The Importance of Lifelong Learning in Managing Risks

Concepts of lifelong learning are critical to managing risks within the healthcare continuum. The first part of this chapter will include general information on professional nursing development and lifelong learning. The importance of staff development as a risk management tool, and issues of competence, mandatory continuing education, and the relevance of continuing education to voluntary certification will also be addressed.

Professional Nursing Development

In 1994 The American Nurses Association (ANA) defined nursing professional development as "the lifelong process of active participation in learning activities to enhance professional practice" (p. 5). Building upon educational and experiential bases that enhance nursing practice to maintain and improve quality health care, nursing professional development encompasses both continuing education and staff development.

There are many different means to meet continuing professional development needs. Formal means include continuing education, staff development, academic education, and research activities. However, many individuals also continue their professional growth through informal means such as consultation, professional reading, experiential learning, and self-directed activities. Numerous factors may influence nurses' professional development (ANA, 1994). These include environmental factors, such as changing client demographics and changing healthcare delivery systems, healthcare consumers, and the growing body of knowledge. Individual learner characteristics also influence activities nurses choose to meet professional development needs. Learning styles, education, experience, cultural background, and motivation are some individual characteristics which possibly influence choice of educational options.

The importance of lifelong learning has been discussed for many years. Sixteen years ago, Cross (1981) stated lifelong learning will be increasingly necessary for everyone, and those who lack basic skills and the motivation for lifelong learning will be severely handicapped in obtaining the necessities of life and in adding any measure of personal satisfaction and enjoyment to the quality of their lives. She also noted that voluntary learning and diversity of educational opportunity through multiple providers are appropriate goals for our learning society. McDonald (1995) indicated lifelong learning is essential in nursing because of the rapid changes in our healthcare delivery system and the changing roles of nursing in that system. Knowledge learned in basic nursing education programs quickly becomes obsolete.

The ANA philosophy of nursing professional development (ANA, 1994) also addressed the need for lifelong learning. The following statements describe some of ANA's beliefs:

• "Lifelong learning is essential for the nurse to maintain and increase competence in nursing practice."

• "Many educational options are necessary to meet the diverse needs of the nursing population."

• "Nursing continuing education and staff development, based on adult learning principles, contribute to professional development." (p. 3)

Nursing's Social Policy Statement (ANA, 1995) discussed nurses' autonomy and freedom within their scope of practice, based upon their commitment to self-regulation and accountability for practice. One form of self-regulation is accountability for the practice knowledge base. Nurses develop and maintain current knowledge and skills through formal and continuing education and, where appropriate, seek certification in their areas of practice as a method of demonstrating this accountability.

Professional development takes place throughout the nurse's career. Levels of development occur over time with advanced experience and learning. Educational programs need to be planned to meet needs and promote professional growth of nurses at various levels of expertise (Stefanik, Braun, & Tavernier, 1995).

The Code for Nurses (ANA, 1985) outlined nurses' ethical responsibilities. Several of the statements directly relate to all nurses' responsibility to maintain professional knowledge and competence in their practice:

Plank 4 - The nurse assumes responsibility and accountability for individual nursing judgments and actions.

Plank 5 - The nurse maintains competence in nursing.

Plank 6 - The nurse exercises informed judgment and individual competence and qualifications as criteria.

Plank 7 - The nurse participates in activities that contribute to ongoing development of the profession's body of knowledge. (p. 1)

Other statements indirectly relate to the need for professional nursing development and detail responsibilities to protect the public from harm.

Many institutions /agencies are reengineering employee work methods to cope with diminishing resources and the changing healthcare environment. Blancett and Flarey (1995) stated that emphasis shifts from training to education with reengineering. Training teaches employees the "how" of a job, whereas education teaches them the "why." It is necessary to educate new employees to increase their insight and understanding so they may be empowered to break existing rules and to give the authority to make decisions necessary to accomplish their work. Senge (1990) conceptualized a learning organization as one in which employees perceive that their job is to learn, and not to be punished. In this environment employees contemplate improvement of the processes and request feedback as an opportunity for further improvement. To manage risk better, nurses face the additional challenge to learn about nursing and healthcare from the perception of patients and families.

Importance of Staff Development as a Risk Management Tool

Staff development personnel typically help nurses identify their risks, become oriented to institutional policies and procedures, increase their skills, and communicate more effectively. Additionally, the individual/department responsible for staff development can be an effective asset to assist nursing staff in managing their risks.

Education is a major part of a sound risk management program (Atkins, 1995). Staff members need to identify what risks exist and how they can help to reduce them. Education also helps employees to identify potential liabilities and report them. A lack of vigilance to education can create an environment where "a lot of problems are slipping through the cracks. When you cut back in services, you increase your vulnerability to crisis situations" (Study finds, 1991). Staff development education is an integral part of that service structure.

The importance of an adequate orientation program for staff members was stressed by several authors (Brent, 1994; Fiesta, 1991; Morris & Ingwerson, 1995). A formalized orientation program for all employees has been recognized as one of the best risk management approaches an organization can initiate. Certainly, new employee orientations must be of sufficient scope and duration to inform the employee of his/her responsibilities and how to fulfill them. Job descriptions and patient care policies, expected conduct, and supervised clinical experience to validate competency should be included. Other content is required by regulatory agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 1995).

However, orientation programs also provide a prime opportunity to introduce all employees to the principles of risk management and quality improvement and instruct them on THEIR particular reporting obligations and channels. As Bennett (1993) stated, awareness of risk management issues is a step the nurse can take to decrease the chance of being involved in malpractice litigation.

Awareness of the healthcare institution's and nurse's responsibilities for quality patient care is an essential component of a nursing risk management program (Luquire, 1989). Healthcare institutions can offer liability education programs that update nurses on current legal issues affecting the profession. Education of the nursing staff should include programs that continually upgrade skills so that quality patient care can be maintained.

Determining what education is needed can be done several ways. One method is to ask staff members what they need. The staff must see a perceived need to change or a perceived benefit. Input that can be used to determine educational requirements (Gaucher & Coffey, 1993) includes:

• Knowledge and skills to perform the job
• Survey of requirements perceived by employees
• Requirements to implement Total Quality Management (TQM)
• Basic management knowledge and skills
• External customer expectations
• Knowledge and skills assessment (p. 253)

Staff education is one of the most important elements of a healthcare risk management program since it provides the foundation for effective risk control and loss prevention (Jesser, 1990). One of the goals of a risk management program is to positively influence the quality of patient care by providing feedback and quality of care information to all departments. Using such information, staff development personnel can collaborate with risk management personnel to plan and provide programs on topics that are current and relevant to the audience, employing the most effective method of presentation for the information.

The literature abounds with various examples of programs designed to decrease the nurse's liability and help manage risk. Medication administration is a frequent area of risk for nurses. Mee, Cirone, and Levinger (1996), as well as Werab, Alexander, Brunt and Wester (1994) devised programs to assist nurses with this skill. Both of these programs emphasized addressing the individual's educational needs rather than group education. The prevention of falls is another focus for risk management activities. Mitchell and Jones (1996) outlined a falls prevention program developed and implemented with the express aim of educating staff to prevent falls. This program was part of a research study to establish whether structured intervention would help to prevent falls in an acute care setting. Outcomes included a reduction in fall numbers and rates, enhanced staff morale with ownership of the program, provision of a learning experience for staff, and the fostering of a professional approach to improving the quality of patient care.

The ANA developed a poster highlighting the role of nurses in risk management and malpractice prevention. The poster, "Nurses & Hospitals: Partners in Prevention," detailed the most frequent professional liability allegations involving nurses and offered precautionary tips for both nurses and hospitals (Role of RNs, 1990). It is interesting to note that suggestions for avoiding the top five allegations all included education as one of the strategies. The allegations and educational strategies are as follows:

Difficult patients represented a clinical challenge which many providers felt unprepared to address. When difficult patients become dissatisfied and angry with care, a professional liability claim can result. Problems with difficult patients and case studies used to help providers deal with them were described by Bartlett (1955). Discussion of the difficult patient can be an effective training technique to enhance patient-caregiver communications. Leonhardt (1995) noted that the quality of communication between the patient family, or significant other and all members of the home care team had a substantial impact on how clients viewed the home care experience.

Successful risk management must address effective communication and documentation as well as proper management of new medical technologies. One technology issue is maintaining patient confidentiality by avoiding unauthorized disclosure of patient data as information is stored and analyzed in computerized systems. Many institutions have employees sign confidentiality agreements and implement routine password changes to avoid such problems.

Levitt (1996) described an event that occurred in her family that emphasized the necessity of honest, open communication. While her father was hospitalized, he fell and hit his back and shoulders on the floor. Even though the physician came in and examined her father because he had "taken a spill", not once during the rest of the hospitalization did the registered professional nurses ever discuss with Levitt or her family the events of the fall. The most basic tenet in every situation is communication. As professional caregivers and one of the most visible members of the healthcare team, nurses must present a good bedside manner, establish an open and honest rapport with patients and families, and report all adverse events appropriately and forthrightly.

Competence Issues

Competence is the personal quality or ability to perform necessary tasks. Training and education help to provide the necessary competence to produce desired outcomes or results. As work requirements change, training and education are essential to maintain competence (Swansburg & Swansburg, 1995). An environment of confidence and competence enables patients and families to experience greater satisfaction with their care.

"A patient who perceives the staff as competent and reliable is less likely to seek compensation through litigation for an adverse outcome" (Atkins, 1995, p. 737).

Marker (1987) suggested that all educational activities could be categorized into one or more of three areas:

• maintaining current competency
• creating new competency, or
• responding to a quality assurance corrective action.

She also suggested all programs be tracked and monitored in conjunction with the program's purpose.

O'Brien (1995) emphasized the role of competence and stated that the development of able, proficient, and self

renewing human resources affects the success of every system and process within an organization. Staff development merges personal fulfillment with organizational missions for comprehensive development. It is the development of all employees via education processes that fosters attainment of competence in all dimensions of the organization: Brunt (in press) described Kelly's modified model of competence within a healthcare organization. The primary model elements are as follows:

• Assessing competence: those processes and programs designed to measure and evaluate the competence of nurses in relation to expected performance standards.

• Developing competence: the processes and programs designed to cultivate, generate, and extend the competence of nurses related to expectations and performance standards new to the individual or new to the organization (Kelly, 1992, p. 31).

The notion of maintenance is too static in today's dynamic healthcare environment. Therefore, the new model removed "maintaining competence" as an element and assumed those processes and programs within competence assessment and competence development. Assessment programs and processes yield data about current competence. Nurses need to communicate professional competence in a caring manner to the patient when delivering clinical services. Examples of methods to reduce risk management exposure were described by Cunningham (1991). Two different scenarios discussed were as follows:

Ms. Rodriquez is a nurse on a med/surg unit at a large hospital. She finds the many demands of her job stressful, and she leaves the hospital each day definitely ready to retreat to her family and favorite pastime. While she is at the hospital, however, she devotes herself totally to her patients. She is careful to always give each patient some special, personal caring, even if it is only a few minutes. A smile and a friendly touch of the hand do not really take that much extra time. Ms. Rodriquez's complaints about the demands of the job are relieved during daily exercise as well as during the time spent with her family. She also has a daily opportunity to get feedback from her supervisor during rounds, and every week she is pleased to see the nursing executive and chief executive officer during their "managing-by-wandering-around" time.

Mr. Nelson also works on a med/surg unit. He too finds the demands of his job stressful, but unlike Ms. Rodriquez, he makes sure that co-workers, supervisors, and patients and their families know how hard he is working, because he regularly tells them. Rarely do Mr. Nelson's patients see him smile, and the only time he touches a patient is when he is moving the patient so that the bed linens can be changed. The demands of the job give Mr. Nelson little time to worry about the look of his uniforms or to exercise, and so he is thirty pounds overweight. Mr. Nelson relishes noting that although the supervisor is regularly on the unit, he has not seen an administrator in months. (pp. 95-96)

These extreme characterizations make the point that confidence and caring can be communicated in no more time than it takes to give a negative impression. The key lies in the attitude of the professional. Some of the specific suggestions for nurses wishing to communicate professional competence identified by Cunningham (1991) included:

• Act professional and dress professionally.
• Be understanding and treat the patient with dignity.
• Deliver care in a caring and gentle manner.
• Listen to the patient.
• Have a confident "take charge" attitude and react calmly in critical situations.
• Display an interest in the family and include family members in care.
• Be a good communicator.
• Be honest with patients (pp. 96-97).

Evaluation of competence continues to be a challenge for educators and administrators. Evaluation studies of the impact of education on practice, particularly those that also assess changes in patient outcomes, involve sophisticated research designs (Puetz, 1992). Self reports of behavior change or audits of performance can be used to measure the impact of education or perceived competence with a particular skill.

Evidence of the link between educational activities and improved patient care is a necessity (Katz, 1992). Accrediting bodies are demanding documentation of educational activities as a means of solving quality problems or managing risk. The 1996 JCAHO standards (1995) suggest that "effective leadership develops an organizational culture that focuses on continuously improving performance" (p.275) and " the leaders allocate adequate resources for measuring, assessing and improving the hospital's performance" (p. 314). The goal of improving organization performance is to continuously improve patient health outcomes.

Paterson and Wendel (1996) suggested that one goal for managing risk in a changing healthcare system is to involve clinicians, administrators, and support staff in an institution-wide effort to promote understanding of the link between the process of care and the outcomes of care, thus reducing systematic variation in the delivery of care. Healthcare administrators often view education as a principal means to counteract deficiencies that could have a negative impact on patient outcomes. However, with healthcare dollars being consumed at an alarming rate, administrative emphasis is now placed on providing quality care in a high-volume environment (Norgan, 1995). If human resources development is to maintain credibility, it must, at the very least, show that educational offerings positively influence clinical performance in this environment.

Mandatory Continuing Education

Whether continuing education (CE) should be mandatory or voluntary has been a source of debate among nurses since the 1960s. Mandatory continuing education has been supported by the National League for Nursing (NLN) as a requirement for relicensure to document currency and competency in nursing practice. Considering the voluntary side, ANA supports voluntary continuing education for professional nurses since they are individually accountable to identify their learning needs and acquire continuing education that relates to their practice (Swansburg & Swansburg, 1995).

Arguments for and against mandatory continuing education, adapted from Swansburg & Swansburg (1995, pp. 45 - 46) are summarized in Table 1

Arguments For and Against Mandatory Continuing Education

Regardless of the nurse's attitude toward continuing education, the number of states requiring continuing education for relicensure is increasing. According to an annual CE survey reported by Yoder Wise (1997), twenty states, plus the Virgin Islands, Puerto Rico, and Northern Mariana Islands, have mandatory CE requirements for license renewal. The number of contact hours required for relicensure varies from a low of five hours/year to a high of 45 hours/3 years. Some states, such as Florida and Kentucky, have specific requirements for AIDS/HIV education as part of their mandatory requirements. Kentucky also requires 3 hours on domestic violence within 3 years of licensure. Additionally, some states require continuing education for inactive license renewals, advanced practice nurses, and nurses who have not practiced within the previous five years.

Thurston (1992) analyzed research relating to mandatory continuing education in relation to attitudes, learning needs, learner characteristics, motivation, and perceived outcomes. He concluded that attitudes toward mandatory continuing education were more favorable in states where CE was mandatory. The strongest personal motivational factor for nurses participating in CE programs was the desire to improve or expand professional knowledge. However, motivational factors were often multidimensional and interacted with other variables to influence participation in CE. Research related to learning needs did not explore the need of nurses in mandatory states versus non mandatory states; rather, it focused on types of learning needs. Most attendance was primarily job-related, and learning needs were often combined with other variables.

Leamer characteristics were explored by Puetz (1980), who reported on a comprehensive statewide survey in Indiana, a non mandatory state, to determine differences and similarities between attenders and non-attenders during the five years prior to the distribution of the questionnaire. The following implications were identified:

The results seemed to indicate overwhelmingly that the nurse who is possibly the most in need of CE to remain current in the practice of nursing is least likely to be a participant. The assumption that many of these nurses will be unlikely to attend continuing education on a voluntary basis seems warranted. Justification for mandatory continuing education requirement for relicensure is obvious when the typical non-attender is a nurse with minimal preparation for nursing, employed primarily in a single nurse situation ... most closely in contact with the patient. (p. 26)

Presumably the greatest controversy regarding mandatory CE is whether it has an impact on practice. It is very difficult to assess behavioral outcomes of a CE program. Participants often are given a "happiness index" at the end of a program to assess if the objectives were met, if the speaker was knowledgeable, and if the room was comfortable. Waddell (1992) did a meta-analysis of the impact of continuing education on practice, analyzing 34 research studies. The overall mean effect size of 0.73 indicated that across these studies, continuing education did positively affect nursing practice. A study done by the Delaware Nurses Association (Hayes, Morin, Sylvia, & Bashford, 1995) identified the most preferred method of acquiring continuing education was attendance at a conference, and the most desirable type of CE program was related to a nursing specialty. This is consistent with a study done by Gessner and Armstrong (1992), who reported that conferences were the preferred method of CE. Reading was the second choice of nurses in mandatory states, where it was third in the voluntary states. However, nurses in voluntary states spent slightly more time reading professional literature.

Gathers (1988) summarized the issues relating to voluntary and mandatory continuing education in the following way:

Neither voluntary nor mandatory continuing education are panaceas for instant upgrading of professional services. They are the beginning of the solution. Continuing education, then, is an essential part of the professional role of nursing. It is an effective tool to maintain currency. It is a multifaceted approach that must be viewed as a whole. Education is not an omnipotent force that, by itself, confers on its consumers the competence that assures excellent clinical practice. At best, it promotes, as Rockhill claims, competence and knowledge; at the very least, it exposes the uninterested to information that they otherwise would not encounter on their own. Mandatory continuing education is better than nothing (p. 124).

Relevance of Continuing Education to Voluntary Certification

Accreditation and certification are defined by ANA (1994) as follows:

1. Accreditation of the provider unit is an ongoing voluntary process which recognizes achievement of national standards for continuing education in nursing.

2. Certification in nursing recognizes the nurse who has demonstrated an exemplary level of knowledge. (p. 3)

Yoder Wise (1991) gave the following reasons for certification/accreditation:

• A national peer review process is the highest form of scrutiny.
• In educational institutions where other academic programs are accredited, the continuing nursing education program should be, too.
• In non-education institutions where there is no 46peee' group, standards form the basis for evaluation.
• National accreditation serves as a marketing strategy for nurses who hold licenses to practice in states where there is an expectation of continued education as a condition for reissuance of a license.
• It is a source of recognition of quality in educational endeavors. (p. 135)

Certification demonstrates a knowledge base related to a specialty. There are over 68 different certifications available for nurses in various specialties (Your Guide, 1995). Many of these certification programs require continuing education for either certification and/or recertification. Styles (1996-97) stated that "credentials name us, define our practice, and attest to our qualifications. We must see them as property, the most valuable tangible assets we have as career professionals. Each adds to our worth to consumers and to competitive, quality-minded employers. In intangible ways, credentials assure us of our own special knowledge and competencies. They allow us to measure ourselves against benchmarks of excellence. They are hallmarks of achievement that add to our self-esteem and confidence" (p. 1).

Continuing education programs related to the individual's practice area provide the greatest benefit. Davee and McHugh (1995) argued that many states' mandatory CE requirements do not address the learning needs of nurses in advanced practice, administration, education, and research. That has not been the case in Ohio. The Ohio Board of Nursing Continuing Nursing Education (CNE) requirements (1993) are based on adult learning principles, "specifically on the principle that you as a licensed nurse are the best judge of your own learning needs and how you learn most effectively" (p. 4). There is a great deal of flexibility for nurses to individualize their selection of the form of educational activities and style of learning to meet the CNE requirements. Some agencies/institutions pay a differential or recognize certification as part of a clinical ladder program. Other agencies encourage certification but do not reward nurses who are certified.

The changing healthcare system and changing roles of nurses within that system increase the risk in day-to-day practice. Maintaining professional competence is key to managing risk and lifelong learning is essential to maintaining professional competence.

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Blancett, S. S., & Flarey, D. L. (1995). Reengineering nursing and health care. Gaithersburg, MD: Aspen.

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Davee, P., & McHugh, J. (1995). Mandatory continuing education relevancyfor nurses with advanced preparation. The Journal of Continuing Education in Nursing, 26(3), 101-103.

Fiesta, J. (1991). QA and risk management: Reducing liability exposure. Nursing Management, 22(2), 14-15.

Gathers, B. J. (1988). Issues in mandatory continuing education. Journal of Nursing Staff Development, 4(3), 120-124.

Gaucher, E. J., & Coffey, R. J. (1993). Total quality in healthcare: From theory to practice. San Francisco: Jossey-Bass.

Gessner, B. A., & Armstrong, M. A. (1992). Reading activities of staff nurses from states with mandatory or voluntary continuing education. The Joumal of Continuing Education in Nursing, 23(2), 76-80.

Hayes, E. R., Morin, K. H., Sylvia, B. & Bashford, M. R. (1995). Meeting the challenge of mandatory continuing education. Journal of Nursing Staff Development, 11(2), 89-94.

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Leonhardt, M. A. (1995). Key strategies for risk management in acute home care. Caring, 14(10), 100-104.

Levitt, A. (1996). Risk management and communication. MEDSURG Nursing, 5(4), 225-226.

Luquire, R. (1989). Nursing risk management. Nursing Management, 20(10), 56-58.

McDonald, N.C. (1995). Staff development: Principles of learning. In R. C. Swansburg & L. C. Swansburg, Nursing staff development: A component of human resource development, (pp. 77-93). Boston: Jones and Bartlett.

Marker, C. G. S. (1987). The marker umbrella model for quality assurance: Monitoring and evaluating professional practice. Journal of Nursing Quality Assurance, 1(3), 52-63.

Mee, C. L., Cirone, N. R., & Levinger, C. V. (1996). Medication event rating grid. Nursing Management, 27(4), 34-38.

Mitchell, A., & Jones, N. (1996). Striving to prevent falls in an acute care setting--action to enhance quality.Journal of Clinical Nursing, 5, 213-220

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Barbara A. Brunt, MA, RNC, is Staff Development Educator, Summa Health System, Akron, Ohio.

Updated Selected References: 1999 through June 2001

Note: These references are not part of the independent study module, but are provided to you as suggestions for additional reading.

Hagedorn, M.I.E., Gardner, S.L. (May-June 1999). Legal issues in neonatal nursing: considerations for staff nurses and advanced practice nurses. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 28 (3), 320-330.

Nelson, L.J. (Spring-Summer 1999). Legal forum: interpreting the law. MN Minority Nurse, 44-45.

Wilkinson, C.L. (April 1999). An evaluation of an educational program on the management of assaultive behaviors. Journal of Gerontological Nursing. 25 (4), 6-11.

Worthington, K., Franklin, P. (April 2001). Workplace rights. workplace violence: what to do if you're assaulted. American Journal of Nursing, 101 (4), 73.