COMPETENCY-ORIENTEDBLENDED LEARNING

Training Technology

• Training

• Technology

• Competencies– Recognizes

– Communicates

Growing acuity and complexity of NH residents, especially those with heart failure or diabetes

Early recognition and communication of status changes critical to quality care

TNH developed a DVD-based blended curriculum, “Clinical Communication in the Nursing Home,” to address documented competency gaps

Positive impact of curriculum: trainees and trainers like it, and it improved recognition and communication of status changes

COMPETENCY-ORIENTED BLENDED LEARNINGCOMPETENCY-ORIENTED BLENDED LEARNINGImproving early detection and reporting of status Improving early detection and reporting of status

changes in NH residents with CHF or DMchanges in NH residents with CHF or DM

Analysis – Identifying the training need and gathering information about the training program and its participants

Design – Blueprinting what should be learned and how

Development – Producing training materials and their testing

Implementation – Delivering the training

Evaluation – Assessing the training’s success and effectiveness

ADDIE MODELCurriculum Development System

GUIDE TO TNH CURRICULUM DESIGNBlend Technology with ADDIE Training Model

Address core clinical elements of competency indicated by front-end analysis

Focus on competency-related knowledge and skill gaps

Demonstrate recognition and communication processes and competency

Instruct and assess core knowledge and skills

Encourage team training and reinforcement

Global dissatisfaction with communication efficiency and effectiveness:

• Medical providers frustrated by nurses’ “inadequate and untimely” provision of signs and symptoms of status changes, especially in residents with CHF or DM

• Nurses frustrated by unavailability and impatience of physicians

• 40% of nurses could not accurately indicate a sign or symptom of CHF exacerbation on the survey.

While the nurses expressed confidence in their organization of information presented to the physician, the physicians disagreed, stating that the nurses’ calls were not organized and that necessary information was not always available or presented clearly.

Physicians desired concise, clear, organized clinical information from a nurse who had physically seen the resident before phoning.

Priorities: Implement a standardized reporting method and provide more education and training concerning recognition and reporting of status changes in CHF and diabetic residents.

FRONT-END ANALYSIS OF TRAINING NEEDS

Goal: Learners will improve their knowledge of cardinal signs and symptoms of CHF exacerbation.

LO: Nurses will list three key signs and symptoms of CHF status change (e.g., dyspnea, fatigue, orthopnea, cough).

LO: Nurses will identify key clinical examination indicators of CHF exacerbation (e.g., increased weight, peripheral edema).

Goal: Learners will improve their ability to identify, organize, and present information to the physician for a non-emergent but significant change in clinical status.

LO: Nurses will increase their confidence and ability for effective and efficient communication of CHF-related information to the resident’s medical provider (physician or ARNP).

BLENDED (DVD-BASED) COMPETENCY-ORIENTED CURRICULUM

Competency-Oriented Blended (DVD-Based) Curriculum

• DVD-Based Multimedia for information and modeling good and bad skills and attitudes

• Instructional Strategies to improve recognition and communicating changes in symptoms, signs, and functional status of residents with CHF (and/or DM)

• Emphasis: Disease signs and symptoms and communication framework• Facilitator’s Guide to DVD, evaluation, and learning exercises• Educational Handout with LOs and tools for learners (staff nurses)

BLENDED-LEARNING CURRICULUM COMPONENTS and APPROACH

SNAPSHOT: DVD-Based Curriculum on Physician–Nurse Communication

Title: Clinical Communication in the Nursing Home: Improving Congestive Heart Failure (and Diabetes Mellitus) Management

Targeted Learners: LPN/RNs involved with care of older nursing home residents with CHF (or DM)

Learning Objectives: Learners (nurses) will gain knowledge of cardinal signs and symptoms of CHF exacerbation. o List 3 key signs and symptoms of CHF status change (e.g., dyspnea, fatigue, orthopnea, cough)o Identify key clinical examination indicators of CHF exacerbation (increased weight, peripheral edema)

Learners will improve ability to identify and present information to physician for a non-urgent change in condition o Expression/demonstration of more confidence for effective and efficient communication of CHF-related information to resident’s physician or ARNP

Time Allotment: Total time: ~55 min (30 min to view DVD and 25 min to address learner and facility site-specific issues on physician–nurse communication with role-play at the session or later, depending on time)

Discussions: Barriers to physician–nurse communication; how to engage physicians in the process of improving communication

Curriculum Delivery Strategies:

Blended-learning involving DVD viewing, facilitator-led discussion, role-playing exercises, and Educational Tool Kit; delivered to small group (10 or fewer nurses)

Operational Definition of Clinical Communication:

Accurate, complete, organized, and understandable such that a physician or other medical provider will have necessary information for deciding on a course of action

Take-Home Message:

Stop. Observe: Look at the resident carefully. Recognize: Is there a change in the resident? Organize: Organize your findings using the “nuts and bolts” tool, then report those clinical findings

Key Questions Addressed:

What are the signs and symptoms of CHF (and DM) exacerbation?What constitutes a resident health status change from baseline?What related information should be presented to the physician?What are the 3 states of chronic disease?Why is it important to catch disease (CHF or DM) exacerbation early?What are the proper steps for clinical communication?

Curriculum Materials: DVD (Clinical Communication in the Nursing Home: Improving Congestive Heart Failure [and Diabetes Mellitus] Management), Facilitator’s Guide, Educational Tool Kit

• Implementation instructions• Tools and resources for implementing curriculum

- Role-playing exercises for the nurses to practice “nuts and bolts” approach to communication with medical providers

- List of resources (including teaching Web sites) on how to perform a lung exam and listen for abnormal lung sounds

• Resources for engaging physicians in QI process - A sample letter to inform physicians of training plans and

anticipated changes in communication practices (“nuts and bolts” approach and tool)

FACILITATOR’S GUIDE

• Nuts and Bolts for Clinical Communication

• Respiratory Rate Check

• Tips for Measuring Weight

• Signs and Symptoms of Disease Exacerbation

• Glossary of Terms

EDUCATIONAL TOOL KIT FOR LEARNERS

Before implementing the training, instructors should watch the DVD to identify content that requires more explanation or modification for their learners.

Before implementing this training, the instructor (i.e., clinical educator, supervisor, risk manager) should review the facility’s internal policies and procedures for clinical calls to physicians.

To utilize this material in your facility, it is important to inform physicians of the change in communication.

Be prepared during the training session to discuss barriers to proper clinical communication and methods to improve communication.

TRAINER PREPARATION TIPS

MORE TRAINER TIPS

– The Lung Assessment Resources sheet provides Web sites and books that can refresh nurses on proper physical examination techniques. (Attachment A.)

– The sample letter to the physician or ARNP can be used to inform physicians and ARNPs about the nuts and bolts structured clinical communication that your nurses will be trained in. (Attachment B.)

– The role-playing exercises can be done with the nurses to practice the nuts and bolts technique. (Attachment C.)

DVD Multimedia Enjoyable 1.3 (.46)Entertaining 1.5 (.74)Easy to understand 1.3 (.46)Length appropriate 1.3 (.49)Informative 1.2 (.41)

Educational HandoutsUsable daily 1.5 (.83)Understandable 1.4 (.83)Informative 1.4 (.83)Applicable to needs 1.6 (.83)

________________________________________________4-point Likert scale: 1 = excellent to 4 = poor

OVERALL CURRICULUM EVALUATION BY NURSE PARTICIPANTS (n = 15)

PRE- VS POST-TRAINING KNOWLEDGE OF SIGNS & SYMPTOMSPre- Post- Difference p

% correct % correctRespiratory rate 86.7 93.3 6.6 1.00Orthopnea 46.7 100 53.3 0.004 Signs and symptoms 66.7 93.3 26.6 0.017Information to communicate 72.0 83.3 11.3 0.059

Clinical Information Pre- Post- Diff pRelated to CHF

Mean (SD) Mean (SD) MeanAccurately collect 6.6(2.5) 8.9(1.3) 2.2 .011Effectively communicate 7.1(2.9) 8.8(1.3) 1.7 .063+

_______________________________________________________________________10-point Likert scale (1 = very uncertain; 10 = very certain)

REPORTED CAPABILITY TO ID AND COMMUNICATE INFORMATION TO PHYSICIANS Pre- Post-

% %

Extremely capable 8 93Moderately or slightly capable 92 7

ACCURACY OF DATA COLLECTION AND CLINICAL COMMUNICATION

CURRICULUM EVALUATION

Further research is needed to ascertain whether this training together with clinical support tools will improve “real-world” practice and reduce exacerbations and the high costs of ER visits and hospitalizations of residents with CHF and related conditions.

Our experience thus far indicates that broad dissemination of the TNH training will require some marketing in industry and agency conferences and probably inclusion of a local “nurse champion” to assure the training can be implemented and reinforced without problems related to possible conflict with individual nursing home policies and procedures.

We are currently testing this “nurse champion” approach in our outreach activities along with a PDA clinical decision-support tool.

WHAT NEXT??

CompetenceCompetence

Knows

Shows how

Knows how

Does

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Pro

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Cognition (Remember)

Behavior (Apply)