The Staff Educator, November 2009

Briefings on Evidence-Based Staff Development (formerly The Staff Educator), November 1, 2009

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Stroke education for patient care technicians

Applying Benner’s framework to staff development

Simulation learning modalities: Going beyond the basics

How will new accreditation decision affect 2010 surveys?

Staff training

Stroke education for patient care technicians

After reading this article, you will be able to:

  • Identify stroke education teaching strategies for non-licensed nursing personnel
  • Evaluate the outcomes of classroom education versus computer-based learning

Designation as a stroke center requires that all clinical and nonclinical hospital employees receive training on how to recognize a stroke and take appropriate actions. This was the challenge JFK Medical Center, a 500-bed acute care and rehab facility in Edison, NJ, undertook in 2007 when it pursued designation as a comprehensive stroke center by the New Jersey Health and Senior Services and a primary stroke center by The Joint Commission.

Why do nonclinical staff members need stroke education? A security officer, for example, might encounter a patient or family member exhibiting behaviors consistent with stroke. The officer must be able to recognize the signs and symptoms of stroke and how to promptly summon qualified patient care providers.

Direct patient care providers need more in-depth education, depending on their roles and the amount of care they provide to stroke patients.

Reaching far and wide

Educating an entire hospital is a daunting task. Donna Kozub, BSN, RN-BC, was assigned responsibility for educating non-licensed nursing department personnel, known as patient care technicians (PCT), in 2007. Kozub’s target audience members were those who had the most contact with stroke patients. PCTs who had little or no direct contact with stroke patients (e.g., pediatric unit staff members) received basic education, but those who had more contact needed additional training, she explains. There were no specific mandates from accrediting bodies regarding the hours of education required, only that staff members must be educated. Length and content was to be determined by the educators.

Kozub began by searching the literature for education specific to non-licensed personnel. “I really relied heavily on the American Stroke Association’s division of the American Heart Association’s wonderful Web site. Part of it is designed for the community, which was a big help when writing at a level appropriate for our PCTs.”

Kozub also relied on an interdisciplinary subcommittee of the Stroke Certification Team to help design the education. Members of the subcommittee included nurse managers, speech pathologists, and the neurovascular nurse clinician.

“We looked at it from not only a content perspective, but how to make the information meaningful for the PCTs so that they could apply it not only to their patients, but to their families and themselves as well,” Kozub explains.

Nurse managers identified specific duties of PCTs so that education could be geared to helping them fulfill their responsibilities. The clinical director of speech pathology and audiology provided essential elements of curriculum related to communication with aphasic patients.

The senior speech pathologist gave input on topics related to dysphagia, and the neurovascular nurse clinician served as a clinical expert to evaluate completeness and accuracy of content.

Teaching strategies

All employees watched a one-hour stroke video. Kozub developed a three-hour stroke education program consisting of two one-and-a-half-hour modules for PCTs from the targeted patient units.

The first module was entitled “Care of the Stroke Patient,” which Kozub offered frequently. “I tried to make it personal and fun,” she says. “There were lively discussions about how stroke risk factors were affecting their own lives and the lives of their families.”

The second module was entitled “Care of the Patient with Dysphagia” and was presented by the senior speech pathologist. During module two, learners could sample various diet consistencies and learned appropriate patient feeding techniques.

PowerPoint, lectures, discussions, handouts, and demonstrations were primary teaching strategies. Participants were evaluated with a written test after each module. Tests were graded at the end of each class and certificates presented to those who successfully completed the program.

“Most PCTs passed the written test without problems,” says Kozub. “They were so proud, and I was proud of them.”

Ongoing education

Although the classroom setting had many advantages, it also meant that program administrators had to offer modules frequently so everyone could attend, take time to grade tests, and keep manual records.

Since stroke education is required annually, changes had to be made to increase efficiency. In 2008, Kozub made the decision to move to a computer-based learning (CBL) strategy. “Although I love the energy of the classroom setting, it just wasn’t practical to offer this type of education annually in the classroom,” she says.

The advantages of CBL were easy access, around-the-clock training, and the ability to print test scores and confirmation of attendance. Disadvantages included the inability of participants to share experiences and practice hands-on feeding techniques and administrators not being able to perform demonstrations.

However, Kozub says the training worked just as well. Test scores with CBL were as good as when the content was presented in the classroom setting, and transfer of knowledge to the patient care setting remained high in both 2007 and 2008. Nurse managers expressed satisfaction with the CBL training since outcomes remained consistently high and scheduling was less of an issue.

Kozub hopes to develop an interactive education program that allows instant feedback when learners are asked to answer questions during the program. This technology could also allow learners to review specific slides and revisit challenging questions.

CBL training is now incorporated into orientation for PCTs hired for targeted units. The hospital also has used specific facets of the training to develop stroke competencies for PCTs. This initiative not only facilitated transfer of knowledge to the patient care setting, but enhanced the self-esteem and pride of the PCTs working with such a special patient population.

JFK Medical Center achieved stroke designation from The Joint Commission and the New Jersey Health and Senior Services. Education will continue to play a pivotal role in maintaining these designations.

Evidence-based staff development

Applying Benner’s framework to staff development

After reading this article, you will be able to:

  • Correlate Benner’s levels of expertise to staff development specialists

Most staff development specialists are familiar with Patricia Benner’s book From Novice to Expert: Excellence and Power in Clinical Nursing Practice, published in 1984, in which she identified five levels of clinical expertise. Let’s look at Benner’s descriptions and see how they can be applied to the practice of staff development specialists today.

Leve1 1: Novice. The novice is new to staff development, has no prior experience, and needs rules and instruction in adult learning, the education process, and writing objectives.

Level 2: Advanced beginner. This group needs help handling new situations and can benefit from practice scenarios and case studies that focus on education strategies.

Level 3: Competent. Competent specialists need help handling unexpected issues, such as scheduling or disruptive learners. They lack the speed and efficiency of more advanced educators.

Level 4: Proficient. These educators have an instinctive grasp of learner needs and program planning. They benefit from opportunities to take on managerial responsibilities and should be encouraged to pursue graduate or postgraduate and/or management training.

Level 5: Expert. An expert staff development specialist plans, implements, and evaluates education intuitively. This person would benefit from opportunities to conduct staff development research and assume responsibility for critical projects such as Joint Commission readiness.

The figure below more thoroughly describes the characteristics of each level as they pertain to staff development specialists and which interventions would be most helpful for their professional development.


Avillion, A.E. (2007). Evidence-Based Staff Development: Strategies to Create, Measure, and Refine Your Program. Marblehead, MA: HCPro, Inc.

Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, CA: Addison-Wesley.


Simulation learning modalities: Going beyond the basics

After reading this article, you will be able to:

  • Describe various simulation modalities
  • Identify strengths and weaknesses of several simulation modalities

Editor’s note: This is part one in a series of articles on simulation learning modalities and efforts to develop national standards pertaining to their use.

The phrase “simulation modalities” may conjure up a variety of images. For example, some nursing staff development professionals think of a sophisticated training mannequin that produces computer-generated EKG printouts, responds to intubation efforts, and virtually behaves in ways similar to an actual patient. Others may think of an IV arm used solely for learning how to start IVs.

The point is, there is a wide range of simulation modalities, but many staff development specialists know of only a few, and still more are as of yet unaware of the vast potential for providing education via simulation.

One innovative educator has made simulation her area of expertise. Mary Holtschneider, RN, BSN, BC, MPA, NREMT-P, director of nursing practice and education at the North Carolina Nurses Association in Raleigh, is the National Nursing Staff Development Organization’s (NNSDO) liaison to the Society for Simulation in Healthcare’s Simulation Alliance Task Force. The task force members are working to develop scenarios, standards, and techniques for simulation use (NNSDO, 2008). Holtschneider’s work with this group will be explored in future articles.

“There are so many people jumping on the simulation bandwagon that it’s becoming increasingly important to identify the various types of simulation and attempt to establish standards for their use,” says Holtschneider. “This way, optimal education outcomes are promoted.”

But before we can delve into standard development, it is important that we understand the various simulation modalities.

Low-fidelity simulation modalities

Low-fidelity simulations are described as those that feel the least real to the learner (Holtschneider, 2009; Mt. Hood Community College, 2009). These simulations can be paper- or computer-based and are generally static models that allow for very little learner interaction within the simulation. Examples include computer- or paper-based tasks, mannequins that do not have the capability for providing feedback (e.g., a Resusci Anne that only offers computer printouts that evaluate the accuracy of breaths and compressions), or an IV arm that allows students to practice IV insertion techniques without feedback devices (Holtschneider, Mt. Hood Community College).

Low-fidelity simulation modalities are relatively easy to implement and transport and less expensive to implement than more sophisticated modalities. However, they are the least real of the modalities and therefore do not provide learners with the experience or the feeling of actually working in real-life settings.

High-fidelity simulation modalities

Also referred to as a high-fidelity human patient simulators (HPS), “[high-fidelity simulation modalities are] often the first thing people think about when we say simulation,” says Holtschneider.

When using an HPS, educators can implement a variety of scenarios that they can tape and play back for debriefing or guided reflection, as well as create blended simulations, incorporating actors assuming the role of patients with low-fidelity task trainers.

HPS is usually dependent on some type of computerized mannequin that allows the re-creation of the physical patient in a realistic physical clinical environment (Stanford, 2009a). Examples of HPS include (Holtschneider; Stanford, 2009a):

  • IV start training using computer interactive devices that allow the learner to see veins, arteries, muscle, nerves, and bones as underlying structures
  • Mannequins that breathe and stop breathing spontaneously, allowing learners to evaluate the effectiveness of their intubation techniques or how well they are bagging a patient
  • Actual or real-time displays of algorithms on EKG, oxygen saturation, and photo-realistic 3-D interactive graphics based on real patients

Mannequin-based simulators have become increasingly common in areas such as the OR, emergency department, and critical care units, where life-threatening situations that require recognition and treatment often occur. Some simulators can even mimic the effects of various drugs, track the distribution of the drug in the body, and determine the exact effects that a specific amount of the drug will have on the human body (Stanford, 2009a).

The costs associated with these types of simulation generally increase with the level of sophistication of the simulator. Complex simulators may also be more of a challenge to set up and transport than more simple simulation techniques. However, the level of realism introduced by high-fidelity simulation modalities truly brings the learner into an interactive, genuine work environment.

Standardized patient educators

A tactic that adds to the high-fidelity simulation modalities is the use of standardized patient educators (SP). SPs are educators who are specially trained to portray patients, family members, and, at times, even members of the hospital staff. They are actors, but “really educators at heart,” says Holtschneider.

Using SPs lets learners engage in mock conversations with patients, deal with family members who are frightened and questioning, and cope with colleagues who may not be acting professionally.

The Association for Standardized Patient Educators (ASPE) is an international organization for professionals in the field of SP methodology. Its goals are to (ASPE, 2009):

  • Enhance the professional growth and development of its members
  • Advance SP research and related scholarly activities
  • Establish standards of practice
  • Foster patient-centered care

SPs are used in a variety of academic settings, such as medical and nursing schools. However, their use is now becoming more common in clinical environments because they add another dimension of reality. However, they also add to the cost. Organizations hiring these educators must screen them carefully and hire only those persons qualified to assume such roles.

Serious gaming

The term “serious gaming” involves the use of video game technology to add another dimension to the learning process. Learners function within specific rules and guidelines while playing interactive computer-based games. These games generally present a complex healthcare situation (e.g., multiple casualties from a terrorist attack arriving at an emergency department) that requires the learner to intervene appropriately.

Although the game format is viewed as a fun way to learn, the games offer deadly serious scenarios. Serious gaming is an increasingly popular training mechanism. There are even conferences on the use of this technology, such as the Games for Health Conference, which was held in Boston in June (Games for Health, 2009).

Video and computer games can be developed fairly quickly and can simulate functional entities in various clinical settings. However, they can be expensive to develop and learners must have appropriate training in their use. In addition, they require the availability of adequate equipment for learners (Holtschneider).

Desktop simulations and virtual worlds

Desktop simulations and virtual worlds can be run on a desktop computer and only need a screen, mouse, and audio inputs and outputs. The learner can view data, see the patient via animation, perform diagnostic or treatment interventions, and interact with the patient by typing or, in some cases, actually speaking with the patient.

An advanced approach to this type of simulation allows several participants to participate in a virtual world simultaneously. Learners can interact with each other, the patient, and others in this world. A distinct advantage of this type of simulation is the ability to interact with various healthcare team members as well as the patient and family (Stanford, 2009b).

Virtual reality and visualization

Virtual reality is a computer-generated world that allows the learner or group of learners to experience various stimuli, often in a 3-D presentation (Holtschneider; Stanford, 2009c).

Learners typically wear head-mounted displays to receive visual and auditory cues. They can interact in the computer-generated world from various sites or be in a physical space in which they can interact with others (Holtschneider).

Virtual reality is a rapidly developing field and gives a true sense of realism. However, the creation of a complex virtual patient and treatment setting can be time-consuming and expensive. It requires a complete computer model of the patient environment; a way to track visual, audio, and touch fields; adequate hardware for all sensory modalities; and hardware to compute all models, track inputs, and produce outputs in real time (Stanford, 2009c).

This overview of simulation modalities shows that the word “simulation” refers to several teaching methods, from the simple to the complex. These variations, as well as the differences in complexity, make it important to have standards and guidelines in place for their optimal use and best possible learner outcomes. In December, The Staff Educator will publish an overview of the efforts to develop and implement such standards and guidelines.


Association for Standardized Patient Educators (2009). “Welcome to the association of standardized patient educators.” Retrieved October 1, 2009, from

Games for Health (2009). “About us.” Retrieved October 1, 2009, from

Holtschneider, M.E. (2009). “Simulation learning modalities: Going beyond sim man!” Concurrent session, NNSDO 2009 convention, July 11, 2009, Philadelphia.

Mt. Hood Community College (2009). “Fidelity simulators.” Retrieved October 1, 2009, from

National Nursing Staff Development Organization (2008). “Collaborative efforts across organizations: Building a simulation alliance.” Journal for Nurses in Staff Development 24(6): 303–304.

Stanford School of Medicine (2009a). “Mannequin-based patient simulation.” Retrieved October 1, 2009, from

Stanford School of Medicine (2009b). “Desktop simulations and virtual worlds.” Retrieved October 1, 2009, from

Stanford School of Medicine (2009c). “Virtual reality and visualization.” Retrieved October 1, 2009, from

Joint Commission readiness

How will new accreditation decision affect 2010 surveys?

The Joint Commission has announced the adoption of a new accreditation decision for 2010, “Medicare Condition-Level Deficiency Follow-Up Survey,” which will be used when surveyors evaluate a facility with one or more condition-level deficiencies out of compliance.

These condition-level deficiencies refer to CMS’ Conditions of Participation (CoP). If a hospital receives this decision, it must address the deficient CoP, after which an on-site follow-up survey will be conducted.

This survey should not be confused with conditional accreditation decisions. According to Joe Cappiello, chair of Cappiello & Associates in Elmhurst, IL, this new accreditation decision is the result of continuing dialogue between The Joint Commission (formerly JCAHO) and CMS concerning The Joint Commission’s pending deeming application decision.

“What CMS probably said was, ‘If you have a condition out, it has to be fixed right away, and you’ll have to go back in there and validate that it was fixed,’” says Cappiello. Historically, CMS requires that correction and verification by on-site follow-up occur within 90 days.

In addition to the news that an accreditation decision is coming, there will be new language in the conditional accreditation rules that indicate additional causes for this accreditation decision. Conditional accreditation occurs when an organization fails to resolve issues stemming from a provisional accreditation status or when the organization is in substantial noncompliance of mandated Joint Commission standards.

Hospitals can now receive conditional accreditation when:

  • The organization fails to provide mandated timely submission of information to The Joint Commission
  • Systemic patterns or repetitive findings arise from previous surveys
  • There is legitimate evidence that fraud and abuse occur within the healthcare organization

These changes have been made as part of the Standards Improvement Initiative. The “fraud and abuse” language brings The Joint Commission’s language into compliance with CMS requirements.

Hospital staff members must be aware of the new language pertaining to conditional accreditation rules as well as the effect of the upcoming accreditation decision.

Editor’s note: This article was adapted from the September Briefings on The Joint Commission.

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