Staff development is the process of assessing nursing competency and developing competencies, quality, and excellence in patient care (Kelly-Thomas, 1998). During orientation it is imperative to assess the competencies of the nurse. Typically nurses learn aspects of infusion therapy “on-the-job,” picking up information and skills that may or may not be accurate. “We’ve always done it this way” is a frequent mantra among nurses; misinformation and substandard care can result. Many nurses are unfamiliar with the Infusion Nursing Standards of Practice (INS, 2006), the Centers for Disease Control and Prevention (CDC) Guidelines for the Prevention of Intravascular Catheter-Related Infections (O’Grady et al, 2002), or even the Occupatioal Safety and Health Administration (OSHA) regulations. Nursing practice can become “tradition” in that the information is passed from nurse to nurse. It becomes the responsibility of the education department or staff development educator to correct misconceptions and teach evidence-based practice. It may be difficult to change those who are “set in their ways.” Evidence-based practice may be more readily accepted when nurses recognize and identify actual infusion-related complications and the cost to the patient in terms of pain, loss of income, and dissatisfaction if appropriate care is not provided.

Competencies are defined as the knowledge and skills required to safely practice an aspect or aspects of nursing. Competency assessment is an evaluation measuring a set of skills and knowledge required to provide care. It takes into consideration technical skills and critical thinking, and the ability to apply these competencies at the right time (Kelly-Thomas, 1998). Minimum nursing competency is demonstrated by a novice nurse who passed the National Council Licensure Examination (NCLEX®). Certification in infusion therapy by the Infusion Nurses Certification Corporation (INCC) validates through examination entry-level competencies in infusion therapy. Standards of practice, professional guidelines, and facility policies and procedures are the framework from which competencies are developed. Competency assessment is not a one-time-only process. It requires ongoing appraisal of skills and knowledge associated with high-risk procedures. Continuing evaluation of competency in health care organizations is necessary to meet the standards of accrediting bodies, such as The Joint Commission, and to ensure safe patient care. Methods of collecting evidence of staff competency may include performance evaluations, performance checklists, and written examinations. A list of examples of infusion-related competencies can be found in Figure 6-1.

Whether teaching nursing staff or adult patients, consideration must be given to research-based learning theories to be effective. Cognitive learning pertains to perception, judgment, memory, and reasoning. Cognitive learning theories are based on Gestalt (German meaning to shape and form) psychology (Merriam-Webster, 2008). Gestalt laws are organizing principles that are part of perception. One law, the law of Pragnanz, states that we are innately driven to experience things as regular, orderly, and simply as possible. The law of closure says that a person will complete a thought, picture, or figure if something is missing, in other words “close the gap.” The tendency of a person to group similar items together forms the basis of the law of similarity. Insight learning is a well-known concept of Gestalt theory, which means solving a problem by means of recognizing an organizing principle. In essence, when a learner recognizes meaning in the experience, learning occurs (Merriam, Caffarella, and Baumgartner, 2006). This theory can be readily adapted to the process of infusion therapy competency development. A teaching plan that is organized and logical facilitates learning. For example, when preparing to teach peripheral IV insertion, including basic, preparatory information at the beginning of the lesson, such as recognizing types of peripheral IV catheters and selecting an appropriate gauge and length of catheter, is logical. This allows the learner to start to build upon basic concepts to the more difficult aspect of the lesson, which would be the venipuncture. Organizing information so that it follows the progression of steps to the venipuncture, dressing, and securement assists the learner in remembering the steps to be successful in that procedure. If the lesson skips important steps, such as allowing the antiseptic to dry, the learner may “close the gap” by assuming the venipuncture can be made through wet antiseptic. Presenting complications of peripheral venipuncture as part of the peripheral venipuncture lesson helps the learner to understand the meaning and implications of each step of the procedure.

Bruner (1966) identified three processes, occurring at the same time, that result in learning. The first process is acquiring new information; the second is taking the new knowledge and synthesizing it to see if it applies to a new task. During the third and last process—evaluation—the learner assesses whether the way the information was manipulated is adequate to the task. Learning through discovery is also emphasized. This approach is valuable because it helps the learner associate new information with something that is familiar. For example, a patient must learn how to use an ambulatory pump for home infusion. The patient has a microwave with a touch keypad. Using the knowledge about how to program the microwave may assist the patient in adapting that knowledge to the working of the pump. Programming the total time for the infusion, pressing a “start” key, and identifying alarms can be used as an example of knowledge familiar to the patient so that information can be applied to learning about the pump. Learning about the pump involves the acquisition of new information—why it is used, how it works, how to start and stop the pump, and how to identify troubleshooting alarms. New information can be “cubby-holed” into previous knowledge; therefore the information is more organized, easier to understand, and applicable to the use of a pump.

Three subconcepts to increase learning competence are recognizing the needs of the learner, taking into account the learner’s style of learning, and involving the learner in an organized activity (Smith, 1982). These concepts also align with the theories of the father of adult education, Malcolm Knowles. Learning is more likely to occur if there is some immediacy in the need to learn, that is, if the information can be immediately applied (Merriam et al, 2006). A nurse needs to learn how to change a peripherally inserted central catheter (PICC) dressing and cleanse the site. The nurse has a patient that needs a PICC dressing change. There is immediacy in the nurse’s need to learn this procedure. The nurse is more likely to assimilate that procedure because it will be applied immediately. If any problems occur during the dressing change, such as assessment of erythema at the insertion site, the nurse will be able to identify this complication and will learn to manage it based on the new information presented with the lesson on PICC site care. Smith (1982) also identifies that learning is very individualized, since each person learns best through different means. Some people learn new material most effectively visually, such as by watching a video or learning via the Internet. Others prefer to listen, using the sense of hearing, to learn. Listening to CDs while driving in a car is an illustration of that concept. “Learning while doing” or a hands-on approach is best for others. A combination of techniques for teaching and learning often strengthens the learning process and contributes to recall of the lesson. The learner may be shown a DVD regarding choices for venous access to illustrate the types of devices and how they are used. The nurse can reinforce that learning by discussing with the patient pros and cons of each device based on the patient’s lifestyle. By handling demonstration models of devices and manipulating a mannequin that has the devices, the patient is most likely to choose an appropriate device. In essence, the cognitive approach to learning is valuable because it helps the learner associate new information with something that is familiar.

The adult learning theory of Malcolm Knowles focuses on involving adult learners in the learning process. The theory is based on the following five assumptions about the adult learner:

In addition, adults need to feel respected. “Talking down” to an adult learner and not recognizing the learner’s current knowledge and expertise hamper learning. The following is an example of application of Knowles’ theory: Nurses in orientation in an outpatient oncology clinic need to learn how to assess and manage catheter occlusions. Central venous access device occlusions occur frequently in the oncology setting. As self-directed adults, the nurses can choose to learn the information or, if previously exposed to the information, can “tune out.” Whether or not the procedure is learned is up to the learner. Comparing catheter occlusion to clogged plumbing can be easily related to a commonplace household problem. Knowing that the assessment and skill of relieving occlusions will be used frequently in daily practice motivates the nurse to carefully learn the techniques.

The first step in a successful program is determining the need for a program. Performing an educational needs assessment identifies what the learners believe is important information needed to safely and competently perform their job. It also helps the educator prioritize the requirements and interests of the learners. A needs assessment can be accomplished through a variety of methods. Methods may include using a questionnaire or survey, reviewing incident reports, observing nurses’ performance, or collecting data from exit interviews or from quality improvement activities. This might include results of chart audits, individual nurse feedback, nursing satisfaction surveys, written test results, new product evaluation, or implementation of new or revised policies and procedures, or feedback from orientation. An example of a nursing needs assessment survey can be found in Figure 6-2.

Once learning needs have been established and prioritized, methods for teaching and learning are determined. Selecting an appropriate format to use should be based on a number of factors such as urgency, availability of time, number of learners, and type of information to be learned. Urgency is a highly motivating factor creating a readiness to learn. If a patient is to have an implanted pump placed for pain management and the staff has never seen or worked with this device, the need to learn is urgent. Under these circumstances, education of staff involved in the care of the patient may need to occur within hours of caring for the patient. Time availability also impacts strategies for learning. If nurses can only attend educational programs when “off-duty” because of short staffing during work hours, creative methods need to be implemented. Motivating the learners to attend after-hours programs may be difficult. Personal and family responsibilities may deter the nurse from attending.

The number of learners also affects how learning is to occur. While a “just-in-time” inservice may be easily facilitated for a small group of nurses, a facility-wide program requires intense planning and creative interventions. The type of information that is to be learned affects program planning as well. The standard framework used for developing programs has long been Bloom’s Taxonomy of Educational Objectives. This framework identifies levels of learning within the cognitive, psychomotor, and affective domains (Harton, 2007). In each domain learning occurs by building on previous knowledge from the simple to the complex. The Revised Bloom’s Taxonomy (Anderson et al, 2001) identifies four types of knowledge: factual, conceptual, procedural, and meta-cognitive. Factual knowledge is basic, “must know” information such as knowing the types of central venous access devices and distinguishing characteristics. Conceptual knowledge is more complex, involving relationships and theories. Learning why a subclavian catheter tip position is not considered central placement based on the anatomy of the veins and the physiology of blood flow uses conceptual knowledge. When skills must be learned, procedural knowledge is used. Changing a PICC dressing using aseptic technique is using procedural knowledge, that is, task-oriented learning. Meta-cognitive knowledge involves the use of critical thinking to solve problems. The learner’s self-awareness and self-regulation come into play. When a nurse identifies a possible catheter-related sepsis and appropriately intervenes, meta-cognitive knowledge is applied. Box 6-2 lists examples of types of educational interventions. Not all types of programs are appropriate for all types of learning (Table 6-1).