Education, the solution to everything, until everything goes wrong.

Are we saddling clinical education with an unrealistic yoke to carry?

First of all, apologies to those who thought this would be cool stuff about gadgets and manikins.

About two years ago, I began a relieving post that involved attending hospital governance meetings in an educator capacity. In the first meeting I attended (hoping to sit quietly and keep my mouth shut), I was bemused to observe the receipt of audit results relating to medication chart compliance and the almost immediate reaction “well it seems we need to do some education.” My mouth was open before my frontal lobe could kick into gear, “really… do we think nurses don’t know how they are meant to sign a drug chart?”

On later reflection, I considered that this actually happens a great deal in clinical education. Problem (audit/RCA/Adverse event = obvious need for more education. Take a second and consider the alternatives, if it is not lack of knowledge that caused the shortfall. Pretty unsavoury options, wilful disregard, flawed process, individual or system incompetence. If we are honest, these things exist in every large system comprised of people. In a rousing plenary at the Rapid Response Systems Conference in 2012, Dr Rinaldo Bellomo beautifully analogised his hospital with an autistic savant child, capable of inconceivable brilliance, such as organ transplantation and yet incapable of simple attentive observation and communication. So what does that mean for clinical education and if we take on time consuming education targeted at issues in which the route cause is actually system or performance, are we actually even educating? That is, will there be any change?

Point One – it is imperative, in the resource starved health system we work in, to evaluate what we do and deliver “needs” based education rather than “wants” based instruction.

Point Two – in the evaluation process, it is important not to burden an education program/strategy/technique with unrealistic expectations. An interesting example comes to mind. A colleague presented recently on his findings from a pilot program of simulation in a local residential aged care facility. This program evolved greatly from origins in a passionate ad hoc endeavour to a well formed, researched and standards based education unit. Following a q and a session at the end, another colleague accessed data gathered in her role looking at hospital avoidance. We received a deflated phone call the following day stating that, unfortunately, the admissions had gone up from that time period when compared to the previous six months (she was very disappointed). So the education was a waste of time right?  (I would love comment/views on this)

Point Three – it is irresponsible to claim direct success in terms of a measurable change mapped directly back to an education program (unless stringently controlled for other variables and stats analysed for significance). A hypothetical example “Educator ran workshop on blood transfusion management for clinical specialty and transfusion errors reduced at next audit cycle.” What else happened in that time?

Point Four – denominators matter. If we had 39 MET calls January 2012 (fictional number) and then 63 in January 2013 (also made up) is that meaningful? The Australian Commission on Healthcare Standards has metrics and guides for comparison of data and trend interpretation. http://www.achs.org.au/publications-resources/clinical-indicator-program/

Thanks for taking the time to read my first blog (rant). This has been something I am very passionate about because I believe education resources should be directed to providing education and not reactive remediation of process or performance failures.

A few points to provoke debate –

Falls prevention education measurable outcome = reduction in falls in hospital?

MET call and recognition and management of deteriorating patient initiatives measurable outcome = reduction in MET calls?

Hospital avoidance education in aged care measurable outcome = reduction in hospital admissions?

Tim Harford’s TED talk inspired me in ways I recall often Trial and Error vs God Complex

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8 responses to “Education, the solution to everything, until everything goes wrong.

  1. Great blog Jesse. Education raises awareness hence MET Calls etc go up. You are so right about education as a cure to what ails the health system! Need to give staff tools and time not just beat them with education for the sake of ‘doing something’.

  2. Nice start! Love the savant analogy. Surely one of the huge barriers to process change in hospitals is the yawning chasm between administrators and coal-face clinical staff. Different perspectives, different agendas, and no contact whatsoever. Could you design a more frustrating system that’s designed to fail? No amount of “education” can overcome this sort of setup.
    Looking forward to more posts.

  3. I think a lot about education versus compliance. In no particular order: it’s not reasonable to expect employees to achieve something they’ve never been trained to do. You have to ask “why” when someone is not in compliance. For example, Peter Pronovost wanted to know why physicians were not washing their hands, wearing a mask and gown, and sterile gloves, and using the correct medical soap when starting central lines. It turns out this required many extra steps because they were not all kept in the same place. Hence, they developed a cart just for central lines which improved compliance. You can obtain compliance with a whip but you cannot achieve quality. For that you need buy-in. You need believers. We’re asking people to do a lot of stupid things that waste their time and have nothing to do with patient care or patient safety so we create a lot of compliance fatigue. 10,000 policies and procedures to follow. Who can keep track? Exposing employees to unnecessary bureaucracy is disrespectful to their time and expertise. I agree that “education” becomes an Orwellian euphemism for something less-than-desirable. What we’re talking about is process and system design.

  4. Thanks for the feedback. Tom, I also think very highly of the work of Peter Pronovost and his collaborators. I used their NEJM paper on CVC practice to help drive implementation of a central line trolley, insertion bundle and daily ward round review of need for line at my old workplace. A key factor is that we don’t all work within hospitals that are ready/willing to change and I am always wary of this as I read QI papers from Johns Hopkins Hospital and others similar (Austin Hospital in Australia. Hopefully we may see more of this change/research culture in my state of QLD as two new public university hospitals are poised to open in the next couple of years.

  5. Pingback: 2 nurses providing critical care education. »·

  6. Nice post.
    I get frustrated with A.C.E. – Ass Covering Education. Problem identified – oh crap – quick let’s get an ‘education’ module pushed out – usually with very poor pedagogical underpinnings – and tick people off as ‘educated’ once they have answered 10 multiple choice questions…
    AKA Tick Me Clever.
    The motivation is often not to educate but a desire to show auditors (or the coroner) we did *something*. Hence the explosion in low-quality mandatory education modules.
    Unfortunately the opportunity cost of these is a devaluation of education.
    Creating a desire for change and improvement in staff is harder. But so worthwhile.

  7. Apparently our ED has the lowest compliance rate with hand hygiene. When I asked ‘do we know why” the answer is nobody seems to know, but you might hazard a guess in view of the remarkably fluid nature of the environment or ? or ? How can we design and implement change without knowing the factors that push us to practise in a particular way?

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