1. Christopherson, Toni Michelle EdD, MSN, RN, CNS, BC

Article Content


Quality and safety in pediatric health care, treatment, and services are paramount. This understanding is highlighted during the time of a regulatory survey such as that by the Joint Commission. Education, as part of a multifaceted approach, can assist in the preparation of nurses not only for survey but also for ongoing improvement beyond the survey. In this article, the author discusses the educational theories that support the engagement of comprehensive educational approaches to meet the needs of diverse learners to ensure quality and safety in the delivery of family-centered care.



One acute care pediatric hospital established a multidisciplinary team to address the educational needs of clinical and administrative staff. The team was composed of unit-based, central clinical educators, ambulatory care educators, clinical nurse specialists, and nurse practitioners. The team worked with infection control, pharmacy, case management, quality management, accreditation and licensing, and other professionals within the organization. Team members designed an educational program using a systematic process: assessment, planning, implementation, and evaluation. The program incorporated a multitude of educational initiatives supported by educational theories to meet the needs of all types of learners.


First, the educational process began with an assessment of educational needs. This assessment included an identification of areas of vulnerability within the organization in terms of compliance with regulations and the organizational safety and quality goals. For example, Quality and Risk Management mock survey data indicated a need for education on the performance improvement projects being conducted house-wide and on a unit-specific level, and more was needed on the National Patient Safety Goals (NPSG). Infection Control Rounds identified opportunities for improvement related to the medication process and hand hygiene. This phase also involved an analysis of the educational resources available. For example, were there any technologically advanced strategies available such as the CHEX Knowledge Exchange or system-wide e-mail access?


Second, the team members designed and implemented a multifaceted educational program to meet the identified needs. The program was designed to address one educational topic weekly. The team developed objectives for each topic. Nurses were involved at all levels of the organization and engaged in a variety of educational activities, including games such as Jeopardy and puzzles; displayed informational posters, flyers, and practice alerts; and one-on-one encounters.


The education started with the CHEX Knowledge Exchange's NPSGs and Survey Process learning module. This individual learning format allowed nurses flexibility in completing the education at their convenience. The module was designed for today's learner who is looking for immediate access and substantial interaction (Goldstein, 2005). It provided a factual foundation (Orefice, 2005) of the overall regulations, survey process, and application to the hospital system. This was followed up by providing all nurses a question-and-answer foldout booklet with critical organizational information.


Another individual learning activity that provided immediate feedback, interaction, and factual information was designed to address the need for hand hygiene education. An interactive education station was set up outside the cafeteria for day-shift staff. The same program was offered to the night-shift staff through a mobile education station. The main attraction was the glow-germ activity that provided immediate feedback on the effectiveness of the staff's hand hygiene technique.


Topic-specific e-mail questions or games known as "JCAHO Brainteasers" were sent out to all nursing personnel. The team also developed an NPSG Jeopardy Game for each unit, which gave prizes for correct answers. The games were particularly effective in stimulating nursing enthusiasm and participation, which also leads to the ability of learners to score higher on tests (Bhoopathi & Sheoran, 2006) and retain information (Fitzgerald, 2003). The nurses would call various departments, search the Internet, and discuss with one another the potential answers to word searches or crossword puzzles.


Charge nurse question and answer sheets were designed to accompany each educational activity and to assist the charge nurses in working with members of the nursing team. Clinical excellence manuals were also developed to assist the educators and clinical nurse specialists in working with staff. The manual contained all the educational materials, which allowed for easy access to information, and it was also used to ask questions of the staff. For the medication process, medication poster boards were developed and displayed in each unit. The nurses could refer to these during their work and during one-on-one mock tracers. The key to these types of one-on-one interactions was that it offered individualized feedback, applied content to the clinical setting, and involved the nurses in the learning process; the educators were careful not to put the nurse "on the hot seat" (Fitzgerald, 2003).


To complement the weekly activities, there were daily, monthly, and classroom activities. There were daily chart audits that actively involved the staff in knowing how and where to find information within the hybrid medical record. Daily excellence in hand hygiene was recognized by offering a prize to staff observed using good technique. On a monthly basis, organizational updates were provided to the charge nurses at their meeting, which further assisted them in their work with staff. The classroom activities involved staff nurses from one unit tracing the care provided to a patient from their unit as documented in the patient's medical record. The activities were presented in the form of a case study that was an actual patient scenario. The contents (policy and procedures and standards of practice) were taught while the skills (informatics and medical record navigation) were being taught, which is what made this a problem-based learning situation (Beers & Bowden, 2005). It has been suggested that problem-based learning increases long-term retention; thus, a retained, substantial knowledge base harmonizing with the ability to apply the knowledge will undoubtedly lead to quality and safety in health care.


These classroom activities also incorporated principals of cognitive learning theory: gain learner's attention, outline session objectives and expectations, present information, assess performance, provide facilitative guidance and feedback, and offer application during practice (Braungart & Braungart, 2003) with a patient selected from the learner's unit. The use of Piaget's cognitive theory specifically allowed for individuals to construct their own knowledge by being actively engaged by physically reviewing the patient's medical record and mentally manipulating the ideas discussed in class (Woolfolk, 1998); constructivism theory further allowed the learner to construct new knowledge by building on prior knowledge (Norton, 1998) of the patient population, medical record, and documentation system.


The clinical excellence team completed training by conducting mock tracers. The members of the team prepared a mock survey manual that included a question guide, mentoring strategies (how to answer questions based upon policy), and policies and procedures that had been identified as requiring reinforcement during audits or tracers and/or that had been identified by other healthcare facilities as challenging issues during regulatory site visits. These mock tracers were designed to compliment environmental rounds and/or mock surveys that are conducted by nursing leaders and other personnel within the facility. This approach was supported by the constructivism theory, where the development and expansion of knowledge occur as a result of the interaction between the learner and others in the social surroundings (Sanders & Sugg, 2005); the nurse and other healthcare providers answered mock surveyor questions while in the actual clinical setting. It is this type of collaborative learning environment, zone of proximal development, that fosters growth toward one's potential (Sanders & Sugg, 2005), and the activity broadens traditional simulation that is described as occurring within a laboratory setting (Kneebone, Scott, Darzi, & Horrocks, 2004) by coupling the simulation in a clinical practice setting that may create even more real-life challenges and learning opportunities that develop the skills necessary for safe and quality care. The results of tracers, rounds, and surveys were tabulated and communicated to appropriate personnel for recognition of excellence, reinforcement of education, and/or addressing of systems issues.


The family can become an integral part of the quality and safety process. Family members working on the Family Advisory Committee can, in consultation with educators, develop educational materials for patients and families. For example, NPSG No. 1 highlights the importance of patient identification. Patients and families can assist in ensuring that two identifiers are used whenever medications or blood products are administered, blood samples or other specimens for clinical testing are taken, or any other treatments or procedures are provided (see The Advisory Committee members and educators can develop flyers that may be given to patients and families upon admission that inform about patient identification and their role in ensuring a safety environment. The emphasis is about "collaboration in care" for the purpose of quality and safety.



The program was designed to use both external and internal incentives. External recognition, which, as a part of behavioral theory, strives to reward or reinforce the behavior that is desired (Braungart & Braungart, 2003), came in two forms: financial award (Clinical Excellence bucks) and certificate of recognition. Financial rewards such movie tickets, free parking, or free coffee were available to nurses who correctly answered JCAHO Brainteaser e-mails, puzzle or game questions, or mock survey questions. A certificate of recognition was also posted in a highly trafficked area to acknowledge the staff and/or units who had the greatest participation in weekly educational activities.


The self-initiated, internal reward needs to be just that-pride in professionalism. There is a need to fulfill one's potential and seek greater understanding, growth, and satisfaction in work, which is described as an internal motivator by humanistic educational theorists (Woolfolk, 1998). It is this type of reward that really speaks to sustained, long-term changes in the quality and safety of care offered by the nurses, which is also very difficult to offer directly as an incentive.


Finally, team members evaluated the effectiveness of the program and how the program could continue in light of the unannounced The Joint Commission survey process and in consideration of the ongoing pursuit of excellent and quality clinical outcomes. The clinical impact was immense, which is illustrated in a few examples. The nurses reviewed and continued to work on their unit-specific projects, which increased their awareness of the process improvement process and their role. The audit of accuracy of patient identification (NPSG No. 1) increased to 100%. Nurses' use of nonapproved abbreviations (NPSG No. 2b) fell to zero. Environment of care data indicated that no supplies were kept under the sinks, and clean and dirty utility rooms were maintained.


The summative evaluation indicated that education was effective in meeting the needs of health team members who described themselves as ready for the survey process. Staff identified the most effective educational activities: (a) staff meetings; (b) charge nurse, clinical nurse specialist (CNS), and educator questions; (c) JCAHO information booklet; (d) weekly posters; (e) weekly JCAHO Brainteasers (e-mail); and (f) mock survey classes. Collectively, these represent auditory, visual, and kinesthetic educational activities as well as individual and group strategies; therefore, these evaluation findings support the multifaceted approach to education in meeting the diverse needs of learners.


The summative evaluation further suggested recommendations for improvement. The inclusion of a more diverse PCS committee membership and the inclusion of additional levels of personnel (staff and managers/directors) would have added strength by enhancing the team's multidisciplinary collaborative efforts and increasing the ability of the team to hold others accountable for the outcomes. The establishment of a budget to purchase materials would have facilitated the process.


Even though the educational process was powerful in producing the desired outcomes, it needed to be a part of the larger organizational initiatives such as system changes, mock surveys, and/or SWOT (multiple multidisciplinary personnel go in to a unit or department and assist in addressing an immediate issue) teams. For example, the staff had received education about the discharge procedure, but compliance with part of the process was still not satisfactory. The education continued and was complemented by a computer system redesign, which improved adherence significantly.



Education needs to be designed to meet the needs of all types of learners. Learning is enhanced when staff perceives the education as immediately applicable to their work. Furthermore, educational programs in pediatric acute and/or ambulatory care need to be general to the organization and specific to the subspecialties within pediatrics, as appropriate. For example, the classroom education had specific organizational objectives, but the documentation and cases selected for review were specific to each unit. These outcomes have given us the insight needed to move forward into the days when The Joint Commission surveys will no longer be announced. This type of educational program must be within an environmental context where nurses are partners in the care team that includes patients and families in the quest to continuously improve quality and safety.




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