CHAPTER FIVE

Training: An Overview

By Dr. John Robert Dew

This article examines the use of training as a key ingredient in safeguarding organizations

against significant quality, environmental, health and safety problems. Training tools and

methods such as controlled operator aids, the use of performance evaluation checklists, drills,

computer-based training, and simulators will be considered.

WHY TRAIN?

There are several reasons why most organizations need to have a formal approach

for assuring that staff have the appropriate knowledge and skills to perform their work.

Initially, some people will oppose this thought, arguing that they hire competent professionals and technicians. However, all work places are subject to the laws of variations, and variation is a major factor in any workers’ knowledge.

Each person brings a unique background of experiences, formal education, and informal

learning to their job. In some cases people come into the workplace right out of school

while others join the organization with years of experience. Some of the experience will be good, while some may foster attitudes and practices that are not conducive to error-free work. A great deal of variation exists in the formal degree programs as well.

While organizations can seek to control the variation of knowledge and experience in

the hiring process, a certain degree of variation will still exist, even in people with similar

backgrounds. Training helps to reduce the variation in knowledge, bringing every person

up to a common level of knowledge that enables them to safely and effectively perform

their work. Training assures that employees have the opportunity to openly question

work practices, creates the correct setting for communicating best practices and gives

management an opportunity to caution staff about poor practices that result in quality

failures, environmental incidents, accidents, and health risks.

Training ensures consistency in the message that employees receive about their organization.

While formal training gives staff the technical information they need, it also

sets the stage for a consistent message from management about the need for effective

planning, safety, and regulatory compliance. Training is one of management’s tools for alerting

employees to the causes of errors and to update employees on events that have occurred at other,

similar, facilities. It is an essential step for bringing new people into the organization and carrying

out any significant change. When organizations ignore the training step and jump in to implement

changes in processes and equipment, they send a clear message that it is okay to be sloppy in

planning and less than adequate in preparing to do work.

Training communicates priorities, both formally and informally. Formally, training

allows management the opportunity to state and restate their priorities regarding safeguarding,

safety, quality and compliance with health, safety, and environmental rules. Informally,

training sends a message to the staff that the organization is either flying in formation with

a clear flight plan, or flying by the seat of its pants. When training is not a priority, then the

organization is basically telling the staff that they are on their own.

Training allows the organization to place appropriate emphasis on key points and to

overtrain in these areas. If proper disposal of hazardous waste is absolutely crucial to

achieving safe and environmentally compliant operations, then management should train

and overtrain on this skill to make sure that everyone remembers how important it is and

how to do it. No one can remember everything, but everyone can remember some things.

All organizations have the ability to place emphasis on some things to make sure that everyone

remembers them through training.

Training is essential for providing staff with knowledge to perform new procedures and to

work safely with new equipment. Any changes for protocol in work practices demand training to

address new concerns and work methods.

Finally, training provides the baseline for enforcement of policies, procedures, and

expectations. When the organization has not provided formal training on tasks, it is

difficult to claim that the performance expectation has been set, and it is difficult to hold

people accountable for meeting the expectation. When the organization takes training

seriously and communicates expectations, as well as provides knowledge and skills to

meet the expectations, then the organization is well positioned to invoke discipline when

expectations are not met.

GUIDELINES FOR TRAINING

The process for effective training has been well studied and documented. There are

five basic steps in training: assess the needs, select the media, develop the content,

deliver the training, and evaluate the effectiveness of the training. These steps are

sequential. It is always best to start with a needs assessment before moving on to the next

step. These steps can be cyclical, meaning that organizations should periodically revisit

their training and conduct new needs assessments to keep the knowledge base of the

work force current with technology and medical practice.

1. Assess training needs.

Training is expensive, so an organization should focus on the areas of greatest need

and benefit for safeguarding systems through the needs assessment process.

Start by defining the scope of the work being performed. Is the scope narrow, like

operating a single piece of equipment, or is it broad, such as supporting control room

procedures? It is useful to take some time and observe the work that is being performed.

Observe the work and the conditions in which it is performed.

It is important to interview the people doing the work. Ask them to describe the functions

in their job. What background information do they need to do the work well? What types of

problems do they encounter? What can go wrong? What has gone wrong in the past?

What would they wish someone had told them before they started doing this job?

Take the observation and the interview data and compile a list of the specific jobs a person

must know how to do in order to be safe and effective. If the jobs involve several tasks,

then make a list of the specific tasks.

Finally, review the list of jobs and tasks and decide which jobs and tasks are clearly known

to even the newest person and label these as no-train activities. Determine which activities will be new to most people and will require some initial training, and label these jobs and tasks for training. Also, look at the list and determine jobs and tasks that could lead to a quality, environmental, or health and saftey failure, and label these for overtraining, so that a periodic schedule can be prepared for refresher training.

A training needs assessment must be conducted whenever a facility performs a

new procedure. If new equipment is brought in for new procedures, then the training staff should

interview sales representatives, review technical manuals, and assure that staff receive appropriate training on the new equipment. Likewise, when work groups are reorganized and job duties are broadened, careful attention must be given to training needs assessment to ensure that everyone fully understands their new roles and responsibilities and are technically able to perform their duties. When management learns of a quality, environmental, or health and safety problem at

another facility, a training session should be designed and provided for staff who are performing similar work.

2. Select Training Media

People often think of training and automatically associate it with sitting in a classroom

and having a staff member give a lecture. While that approach is sometimes the best alternative,

an organization should consider the full range of training media available to select the

most cost-effective and effective media.

Effective training can utilize video-based training (VBT), computer-based training (CBT)

on-the-job training (OJT), classroom training, simulations, and self-study. Each approach has pros

and cons in terms of cost and effectiveness.

Most organizations can benefit by partnering with community colleges and universities for use

of facilities, distance education courses, and access to the most up-to-date video, web-based, and

computerized educational materials.

Video Based Training (VBT) captures a training process on videotape for replay at the learner’s convenience. It requires that a script be prepared that details the content of the training, ensuring that the right content goes into the program. Video gives an organization a high degree of flexibility in delivering the training since it can be used any time of the day or night. It also assures that the training content is always delivered in a consistent manner. On the downside, video requires some investment in shooting and producing. Organizations can find off-the-shelf technical training programs on videotape. If an organization needs to train a lot of people in a task or program, and if the task is not likely to change much over several years, the video is often the most cost effective way to deliver training.

Video is widely used in healthcare for both staff and patient education. Easy access

allows patient and families to view materials at their discretion. The staff’s ability to view

short videos in conference rooms benefits both the facility and the individual. A videotape

about specific types of quality, environmental, health and safety events can be custom-made

for a facility whenever management is concerned abou the level of errors and the potential

for a significant event.

Sales representatives for new equipment should provide a training videotape to support

staff training, along with operational manuals for the training staff to review.

Computer Based Training (CBT) offers another dynamic approach to delivering training. Like VBT, CBT offers an economical way to provide standardized training for large numbers of people. The training can be conducted when it is convenient for the learner. Also, like VBT, CBT requires thorough up-front planning, as well as a larger investment in programming and scripting. CBT can use just a personal computer, or it can be linked with visual images on a CD ROM. CBT programs can be developed for distribution to facilities across a wide network for low costs and is proven to have a high-retention rate of content. CBT can also provide the capability to include examinations and to document that people have passed specific programs to qualify for doing work. Again, organizations should examine the possibility of partnering with a community college or university to benefit from the computer based training resources.

On the other hand, CBT is a high-cost approach to training if it will only be used by

a few people. It can be expensive to modify, and requires time to plan and develop.

On-the-job Training (OJT) offers another approach to training people to safeguard systems. This approach has the advantage of being low in preparation cost, and offers the learner an immediate opportunity to see first hand what the task may be and to ask immediate questions.

OJT offers good retention of material. However, the risk of OJT lies in the variation in knowledge and presentation by the person conducting the training. Some people know a great deal of information and will share it; other people know less and will share less. Without a prepared checklist or outline, it is possible for the content of OJT to be less than adequate,

so always require instructors to use a checklist. OJT can be a low-cost form of training for a small number of people. For large numbers, the cost goes up due to the time required by an experienced person to provide the training.

In the healthcare setting, organizations are improving OJT by assigning specific reliable

individuals to be trainers, often called proctors. Proctors can be very effective in

providing training for high risk and highly technical areas such as ICUs , labor and delivery units,

and emergency departments. The new person is assigned to an experienced proctor for a

designated length of time. The proctor uses checklists to assure consistent training of

understanding the practice.

Classroom instruction can also be an effective way to conduct training. Classroom

instruction can be one of the most expensive forms of training since it requires the development of

a lesson plan, the time of an instructor, and the cost of a classroom. The advantage of classroom

instruction is that the lesson plan can be quickly prepared and modified to meet changing needs.

It is also possible to design and administer examinations easily with classroom instruction, and for

the instructor to remediate participants who had difficulty with the material. It is essential to

have lesson plans to reduce the variation in the content taught in the classroom.

Classroom training is cost effective when training small numbers of people, as well as when the content of training is subject to frequent changes. Classroom training can be revised faster than any other method if it is going to a small audience.

Simulations can be a cost-effective form of training in areas where the risk of a quality,

environmental, or health and safety failure is high and the consequences are severe.

Simulations can range from practice in performing a specific task with a model up

To the complete simulation of a power plant control room, airplane cockpit, or the wheelhouse

on a riverboat. In healthcare, simple simulators, like Annie the mannequin, can be used for hands

on practice of cardio pulmonary resuscitation and in the practice of administering anesthetics

where the smallest variation in practice can lead to major problems.

Self-study is another viable approach for training people to safeguard work systems.

Self-study manuals can be written to provide people with consistent and accurate information,

and can be used by the learner at their convenience. Self-study manuals can include trial

exams for the learner to self-test and to help the learner refer back to the text when an item

was not understood. In terms of the cost of development, self-study materials cost about

the same as VBT, and are most effective when a large number of people need

to be trained, or when the training needs to be given to people in remote locations. Self-study

pamphlets and books can also be combined with self-administered tests [KR1] for annual training

reviews. Staff take self-administered tests to verify what they know and to identify areas

they need to study, based on their wrong answers when they test themselves. This saves

time by focusing attention on learning what the staff does not know or remember, and does

not spend time rehashing what the person already knows and remembers.

Web Based Instruction is rapidly gaining speed. “Webinars” that combine powerpoint

presentations with an audio presentation over a phone line are an effective method to provide

specialized training for a few people in an organization. In the past, this type of training usually

required sending an employee to a training program in another city or state. Webinars avoid

travel costs and travel time for staff.

DEVELOPING CONTENT

Regardless of the media used in training, organizations should employ a constant approach

in developing the content. This approach is called the What, Why, How model.

In this approach, the learner finds out what is to be done, why it is important to do it correctly, and how to do the work properly, including specific warnings about common mistakes.

WHAT - WHY - HOW MODEL

WHAT EXPLAIN WHAT NEEDS TO BE DONE.

WHY EXPLAIN WHY IT IS IMPORTANT

HOW PROVIDE SPECIFIC STEPS & GIVE WARNINGS

Start by defining what will be done. Tell the learner what task or concept to focus

on. Next, explain why the task is important. This might include importance in terms of

proper diagnosis, proper record keeping, proper treatment, patient safety, conformance

to environmental laws, avoiding electrical hazards, or any one of many other reasons.

Finally, describe and/or show the proper steps in performing the task and provide

warnings about hazards and potential errors that could result in adverse events.

The What, Why, How model satisfies the manner in which the mind processes information. If

you skip past the Why step and go directly to How, the learner does not listen to the How

because he or she is strill trying to figure out Why they should be paying attention. If you skip the

What step, then the learner is constantly jumping back to What, trying to figure out what he or

she is going to be able to do with this training.

What, Why, How should be used by proctors in providing OJT, as well as for other types of

training. For each new task, start by specifying what the overall task will be, why it is important

to perform in the specified sequence, and then how to do the task. Be sure to include guidance on

any common errors that can occur. When possible, proctors should point out the procedure that

is available to provide guidance for the work.

LEARNING OBJECTIVES

As you begin to develop a training program, it is important to clarify the learning objectives

for the participants. Learning objectives should be stated in terms of actions the participants will

be able to take by the end of the training. [KR2] For example, participants will demonstrate

their knowledge about a policy or procedure, either through an examination or by drawing

a flow diagram of the process. Participants will explain how a task is performed. Participants

will identify equipment that is used, or they will perform a specific task. Participants will

demonstrate proper techniques in performing a task.

A brief lesson plan should be prepared to identify the learning objectives for each

training activity. As a minimum, the lesson plan should define the topic, anticipated length of

training, the learning objectives, the handouts or audiovisual aids, and an outline of the content.

For better control of the training process, lesson plans should be expanded to include a script

of the specific information that will be covered by the instructor. This will assure that the same

content is taught in all classes. A content outline defines the topics, but it does not ensure

consistency in content delivery. Expanding the lesson plan to include the specific content

information is the best way to assure that classroom style presentations are conducted in the

same manner.

TRAINING DELIVERY

Organizations often want to deliver training in a manner that is most conducive to the

organization’s needs. Let’s train everyone in the same thing at once so we can be efficient.

However, from the learner’s point of view, timing is of the essence. If you give someone

information today that they will not use for several weeks, the odds are that it will not be

remembered, and the time spent in training was wasted.

While it may be efficient to give people a lot of information at once, we know that people

only retain a small amount of what they hear at any given time. Small doses of training

are more readily learned than large volumes. People may retain as much from a 30-minute training session per week as from an eight-hour, day-long or multi-day workshop.

It is important to evaluate whether or not the learner has understood and retained the

information in the training. We often make the mistake of believing that if we tell something

to someone and they do not question us, that means they understand. This is usually

not the case. Instructors must evaluate to see if participants fully understand the

content of the training.

Organizations must also consider the benefits of a variety of approaches to annual refresher

training in Ocupational Safety and Health Administration (OSHA) and other required areas. For some organizations, it works well to require everyone in the organization to complete their refresher training in one specific week. In other settings, it may be better to give each person an anniversary date some time in the year so that the refresher schedule is staggered. New computer training data bases allow organizations to keep track of who is due or overdue for required training.

EVALUATION

Investing in training can add almost no value in safeguarding against quality, environmental,

and health and safety events if an evaluation step is not included in the training process.

Evaluation can occur during the training, at the close of the training, or after the training.

During the training it is essential to confirm that the learner fully understands the content.

This is done in CBT by building in review questions that the learner must answer at the end

of each section in order to move on. The same method can be written into self-study texts.

In the classroom setting the instructor often uses inadequate questions, such as “Does everyone

understand this?” Almost no one will admit that they did not understand something.

Classroom instructors and OJT proctors need to employ “test-for-understanding” questions.

These are questions that require the learner to respond in a way that will indicate to the

instructor whether or not the material was understood. Good test-for-understanding questions

are questions like, “How would you apply this idea?” “What would you do if you were in

this situation?” and “How does this differ from the last example?”

Examinations should be used at the end of a training course to verify that the learner

understands and can apply the information from the training. This can be done through a

written exam, an oral exam, or a performance test.

It is a good idea to decide what types of testing will be used before beginning to design

the training, and to determine exactly what information or skill will be tested. While instructors

do not want to “teach to the test,” it is important to make sure that any items on a test are

well covered in the training.

Written exams offer an advantage when an organization wants to keep a record to verify

that the training was conducted and that the participants demonstrated their knowledge, such

as training required by OSHA. Oral exams offer the advantage of being less of a threat to

individuals with exam anxiety.

Performance tests are situations where a person is expected to perform a task after being

trained so that a proctor or instructor can observe that the individual has learned how

to perform the procedure. For example, many facilities use controlled substances and require

special training. A performance test in which the employee shows his or her knowledge of how

to use the controlled substance makes a great deal more sense than just using a written exam.

Performance Evaluation Checklists (PECs) are a useful tool for periodically verifying

that employees still know how to properly perform important tasks. A manager or trainer

prepares a PEC by making a checklist of the proper steps in performing a job. Each staff

member performs the job while being observed by an independent person, and the staff member

receives feedback if any steps are omitted or performed incorrectly. PECs can be used on

a regular schedule to provide structured assurance that employees are correctly performing their work. Completed checklists can be used as records to document proficiency if the facility needs to show this to an auditor. PECs are commonly used for skills validation of pharmacy personnel. The PEC can be used for updating credentials and as a record for required retraining. A PEC can also be used to observe proper compliance to wearing personal protective equipment and hand-washing techniques.

CONTROLLED OPERATOR AIDS

Because of the complexity in performing some work and the awkward nature of procedures,

it makes sense in some cases to use a controlled operator aid. A controlled operator aid is a set of action steps that are posted on a piece of equipment or given to an employee in a small notebook that serves to remind people how to perform a job. These are useful tools to refresh a person’s memory without having to go back and read a procedure.

The risk of introducing operator aids is that they can get out of control. Uncontrolled

operator aids are the hallmark of a tribal culture. In the tribal culture, each person has their

own set of reminders about how to operate equipment. People make notations with magic

markers on equipment and in other informal ways in which there is no systematic control and

clear communication.

Controlled operator aids are part of an orderly flow down of information. The content

of operator aids should be defined in a procedure and covered in training. When aids are

issued they must be periodically be reviewed to ensure that they are up to date.

USE OF DRILLS

Drills are another useful way to evaluate and assess learning in almost any healthcare

setting. Drills are primarily useful to keep staff alert to dealing with emergency situations,

such as the release of a toxic material, the sudden emergence of a fire, or the loss of power

or oxygen systems. Drills can be used to ensure that employees know how to shut down

and secure medical devices that use nuclear sources, and how to verify patient security in

emergencies.

Employees can make costly mistakes when an emergency or off-normal [KR3] situation,

such as an unplanned loss of electricity, arises if there have been no drills to prepare them.

A typical drill program will focus on developing specific drills to prepare people to deal with

likely situations. Specific drills are prepared to focus on the proper shut down of equipment,

proper location of exit points, and proper communication practices in the event of an emergency.

The purpose of a drill is not to create a situation and watch what happens. Instead,

drills should be based on the objective of observing specific learned behaviors. Drill planners

should develop checklists of specific tasks and activities to be observed in addition to measuring

the amount of time it actually takes to perform a task.

TEAM TRAINING [KR4]

Manufacturing and healthcare facilities are paying more attention to training people to function

as a team. Drills and simulations are often best performed in a team settings. In addition to

technical training for a team, the organization should also provide team training on personality

traits so that team members will understand and value the different strengths that people bring to a

team. Workshops on communication skills are important in developing effective teams, along

with sessions that focus on encouraging the team to conduct self-assessmennts.

Team training is any activity designed to improve a work group's ability to

perform more effectively as a team. This can range from training that helps people

assess and discuss their personality traits and communication skills up to

outdoor teambuilding activities. Some organizations use trust walks to build

teamwork, where all team members but one are blindfolded and led through a

park by the one team member who can see. There are hundreds of variations

of teambuilding activities available and dozens of consulting groups

that specialize in facilitating these activities.

Summary

Effective training can constitute an important safeguard to ensure appropriate

quality of work, conformance to environmental regulations, and observance of

health and safety standards. Careful consideration should be given to the cost

and timeliness of training, with the understanding that the design and delivery

should focus on the learner, not the convenience of the organization.

Dr. John Robert Dew

jdew@aalan.ua.edu

This article is an adaptation of material co-authored with Meri Curtis and published

in Diagnosis and Prevention of Adverse and Sentinel Events.