1. Puterbaugh, Susan MBA, RN, CNOR

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"Staff education" seems an easy answer to many nursing problems. As a clinical instructor, I am often called upon to intervene when deficiencies are identified. For example, suppose a hospital's protocol for medication administration addresses the timing of administration, but medications are being given late. Hospital administrators might ask the education department to review the medication administration schedule with each nurse. Is this the most effective solution, considering that talking to each nurse individually is very time-consuming?


Every technologic advance requires nurses to learn something new. Even standard health care equipment, such as IV pumps, intercoms, monitoring systems, and defibrillators, is often updated, requiring nurses to undergo in-service education. Added to that are mandatory annual continuing education, instruction on new and revised nursing standards and methods for electronic documentation and medication delivery, and recertification for basic and advanced life support.


Administrators' seemingly reflexive response to any problem that arises is to think that more education will fix it. The importance of "critical thinking" is often referred to in health care. It involves analyzing a situation in a novel way to find creative solutions. And critical thinking should be used before it's simply assumed that education can solve every problem. When more education has been provided but the problem remains, it should be obvious that education wasn't the solution to begin with.


In Analyzing Performance Problems: Or, You Really Oughta Wanna, authors Robert F. Mager and Peter Pipe describe how to determine whether an employee's poor performance of a task is due to insufficient skill. Briefly, if the employee used to be able to perform the task and no longer can or does, additional training is not the solution. The manager must determine why the employee is not performing as required. This is where critical thinking comes in. I suggest that the manager ask herself or himself the following questions:

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* Are the task's expectations precisely defined? Is the desired performance clear?


* Are the rewards for doing something greater than the rewards for not doing it? How do others on the unit influence this equation?


* Is the employee aware of the issue's importance? Does the manager reinforce that importance by following up on its status?


* Are the time, staff, and equipment needed to complete the task consistently available?


* Does the employee receive feedback on her or his job performance?


* Is the problem actually a systems problem that cannot be solved by education?



This process should be familiar to managers who perform a root-cause analysis when a critical incident occurs. Once the root cause is identified, problem solving can begin. Easy fixes-such as referral to education-are not appropriate when a patient's care is jeopardized. Systems problems must be identified and properly resolved. In the example involving the delayed administration of medication, hospital administrators should first investigate the cause of the delay. They might find, for example, that the nurses are well aware of the administration schedule and that the problem is caused by the late delivery of medications from the understaffed pharmacy. Educating the nursing staff wouldn't be appropriate in that case.


We can and should educate nursing staff, but when a problem is identified, we should remember that more education is only one solution to be considered. It shouldn't be a knee-jerk response. Let's give nurses more time to care for patients by having them spend less time learning what they already know.