This was a presentation I gave to the Canadian Society for Training and Development in 2005.
e-Learning and Communities of Practice in Healthcare
During 2003 to 2004, we worked with a Montreal area hospital to implement online learning for nurses as they adopted the new McGill nursing care methodology, as well as the creation of virtual communities of practice for social workers. From the initial performance analyses conducted on the hospital wards, to the implementation of the open source Moodle and Mambo technology systems, the consultants worked closely with the hospital staff in the development of their knowledge base, using domain ontologies.
Learn about the need to conduct a performance analysis prior to recommending any e-learning intervention
Learn how ontologies can help with the creation of shared professional knowledge bases
Learn about the benefits of using open source software for workplace performance support
My initial role in the project was to conduct the performance analysis. Well, actually I came into the project late and the analysis and solution had already been contracted for — an e-learning program to train nurses. I was able to get two days to conduct what we called — a confirmation of the analysis. It was the first analysis because one had not been done. It was assumed that training was the solution.
I wrote about this experience last year, in get out of the office.
Our team had been contracted to develop an e-learning program for nursing staff. I was able to negotiate a ‘confirmation of the analysis’, as I had not been involved in the design process. I was given two days to interview staff on various wards. As I was not hospital staff I was accompanied by the senior nurse.
We learned a lot during those visits to the wards, and even had some procedures changed on the spot as the senior nurse became aware of some redundancies. As a result the e-learning program was cancelled and we developed a few performance support tools and some job aids instead. Training was not the solution to this challenge — getting the right information to trained and experienced nurses was.
On completing my hospital visit I thanked the senior nurse for her help. In turn she thanked me for the opportunity to make her first visit to the wards. I asked how long she had been at this hospital. Two years she responded. I said nothing but was shocked that the person in charge of clinical nursing had never been to the workplaces of the people she was supporting. How many other managers in how many workplaces are in the same situation?
As illustrated in the figure below, an analysis of tasks or job performance included these components — inputs, employee performance, outputs, consequences, and feedback. Each component is essential for the system to function optimally.
- Is the nurse able to recognize inputs and take appropriate action?
- Are the results of other tasks (outputs) necessary to do this one?
- Are the procedures and workflow logical?
- Are the required resources available? [time, tools, people, information]
- Are there clear work standards?
- Does the nurse understand these?
- Does the nurse feel the standards are attainable under the work circumstances?
Skills & Knowledge
- Does the nurse have sufficient skills and knowledge to do the task?
- Does the nurse understand why the task is necessary/important?
- Is the nurse physically, mentally, emotionally prepared to do the task as required?
- Are rewards and consequences aligned with the importance of the task?
- Do rewards and consequences make sense to the nurse?
- Are rewards and consequences timely?
- Do nurses receive work performance feedback?
- Is this feedback — significant, precise, on time, about good as well as poor performance, easy to understand?
The model is focused on the job performance of nurses implementing the McGill approach to nursing care planning. We can see that nurses had inputs (resources, tools) and outputs (documentation), consequences (patient health, better communication with colleagues, patient and family), and feedback (from clients, peers, coaching, etc.). This provides a good picture of work performance and the factors that influence it.
Optimal performance requires all areas of work be addressed. If we address only one of these factors, such as the input in the form of training, without addressing the other inputs (the tools used on the job) or feedback on a successful task, we have no chance of achieving consistent performance on the job. The objectives was to understand the entire performance system and determine the critical factors to achieve optimal performance of nurses using the McGill model.
Summary of the Performance Analysis
- New tools are being developed to help with the tasks ahead
- Simplification of the patient documentation system
- Extrinsic rewards for attending the training session
- Barriers to using e-learning technology
- No mentoring system — facilitators, tutors, peers
- No feedback system at work
- Conflicts with other work tasks
- Verification system not yet established
- No clear system of rewards and/or consequences
- Coach learners on how to use the new technology.
- Provide ongoing supervision for learners — technology and content.
- Demonstrate that the McGill approach is more efficient, better for the client, etc.
- Demonstrate that the work tools will eliminate redundancies.
- Develop a comparative table between the (older) Henderson and (newer) McGill approaches.
- Teach Ecomap and Genogram tools as a language.
- Demonstrate that the tools can be built in an evolutionary way.
- Give many practical examples.
Detailed Observations & Comments from the Performance Analysis
O1. There is still some misunderstanding about the usefulness of the McGill approach. Many of the nurses encountered in different departments have only a vision of their own needs, rather than a long-term view of the patient.
C1. Knowledge of why and how to use the McGill approach is a central prerequisite for improving job task performance.
O2. There are many conflicting tasks and priorities. Nurses in several departments (medicine, surgery) report spending too much time with basic care that could be done by an assistant.
C2. Without considering other changes, the addition of elementary care assistants, especially in medicine and surgery, will directly contribute to the more effective use of nurses’ skills.
O3. There is redundancy and duplication in nursing work processes. Some departments, especially obstetrics and pediatrics are satisfied with their system, they don’t want any changes. There is some concern around the implementation of the new paperless system which is to be implemented this fall and become operational in April.
C3. In this project we have to bear in mind that the documentation system used for the paperless system will not be available until we develop the practical applications for distance learning. Therefore, distance learning may not correspond directly to the task to be performed at work, limiting the transfer of training contents to the work organization.
O4. Many nurses lack the time to complete their tasks at work. This is due to the following factors: basic care is not provided by assistants; there are increasing demands that conflict with each other; there is an abundance of paperwork to be completed; and there is a heavy patient load.
While work will be transferred to an automated paperless information system, there are still many nurses who lack basic computer skills. This will make job performance difficult.
There appear to be more training programs planned for the fall, and these programs may increase the demand for attention from learners. For example, the psychiatry department has an intensive training schedule of 80 days/person for this period.
C4. The project team received confirmation that there would be adequate access to computers in the new hospital; however, the lack of computers may be an issue for the success of distance education. Lack of knowledge about the McGill approach was identified as an upcoming problem, and distance education must address this need to ensure job performance. Additional training programs may put more pressure on nurses, and on our ability to implement all the objectives of our training program. Competition for training time will result in a significant number of nurses completing the training requirements.
O5. Standards for completing patient documentation are not understood in the same way by all nurses.
C5. A clear performance standard supported by all departments should make work performance easier to understand.
O6. There are few examples of completed documents in the nursing care plan.
C6. The examples and job aids in the training program will be of great assistance. They are currently being developed by the clinical nurse.
O7. Priority conflicts are a problem, and patient record documentation cannot be completed during a shift. Many nurses report that they perform basic care because of a lack of assistants.
C7. Without any other changes, the addition of more elementary care assistants, especially in medicine and surgery, could contribute directly to a more effective use of nurses’ skills.
O8. According to the management team, almost all nurses have the ability to change their practices to use a new model of care. Many nurses lack basic computer skills, which are essential for distance education.
C8. Lack of computer skills is a central barrier to distance learning and achieving better job performance (use of paperless system). It is essential to align the objectives and mode of delivery of basic training around the e-learning program with the McGill approach.
O9. Many nurses do not understand how a new model of care will help them in their daily work.
C9. Explaining the systemic needs for using the McGill approach will be an essential component of any training program.
O10. Many nurses are not emotionally prepared for other demands of education and change in the system of care. Moving to a new hospital with new concepts of care in addition to information technology, consolidation of departments, etc. all add to nurses’ perceived stress levels.
C10. Any distance education program will require an introduction from small face-to-face groups to clear up any apprehensions that nurses may have about the technology. A support system will be required to overcome nurses’ resistance to technology.
O11. There do not appear to be very serious consequences for incomplete completion of a care plan and its accompanying documentation.
C11. The lack of serious consequences could contribute to a lack of motivation for training, or a refusal to use the new approach at work.
O12. Most nurses feel that there is already too much paperwork to fill out, so most nurses accept that there are no serious consequences for filling out forms incorrectly.
C12. Workplace consequences cannot be dealt with in the training program, but are the responsibility of management and supervision.
O13. The few possible consequences seem to arrive late because there is no informal system of feedback on work performance.
C13. This is another management responsibility not addresses by training.
O14. There does not appear to be a formal or informal performance monitoring program for nurses.
C14. The lack of feedback will make it very difficult to determine the success or failure of the training program.
This post as a PDF — nursing-performance-analysis-case-study