A director of nursing services’ (DNS’s) active involvement in staff education is vital, even though the level at which the DNS is involved in the planning and execution of education is largely determined by the size and resources of the facility. In smaller facilities, the role of organizing and leading in-services often falls to the DNS. For example, AADNS’s curriculum development specialist Amy Stewart, RN, DNS-CT, RAC-MT, was responsible for in-servicing her 111-bed facility as a DON. However, points out Linda Shell, DNP,MA, RN, principal of lindashell.com, even if your facility is large enough to have a dedicated staff educator, “as a DNS, you need to have a good working knowledge of how to effectively conduct in-services to ensure that you are providing good oversight.” No matter how hands-on or hands-off your involvement with staff education, the eight expert-approved tips below will help you to achieve greater impact in your role.
1. Strategically Plan In-Service Content
“It’s always better to be proactive than reactive,” observes Stewart. She advises that DNSs map out education for the coming year on a month-by-month basis, including topics that address regulatory requirements and basic skills, as well as building in areas for content needs that become apparent throughout the year.
Stewart suggests that it’s wise to evaluate competencies annually at a skills fair shortly before your facility’s window for annual survey, on topics DNSs anticipate will be addressed during survey, including infection control, IV insertion, and trach care, if applicable. By doing so, these skills will be fresh in your staff’s minds for survey. Even more, this allows you to plan future in-services to review content and skills in areas where staff didn’t perform as well. This type of in-service can also indicate whether a deficiency is prevalent among staff members or is isolated to one or two individuals who might need extra coaching.
This method of skills review will also prepare you in case any staff skills-related deficiencies arise during survey. According to Shell, when it comes to deficiencies at survey, “the first thing you will have to answer about a staff member who causes a citation is: Was this person trained and provided the knowledge to perform the skill properly? For example, were they trained to properly use a mechanical lift, transfer a resident, pass medication, etc.? More, surveyors will look at the documentation to ensure there was a return demonstration of some sort to verify that the staff member had demonstrated that they were able to perform the skill correctly in the past.” To this end, all of your education and training should be documented in the employee record so that it is easily accessible if a situation arises.
Shell also suggests doing a preassessment of new staff upon hire, which will help to determine which skills they need to understand better. “This helps to eliminate assumptions—what the facility leadership might assume the new hire knows, and what the new hire might assume the facility leadership knows about his or her qualifications,” says Shell. The Centers for Medicare & Medicaid Services (CMS) is beginning to take a closer look at facility leaders’ abilities to assess clinical competences, so it’s better to build these processes in now.
It’s also important to continuously stay abreast of education needs in your facility as they present themselves. “As a DNS, I kept a notepad to write down items I observed, to follow up with education, constantly assessing the needs for the facility on my rounds,” says nurse consultant Linda Winston, MSN, BSN, RN, DNS-CT, RAC-MT.
Planning in-services ahead is also important because it allows you to communicate dates early to staff, which is particularly important for staff members who may be relying on child care. Of course, on occasion an in-service need may arise unexpectedly, but when possible, plan ahead.
2. Know Your State’s Requirements
State requirements for in-service education vary. In some states continuing education credits aren’t needed, while in others, nurses must earn them annually for relicensing. “You want to make sure that your nurses and nursing assistants are leading in the care they provide and that you are supporting your staff in meeting their education needs. Keep in mind that educational opportunities can also be used as a recruiting tool, attracting dedicated talent,” says Shell.
3. Show Up First
“It is really important for the DNS to be the first one at the education program, serving as a role model, even if the DNS is not the one leading the in-service. If you are expecting your staff to attend, you need to attend as well,” according to Shell. “It’s hard to hold people accountable if you don’t know what information was delivered.”
Especially if you aren’t leading the in-service, attending the program can help you identify strengths and weaknesses in your team’s knowledge and skills. Shell adds, “It’s not only important to observe whether they can perform the skill, but also, what is their attitude towards the skill? For example, what is their comfort level? Do staff generally prefer to use a catheter on women as opposed to men? If you discover anxiousness, how can you create a comfort level?”
4. Have a Learning Plan
According to Shell, when it comes to planning education, “it’s important to start with the end in mind.” Winston outlines this: “A solid learning plan should include a relevant topic, objectives, teaching strategies, a summary of major points, and a method for evaluation.”
The lecture portion should be no more than 20 minutes of a 60-minute session, and it should strive to be as interactive and engaging as possible, using photos and requiring participation, says Stewart. She suggests no more than three objectives for a one-hour in-service. She also suggests framing the objectives as “I can” statements, especially for CNAs. For example, at an in-service on catheter care, have the CNAs repeat before and after the session, “I can perform catheter care,” to help them internalize the objective.
The lecture portion in particular should “focus on the why,” says Stewart, “as in, Why we are doing this—to meet a regulatory requirement? In response to a survey event? More importantly, you should focus on why the information being taught is important to the resident.” This emphasis on the why is particularly helpful in soliciting staff buy-in for a new policy or procedure, adds Winston. “When you are implementing a new form or policy, you need to get staff buy-in to adapt to the new procedure. They may walk away and say, ‘Oh, this is just for the state,’ so you have to show them that it’s not just a paper requirement, it’s a care requirement.”
It’s important to keep in the front of your mind that in-services provide a positive, blame-free learning environment and can offer a fun challenge for staff, says Winston. Stewart suggests asking participants (CNAs in particular) to write down any questions they have about the content during the lecture portion. “Sometimes people are nervous about raising their hands and asking questions. I collect the questions, review them, and follow up with the group on any questions that aren’t covered in the session, either at the end or as a follow-up,” says Stewart. Engaging staff from the outset of the in-service is key.
5. Engage, Engage, Engage
Sometimes, in-service education can get lost in a slew of handouts and PowerPoints, missing the opportunity to truly educate. In planning staff education, “be very clear about your goal,” reminds Shell. “We can spend so much time on the knowledge that sometimes we miss the skill. For example, do you want your staff to know about handwashing, or to wash their hands correctly? Do you want them to have a lot of knowledge, or do you want them to be able to perform correctly? If you want the latter, this requires showing, practicing, observing, and giving feedback.”
Stewart and Winston agree that the key to successful in-servicing is using interactive strategies that require participants to demonstrate that they have learned something. They suggest the following activities:
- Case Studies: Using case studies (removing real names) can be very effective. Winston suggests using events from the facility, neighboring facilities, or the news to help the case studies feel relevant and resonate with staff. “For example, if there is an issue identified in the news such as a specific medication causing adverse events, it provides an opportunity to reevaluate policies and reeducate our staff.” Winston suggests breaking the room up into groups of four to five people to examine case studies.
- Group Presentations: Breaking up the room into small groups to lead group presentations can also be an effective method for engaging staff. Stewart suggests that staff members with more experience in a specific area can be strategically distributed among different groups.
- Return Demonstration: Return demonstrations are particularly effective for evaluating skills, such as catheter care. When organizing return demonstrations for a large group of people, Stewart suggests bringing in nurse managers to help evaluate staff skills in stations.
- The Crime Scene Investigation: Ask a staff member to survey a room and identify what is right and what is wrong in the room and, “most importantly, how to fix it,” says Winston.
Despite how interactive and engaging your teaching method might be, it’s important to stay connected to what’s happening in the room. Throughout the in-service, “watch your participants’ faces,” says Stewart. “If it seems like they aren’t grasping the information, try to go over it in a different way.”
6. Measure Learning Beyond the Classroom
“In long-term care, we are good at doing in-services, but not so good at measuring the success of in-services,” says Stewart. “The goal of any staff education is to ensure knowledge of whatever is being taught. Let’s say we are doing an in-service because of a citation. I suggest doing a pretest and a posttest, and then comparing average scores to demonstrate that you have improved a process.”
In-services should also have a direct link to your QAPI program, says Winston. “Even before you administer an in-service, you should be thinking about how it supports your operational goals and how you are going to measure learning once staff members are back out at the organization. What improvements do you expect to see in your facility? How is it going to affect the resident environment?”
If you are in a larger facility, that task of measuring the application beyond the classroom might fall to the staff development team member. “In the case of handwashing, for example, this might mean a skills audit,” says Shell.
On an operational level, facilities often deal with laundry concerns. Winston gives the example of staff education addressing how laundry is to be distributed and removed. For example, if leadership noticed a loss of small cloths, perhaps due to staff members throwing cloths away instead of having them cleaned, they could host a staff education and be clear with the staff that “this is where we want to see change.” After the education, leadership should be able to measure losses and find improvement.
7. Involve Other Staff
“Especially if you are in a smaller facility, your best educator might be a star on your team,” says Winston. “By identifying talent within your building, you will engage people in the environment to be teachers and role models.”
In other cases, in-services can be an opportunity for leadership and staff to connect. Stewart recalls a time when UTIs were a persistent problem at her facility. The medical director suggested another in-service on catheter use, and attended the event. “Although it made people nervous at first, it was a great opportunity for staff to interact with the medical director.”
On the same note, if you are going to in-service on medication administration, be sure to bring in the person who handles medication. If you are going to do an in-service on hospice residents, involve hospice team members.
8. Diversify Teaching Methods Based on Content
“There is a variety of ways to deliver education, and it’s important to choose teaching methods that are most efficient and applicable to the content,” says Shell. “Delivering all of the education required is a challenge, especially if you are taking people off the floor each time.”
To meet basic requirements, it often makes sense to consider online learning, suggests Shell. Topics that might be appropriate include HIPAA, back safety, and OSHA requirements. She suggests assigning an online module each month, if possible. “Also, it might be worthwhile to consider using outside providers, such as hospice providers, wound-care vendors, or pharmacies that are already working in your facility.”
It’s also important to remember that not every in-service needs to be a formal 60-minute session. “Maybe you do a 10-minute “Just in Time” training on something that needs review. Or you build in-service training into meetings that you are already having. Share a new study about falls, or a case study from your facility (without using names) about an incident with a resident in the memory care unit, and have staff engage on those topics,” says Shell. By making education a part of the culture, you will foster an environment of learning and cultivate a happier and better-performing staff.
“The role of education is critical in our field,”’ says Shell. “Residents are complex, systems are complex, and families are complex. Making sure that you have a quality education program makes for quality care and quality staff members who feel confident about meeting expectations of their jobs.”
In-service education presents great opportunities for DNSs: opportunities to positively engage staff, to reiterate the importance of best practices to support resident care, to bolster and measure staff skills, to teach and promote collaboration, and to take the pulse of what’s happening in the facility. No matter whether you are tasked with planning and leading every in-service, or you are simply required to sign off on the staff development educator’s plan, make sure that you are harnessing the opportunity that in-services offer you.
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