain:
- 10 percent of what they read
- 20 percent of what they hear
- 30 percent of what they see
- 50 percent of what they see and hear
- 70 percent of what they say
- 90 percent of what they teach someone else
A good example of this is illustrated by the ancient Native American saying, "Tell me and I'll forget, show me and I may not remember, involve me and I'll understand." And because so much of adult learning tends to be problem-centered, encouraging healthcare professionals to be actively engaged during the learning process, is critical to retention and to ensuring that they disseminate the proper protocols and techniques to their colleagues.
"In order for participants to retain the information taught, they must see a meaning or purpose for that information," says Christian Oliver, a product manager at HealthStream, a healthcare learning solutions company. "They must be able to interpret and apply the information, including the ability to assign the correct degree of importance to the material. Training plans need to provide a blend of instructional strategies to meet these needs." Oliver continues, "Three days after a training session, we only retain about 50 percent of what we see and hear, on average, and even less of what we only see, or only hear. We tend to retain a lot more over 80 percent -- of what we say as we do something. So, if we explain what we are doing to a partner while we do it, our chances of retaining it are a lot higher. Creating opportunities where this can happen through small group discussions or practice sessions with a partner, for example is a good way to increase retention."
Pettis says infection preventionists face a number of barriers to effective education in the healthcare setting including rapid change (encompassing everything from an evolving regulatory landscape to fast-moving innovation in medical technology); the challenge of information overload in a 24/7 society; constant healthcare worker turnover; and the complexity of the educational message that must be delivered and then monitored for translation into practice. There are basics, such as hand hygiene, that require constant education and reminders -- these perennial issues dictate messages that may sometimes become so frequently heard and seen that healthcare workers tune them out. Critical information becomes tedious and healthcare workers' practices become rote, thus exacerbating lack of compliance with principles and practices that drive good patient care and ensure patient safety.
There are a number of topics that bear repeating, according to Bill Anderson, director of training solutions for DuPont Sustainable Solutions. They include basic infection control precautions, such as hand hygiene, environmental cleaning, instrument decontamination and safe injection practices, as well as how and when to use standard precautions, transmission-based precautions and personal protective equipment (PPE). Anderson adds, "There is a need to provide a deeper understanding on how infection spreads, the sources of infection, and modes of transmission."
There is a fine line between what bears repeating and what healthcare workers tune out; some in-service topics that are simply run into the ground and become less effective over time. "I think that self-learning packets have been over-used and although they are quick and easy, many staff either skim the information or quickly take the test and not read the information," says Linda R. Greene, RN, MPS, CIC, director of infection prevention and control at Rochester General Health System in Rochester, N.Y.
What does work, then? "I have found one of the most appreciated and well received approaches, at least with clinical staff, is the use of case studies to both engage the audience and illustrate important points," Pettis says. "It incorporates the concept of 'teaching by story telling' and it allows for more participation. People are more apt to remember details when they are included in an actual story. The other thing I find more an more speakers incorporating with good results are the hand-held answer clickers. Finally, to me the most important thing to improve engagement and maximize influence is by putting a face to infection prevention by addressing the human costs associated with HAIs rather than rates, etc."
"Case studies work well," Greene agrees. "I would also add that simulation is very effective especially with issues that involve psychomotor tasks. I am also a huge proponent of 'just-in-time' learning, since staff members really seem to pay attention when an issue is occurring in their area. I think that we, as a profession, have not done enough with the 'how to' component. Since a major initiative is the 'science of implementation,' we need to teach not only the evidence based strategies, but how to operationalize these."
Conducting in-services that hold the healthcare professional's attention is a constant challenge for infection preventionists. "Teaching is one of the most enjoyable things to do in this role," says Michael Olesen, an infection prevention and emergency management consultant. "It's not easy though; some people have what it takes and some people don't. The hardest part is connecting with the audience in a meaningful way."
Olesen says he sees three major flaws that cause in-services to fail. "First, instructors need to move beyond using presentation software as a crutch. A common problem is that the presenter simply reads the slides. Most people don't need someone to read to them and they could do that style of learning at their own convenience. It's important to have some key points that are covered on the screen but a transcript is not necessary or appreciated. Along the same lines, handouts can be distilled down to the main points that are covered instead of just being a printout of the entire set of slides used in the presentation. Its also very helpful to have a page of references for all of the data used during the presentation." Olesen continues, "A second problem is a failure to connect with the audience. Adult education does not need to be formal and stiff. Presentations are often done in a very dry way that loses the audience. A presentation does not have to be strictly for entertainment, but it is possible to educate and entertain at the same time."
Olesen adds, "Speakers often also fail to drive behavior change, when that is often the primary goal of a presentation. Too often, especially in medicine, speakers tend to present data without making any emotional connection to it. When only data is presented, people may internalize the information but they don't change behavior, at least in the long run. Anecdotes go a long way toward taking data and applying it in the real world. I welcome any in-services that can be provided by any outlet, as long as they are done in an unbiased manner and provide meaningful information that I can use. I think too often we get too suspicious of vendors when they can give useful material as well."
As Oliver emphasizes, "Experienced trainers know the content of the training must be tailored for relevance to the audience, or the message will not get through. Focusing on general infection prevention topics, rather than targeting the training to the needs of the audience, will not achieve the objectives. For example, training on surgical site infection (SSI) prevention specifically for operating room (OR) nurses is likely to be much more helpful and relevant than a general overview."
There are several important considerations when engaging and teaching the adult learner in the healthcare environment, according to Oliver. "An understanding of the motivations of the learner is critical why are they there? Is it because they are trying to earn the last few CEs they need? Or is the content critical to success on their job? Are they attending because someone told them they had to? Instructors need to keep these motivations in mind, because they directly impact how people approach the learning experience. And then instructors have to come up with strategies to make the content relevant to the learner."
Anderson notes that because people learn differently, "providing a variety of ways to learn may engage and appeal to a wider range of employees and result in longer-lasting benefits." He adds, "A 2003 examination of blended learning by researchers at the University of Calgary concluded that this method 'has the proven potential to enhance both the effectiveness and efficiency of meaningful learning experiences.' There are dozens of studies, surveys and reports that tout the benefits of blended learning." Anderson points to the American Society for Training and Development, in a 2006 article, that cites these specific benefits of using a blended learning approach:
- Promotes connections and conversation among individuals within an organization
- Provides consistent and updated messages across an organization
- Capitalizes on the knowledge of all employees
- Improves performance and controls costs
Additionally, in a 2006 survey of corporations in China, South Korea, Taiwan, the United States and the United Kingdom, a majority of respondents reported that "improving the quality of the learning experience, an increase in the availability and accessibility of learning, and cost reductions" were the major reasons why their organizations had adopted blended learning.
Anderson says there are a number of tools that work together to enhance adult learning. "Online or e-learning delivers consistent instruction and content, i.e., each trainee receives the same material delivered in the same manner with the same examples," he says. "It is available 24/7, allowing trainees to learn at their own pace and at their convenience. Online training also means retraining and refresher training are not limited by classroom availability and other scheduling conflicts. Studies have shown online learning to be cost effective and a major time-saver."
Anderson continues, "Additionally, learning can be enhanced with interactive courseware that incorporates compelling content with sound instructional design. Content thats customized to include facility-specific video, graphics, and training points can add relevance to trainees. Incorporating sound instructional design using the ADDIE (Analyze, Design, Develop, Implement, Evaluate) model can help ensure training and testing to the learning objective. Traditional media allows for portable, on-the-go instruction. For example, trainers who travel frequently and dont have online access in certain locations are able to check out DVDs and handbooks at their convenience. Traditional media can also deliver training in multiple languages. Important safety compliance skills can be reinforced by reviewing the key training points and learning objectives, and testing with a quiz that can serve as a pre- and/or post-evaluative tool."
Blended Learning Trends in Workplace Learning Settings: A Multi-national Study. http://wiki-riki.wikispaces.com/file/view/AERA_08_Full_paper.pdf
Blended Learning for Compliance Training Success. 2002. www.astd.org/NR/rdonlyres/456DB5F7.../0/blendedlearning.pdf
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Rossett A. How Blended Learning Changes What We Do. American Society for Training and Development. 2006. http://www.astd.org/LC/2006/0906_rossett.htm
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