#Ebola – The Glaring Gap Between Staff Education and Proper, Effective Training
I saw this headline the other day: “U.S. Soldiers Get Just Four Hours of Ebola Training”
The phrase “just four hours” implies that it wasn't enough. How do we know? Maybe four hours of training, done properly, is all that's needed.
It might also be four hours MORE than the amount of training given to nurses, physicians, and other hospital staff.
From an article that talks about THR Presbyterian hiring a P.R. firm (!!!):
Dr. Daniel Varga, the chief clinical officer for the parent company that oversees Texas Health Presbyterian Dallas, was out front Friday in a new public relations offensive to restore trust after missteps in handling the nation's first Ebola case.
Lesson for other hospitals – it's better to not violate or destroy trust to begin with. That's true for any of us in the workplace or in our personal relations with friends and family.
This #PresbyProud campaign looks like a “grass roots initiative” but it looks like what they call “astroturfing” when a PR firm gins up people to do things that look like an organic movement. It's possible to be #NurseProud in a sincere and loving way, while being ashamed of the organization.
A picture from CNN:
More from the article:
Varga said he believes the hospital “did do a good job of communicating and disseminating information. Where we fell short was in actually taking that through the next iteration and going through training, simulation, reinforcement.”
Information and creating awareness is, at best, the first step in effective training. That's been known since the 1940s with American manufacturers (and hospitals) used the Training Within Industry program to properly train all of the new workers that came into those workplaces. The TWI methodology is something I've used in hospitals, as have others (including Virginia Mason Medical Center) in a recent resurgence of focusing on basic “blocking and tackling” that creates an effective organization.
In the TWI methodology, we learn it's not effective to just throw a procedure at somebody.
As I heard on CNN the other night, you don't teach a kid to swim by throwing them into the pool after either showing him a PowerPoint or having him watch a YouTube video of Michael Phelps.
TWI shows us how to train EFFECTIVELY. In a nutshell, you:
- Put the student at ease (maybe hard to do when there are fears about Ebola)
- Find out what the student already knows
- Read through the written job instruction sheet with them
- DEMONSTRATE how something is done (such as properly putting on a removing personal protective equipment)
- Explain “key points” and “reasons why” you do certain things a certain way
- Have the student TRY doing it themselves
- Have the student TRY again, while explaining back the key points
It's the instructors role to ENSURE that the student not only understands, but can DO things the right way. You continue teaching until you're certain they get it. Healthcare and nursing has a tradition of “see one, do one, teach one.” One isn't always the right number.
A good instructor FOLLOWS UP to make sure the student has retained the learning and the ability to do something over time. Good training needs to be followed by good supervision.
Here's an example of what good TWI-based training looks like (from one of my hospital lab projects). You see the instructor and the student. It's one-on-one. It's detailed. It helps confirm that the learning has taken place. It's time consuming, but I don't know of any better way.
When I hear from friends or colleagues about their hospitals' Ebola prep, I hear a lot about education and awareness. I don't hear about practice.
I can be AWARE of how to do something, but it doesn't mean I can DO it.
Back to the military. What did they get in “just” four hours of training?
A team of two can train as many as 50 personnel over that four-hour time frame, USAMRIID told The Daily Beast. The training includes hands-on instruction on how to put on, remove, and decontaminate personal protective equipment, followed by a practical test to ensure that soldiers understand the procedures.
“All training is tiered to the level of risk each person may encounter,” said USAMRIID spokeswoman Caree Vander Linden.
That sounds far better than most hospital training. They “just get shown a video” or “just get a memo?”
Briana Aguirre, an ER nurse at Presby said the preparation, communication, and supplies were lack (as was the response from leadership when she asked questions).
That video describes at least ten process failures and leadership failures. A VP said he would get back to Briana with an answer to her questions and he never called her back.
Briana said that there was a (very) optional 30-minute seminar on Ebola prep. When they needed somebody to care for Nina Pham, they asked the nurses who had the proper training (figuring out who would care for her) and nobody put their hand up. Briana volunteered to care for her anyway.
Why would Briana lie about any of this?A cynic might think she is lying and making up stories because she's secretly a union organizer (since the National Nurses United union has been outspoken here). Some might throw that accusation at her. I wouldn't. I trust that she was put in a bad position and was a hero for 1) doing the best she could and 2) speaking out.
The problems she describes are common problems. Everyday problems that we see in most hospitals.
I feel a lot of empathy for the individual staff. For the hospital leaders there at THR Presby, not so much.
The only empathy I have is that it was, in a way, BAD LUCK that Thomas Eric Duncan came there. Similar things would have probably happened had he gone to another hospital or another health system.
THR, in their PR efforts, has released two videos.
They claim the hospital is safe and there aren't any problems. Either these staff have been put up to lying… I can understand their worry for their jobs. They might be in denial about how unsafe hospitals can be. It's what former Toyota employee Pascal Dennis always refers to as “happy talk.” Happy talk sounds good, but it interferes with real improvement.
These videos are slick… they're too slick. If lots of people can make their own “Ice Bucket Challenge” video, I'd expect to see nurses make their own simple #PresbyProud videos on their own. This is a PR campaign. Does that really rebuild trust?
As ABC reports:
To weather the storm, the hospital will need to convince people that Texas Health Presbyterian is still a safe hospital, said Dr. Dan Varga, the chief clinical officer of Texas Health Resources, which owns the Dallas hospital.
“I would tell this community that Presby is an absolutely safe hospital to come to,” Varga told ABC News chief health and medical editor Dr. Richard Besser on Thursday.
No hospital is “absolutely safe.” That's a lie… or at best it's misguided PR spin. Comments like that don't restore any of my lost trust.
Are Briana and another staff member quoted here lying about Duncan's infected trash being piled up to the ceiling in a hallway with a lot of traffic? Probably not.
“Virus-infected stuff was piling up there,” she said. “It was a reservoir.”
The hospital claims, somehow, “it went “above and beyond” national guidelines on waste.” Maybe the national standards on Ebola waste are terrible??
I'm no PR firm, but my advice to the hospital would be:
- Be humble and contrite
- Be open and honest about what happened and what didn't happen
- Talk about what you WILL do to protect staff and patients
That would help restore trust. That would also help other hospitals better prepare… not just for a possible Ebola patient, but in general.
THR isn't an unusually bad hospital. They don't deserve to be shunned forever and they shouldn't be shut down. They need to improve. We all need to improve.
The problem at THR wasn't bad nurses or bad doctors. As usual, it's about systems and leadership. The systems failed at THR. It seems like the leadership continues to fail. And that's a “preventable management error.”