COMPETENCY-ORIENTED BLENDED LEARNING

1. COMPETENCY-ORIENTEDBLENDED LEARNING • Training • Technology • Competencies • Recognizes • Communicates Training Technology

2. COMPETENCY-ORIENTED BLENDED LEARNING Improving early detection and reporting of status changes in NH residents with CHF or DM 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

3. ADDIE MODEL Curriculum Development System 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

4. GUIDE TO TNH CURRICULUM DESIGN Blend 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

5. FRONT-END ANALYSIS OF TRAINING NEEDS • 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.

6. BLENDED (DVD-BASED) COMPETENCY-ORIENTED CURRICULUM • 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).

7. Competency-Oriented Blended (DVD-Based) Curriculum

8. BLENDED-LEARNING CURRICULUM COMPONENTS and APPROACH • 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)

11. SNAPSHOT: DVD-Based Curriculum on Physician–Nurse Communication

12. FACILITATOR’S GUIDE • 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)

13. EDUCATIONAL TOOL KIT FOR LEARNERS • Nuts and Bolts for Clinical Communication • Respiratory Rate Check • Tips for Measuring Weight • Signs and Symptoms of Disease Exacerbation • Glossary of Terms

19. TRAINER PREPARATION TIPS 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.

20. 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.)

21. OVERALL CURRICULUM EVALUATION BY NURSE PARTICIPANTS (n = 15) 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 Handouts Usable 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

22. CURRICULUM EVALUATION PRE- VS POST-TRAINING KNOWLEDGE OF SIGNS & SYMPTOMS Pre- Post- Difference p % correct % correct Respiratory rate 86.7 93.3 6.6 1.00 Orthopnea 46.7 100 53.3 0.004 Signs and symptoms 66.7 93.3 26.6 0.017 Information to communicate 72.0 83.3 11.3 0.059 ACCURACY OF DATA COLLECTION AND CLINICAL COMMUNICATION Clinical Information Pre- Post- Diff p Related to CHF Mean (SD) Mean (SD) Mean Accurately collect 6.6(2.5) 8.9(1.3) 2.2 .011 Effectively 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 93 Moderately or slightly capable 92 7

23. WHAT NEXT?? 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.

24. Behavior (Apply) Professional authenticity Cognition (Remember) Competence Does Shows how Knows how Knows