Dr. Patricia Chesser-Smyth Michael Bunyan

W20044656

Nurse as Educator in Practice/Preceptorship

Title: Lesson Plan for Practicing Nurses to Promote Effective Hand Hygiene

Date of Submission: 3rd Dec 2013

Word Count: 2750

1 Contents

2 Introduction

Nosocomial infections are a significant source of unwanted health outcomes suffered by patients in hospitals and other healthcare settings and it has been proven that ineffective hand hygiene by health professionals is the biggest contributory factor to the spread of these infections (Helder et al. 2010). Nosocomial infections can stretch resources in our already overburdened healthcare system, therefore, improving hand hygiene is essential not only in improving patient outcomes but also in limiting resources involved in dealing with managing these infections (Stevens and Scott 2012). In their qualitative study Erasmus et al. (2009) discovered that although nursing professionals recognised the importance of hand hygiene they also acknowledged that concordance is somewhat haphazard due to a multitude of factors. Concurrently, an observational study focusing on hand hygiene noted that out of 1037 observed episodes only 74.7% of health professionals complied with hand hygiene practice. Consequently, one of the recommendations from the same study was that education and reinforcement of effective hand hygiene practices for registered nurses was needed on a regular basis (Chau et al. 2011).

From an Irish perspective hand hygiene in our health system has been highlighted by the Health Information and Quality Authority (HIQA) as substandard, four out of five hospitals audited in 2013 were found in breach of hand hygiene standards to the point that it posed a risk of nosocomial infections to the patients in these hospitals (Irish Times 2013). The cost to the Health Services Executive in 2012 due to nosocomial infections was estimated to be €320 million in treatment, medications, nursing hours, inpatient care and compensatory payments (Health Services Executive 2013)

As ineffective hand hygiene has been identified as the biggest factor in contributing to cross contamination this assignment will propose a lesson plan that would be aimed at practicing nurses - irrespective of their strand of nursing – to compliment and reinforce their existing knowledge on effective hand hygiene practices. The aim of the teaching plan would be to reinforce practicing nurse’s knowledge and skills

3 around effective hand hygiene. The learning outcomes would include being more aware of possibility of cross contamination, reinforcement of the importance of effective hand washing technique, awareness of the Strategy for the control of Antimicrobial Resistance in Ireland (SARI) 2005 guidelines and importance of these guidelines and finally be able to demonstrate effective hand washing technique. There will be a discussion on the assessment of the target group on how to ascertain what pre-existing knowledge is known and how to identify potential barriers to teaching. Following this an explanation on the implementation of the teaching plan will be undertaken which will consider the logistics of the delivery of the plan to the target group. There will then be an extensive discussion of the actual teaching plan including how the material would be delivered, teaching theories used and rationale provided for using these theories and also why certain theories were not utilised. The assessment of the teaching plan will be examined following this stage, followed by a section based on the target group evaluation and self-evaluation of the teaching session.

Assessment of Target Group

Over the last number of years there has been an explosion of evidence based practice in nursing, there has also been an ever-growing importance on independent life-long learning (Linton and Wei-Fen 2013, Yu-Chih et al. 2013, Kedge and Appleby 2009). However, it is also hugely important for a person engaging in the education of nurses to be able to assess the pre-existing knowledge of their target group to be able to adapt a more suitable teaching plan, irrespective of the subject content. A study to evaluate perception of nurses to training programs identified that assessing your target group’s existing knowledge on the content being taught can assist the educator in their delivery of the subject matter (Castro and Takahashi 2008). Therefore, for the purposes of this teaching plan this author would develop a questionnaire (Appendix 1) that would be distributed to the target group prior to the teaching session to ascertain the group’s existing knowledge base to hand hygiene. The answers received could assist the educator in the delivery of the content of the lesson. This stage would also be a good opportunity to identify issues that might become barriers to teaching if not

4 addressed. In consultation with the clinical nurse manager of the ward where nurses would be attending the lesson, the educator could identify the ability and interest level of the nurses, the ability to work in groups in a teaching scenario, any special needs of the target group and identify any learning preferences. The identification of these issues can assist the educator in the development of their teaching plan and in deciding what teaching strategies to employ.

Implementation

For the planning and implementation of this lesson plan there would be a lot of factors that would need to be addressed prior to the actual teaching session. The director of nursing for the sector would need to be consulted on the idea to gain his approval by putting forward the rationale for this teaching session, also, to gain any input he might have towards the plan. After the plan was sanctioned at this level the next person to contact would be the clinical nurse manager (CNM) of the unit that you proposed to do the training in. This would be an essential element to the success of the training. The CNM’s input would be crucial from the point of view of allocating time for the nurses to attend, allocation of a location for the teaching, the identification of potential barriers to teaching and assistance in negating these barriers, the circulation of the target group assessment questionnaire prior to teaching and to assist in gaining the nurses participation to the aims and objectives of the plan. The input and assistance of the CNM can greatly influence the success of the teaching session. The current literature would support this point. In the conclusion of a cross-sectional study it was stated that the participation of nurse managers can only improve the quality of clinical teaching (Ramezani and Kermanshahi 2011).

Lesson Plan / Theories

A structured lesson plan is essential to the success of the lesson delivery. Any teaching plan can and should be based on five educational doctrines, they being, let learners know why something is important, assist learners to direct themselves, relate

5 topics for teaching to learners’ experiences, motivate learners to learn and negate learner’s pre-existing behaviour and beliefs about learning (Knowles 1984). Haider (2007) states that a teaching plan should be well devised and should always meet the needs of the individual learner. An appropriate lesson plan can serve many purposes for the educator. It can give structure to the lesson, it gives the educator prompts for the lesson, it can facilitate a range of different teaching methods but also allowing flexibility to adapt to the needs of the learners. Liou et al. (2013) state that the development of an appropriate and complementary teaching plan can be conducive to a healthy learning environment. An effective lesson plan should account for the variety of students and contain a number of teaching styles (Ronsen and Hanssen 2009). There are many learning theories that are available to educators to draw from to aid them in the delivery of their content. The importance of utilising appropriate learning theories and research based pedagogies should not be underestimated as the learning environment is in constant change and teachers need to be able to adapt to these new situations (Steiner et al. 2010).

For the purposes of this teaching assignment this author decided that he would use a combination of the cognitive, social and behaviourist theories of learning. The rationale for this decision was that because there were different styles of teaching built into the lesson plan (Appendix 2) then it would need to be supported by a combination from the known theories. Further rationale for this decision was that to engage the learners this author believed that adopting different teaching strategies and theories would assist in making the content more applicable to a wider range of learners and maintain interest during the session. This is supported in research by Ozkan and Ulutas (2012) who concluded in their study that the use of different teaching strategies can enhance the learning experience.

Stages one to four and stage nine of the lesson plan would draw on the cognitive theory of learning. Jackson and Londell (2009) describe the cognitive theory of learning as a theory where the learner can relate to what is being taught and applies the knowledge given to past experiences. The cognitive theory is appropriate here because the lesson being taught is to reinforce the practicing nurse’s effective hand hygiene practices, therefore, using the pre-existing knowledge that nurses have they

6 can relate to the content and it will assist them to re-evaluate their practices and then re adapt them. For these stages the lesson would be delivered in lecture style using a PowerPoint presentation to compliment the verbal delivery, also, the teacher would use appropriate socratic questioning skills to facilitate the nurses using their own existing knowledge. At all of these stages there would be encouragement for the nurses to engage in active questioning to compliment the content being taught. Strategies such as appropriate questioning can and does promote critical thinking skills in nurses, furthermore, appropriate questioning can lead to empowerment on the nurses’ behalf to actively engage in the lesson (Simpson and Courtney 2008, Scheckel and Hendrick-Erickson 2009).

The sixth and seventh stages of the lesson plan are taught under the social learning theory that was developed by Albert Bandura in 1963. This theory emphasizes the impact of learning by observation and that the subsequent behaviour is controlled by cognitive variables (Malim and Birch 1998). Although Bandura’s theory was proven using children in his experiments it is now widely accepted in the literature that nurses can learn by observation. Rutherford-Hemming (2012) reports that simulation methodology in nursing education is very beneficial and has its basis in adult learning theory. Bjork (2013) advocates observational learning among nurses and states that through demonstration the educator can have an impact on the norms that can become common place on a hospital ward. Therefore, seeing as ineffective hand hygiene has clearly become common place in some of the hospitals in Ireland - as reported by HIQA in the introduction of this paper - it is evident that the adoption of this theory in the lesson plan would assist in the reinforcement of effective practice and also help the educator to attain the learning outcomes of the lesson. The resources used for these stages are the hand washing facilities in the clinic room of the unit. This would give a perfect setting for the demonstration needed so the nurses could observe the correct procedure as recommended by SARI’s 2005 guidelines. The demonstration would be carried out twice to enforce the correct procedure. Again in these stages the nurses would be encouraged to actively ask questions to clarify any issues. One possible drawback to this theory is that learning using demonstration in this manner does not always lead to a change in behaviour (Chesser-Smyth 2013). Therefore this

7 author decided to use the social learning theory in combination with the other theories discussed to compliment the delivery of the lesson content.

There is however, a theory that encompasses the entire lesson plan. This would be the behaviourist theory, particularly Skinner’s 1930 work in relation to operant conditioning. This would be suitable to this lesson plan because fundamentally the educator is trying to modify the behaviour of the practicing nurses. Operant conditioning works on the premise that positive and wanted behaviour is reinforced and that negative or unwanted behaviour is ignored or in some cases punished (Brunner et al 2013). The educator could “pitch” the lesson to the nurses by stressing that if effective hand washing was to become common place then the workload of the nurses would decrease due to less nosocomial infections being present on the unit and that the reduction of these infections could redirect monies being used in their treatment to other resources, this being positive reinforcement. The use of operant conditioning in behaviour modification to achieve effective hand washing practice has been widely studied. Erasmus et al. (2010) reported in their systematic review that the teaching of hand hygiene should draw on the behavioural sciences, Song et al. (2013) concluded in their retrospective study that getting health professionals to change their hand hygiene practices can substantially reduce costs in a unit, and finally, Cumbler et al. (2013) state that operant conditioning in particular can and does expedite behaviour change.

There are a number of theories that this author decided not to use in the teaching plan due to their unsuitability. Pavlov’s 1901 theory on behavioural conditioning, specifically classical conditioning was not suitable because his form of reinforcement – in comparison to Skinner (1930) – included a reward for a desired response. Rationale for this decision is that the educator would not be in a position to “reward” behaviour change as it would not be in the scope of the educator to do so, however, being able to highlight the positive consequences that Skinner advocated would be easier to portray. The humanistic theory of learning which was developed by Maslow, Rogers and Knowles in the 1960s was also discounted from the teaching plan. This theory advocates that teaching should be student-centered and personalised, however, with the subject matter being taught in this lesson plan it was

8 about changing a collective group’s perception of what effective hand hygiene entailed and about changing that ineffective behaviour. Therefore, adopting the humanistic approach would not have suited the subject content. The humanistic does have benefits from a teaching point of view. The literature would say that using the humanistic approach for “bedside teaching” is more suitable than in a classroom setting (Ramani and Orlander 2013). Finally, the constructivist theory which was drawn from Piaget’s 1977 and Kelly’s 1991 cognitive theories of learning was also deemed not suitable by this author for this lesson plan. The constructivism theory has its tenets in the belief that learner’s prior knowledge is the “platform” for learning. The aim of this lesson plan was to change the prior knowledge that has been proven and highlighted to be ineffective, therefore, building on prior knowledge that could be perceived as flawed would have been counterproductive.

Assessment / Evaluation

McWilliam and Botwinski (2010) state that the assessment of a nurse’s clinical skills is paramount to the teaching process. This author would propose using an Objective Structured Clinical Examination (OSCE) – a summative assessment - to evaluate the skills that had been taught in the lesson. The aim of the lesson plan was to change the behaviour of ineffective hand hygiene, therefore, after demonstrating the skill it would be appropriate to evaluate the learner’s skills in this manner. An OSCE is considered a very suitable form of evaluation in task-based parts of nursing due to its high degree of standardization (Martensson and Lafmark 2013). This is further supported by Oranye et al. (2012) when they concluded that their observational study validated the use of the OSCE for assessment of nursing skills.

The final part of the education process would be the evaluation of the lesson and its content from the viewpoint of the learners. This is an essential part of the process as the educator needs to establish that the teaching plan was effective and have the awareness that their own style of teaching might need to change or be adapted to suit future teaching forums. For the purposes of this lesson plan this author found that a questionnaire that would be completed at the end of the lesson would be the most

9 appropriate method. The answers to these questions would assist the educator in further teaching sessions and also give the educator an insight into their own performance. There would be open questions in the evaluation so that the educator would get a good qualitative opinion from the learners. The benefits of educator evaluation is supported in the literature where is states that evaluation of learning styles is key to creating effective learning environment and appropriate learning opportunities (Williams et al. 2012).

Conclusion

In conclusion, in this assignment the importance of an appropriate lesson plan has been discussed. Also, the different theories used in the lesson plan were discussed and rationale was given to justify their use. The use of teaching theories by nurse educators is essential to achieve the aims and learning outcomes of modules and their use and importance should not be underestimated.

References

Bjork I.T. (2013) Exploring informal learning among hospital nurses. Journal of Workplace Learning 25(7), 426-428.

Brunner E., De Herdt A., Minguet P., Baldew S. & Probst M. (2013) Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disability and Rehabilitation 35(1), 1-10.

Castro L.C. & Takahashi R.T. (2008) Perception of nurses on the learning evaluation process in training programs in a Sao Paulo hospital. Revista da Escola de Enfermagem da USP 42(2), 305-311.

Chau J.P.C., Thompson D.R., Twinn S., Lee D.T.F. & Pang S.W.M. (2011) An evaluation of hospital hand hygiene practice and glove use in Hong Kong. Journal of Clinical Nursing 20 (9/10), 1319-1328.

10 Chesser-Smyth P. (2013) Learning Theories. Provided in Nurse Educator in Practice/Preceptorship, Waterford Institute of Technology, Waterford, 8th October.

Cumbler E., Castillo L., Satorie L., Ford D., Hagman J., Hodge T., Price L. & Wald H. (2013) Culture change in infection control applying psychological principles to improve hand hygiene. Journal of Nursing Care Quality 28(4), 304-311.

Erasmus V., Brouwer W., Van Beeck E.F., Oenema A., Daha T.J., Richardus J.H., Vos M.C. & Brug J. (2009) A qualitative exploration of reasons for poor hand hygiene among hospital workers: Lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infection Control and Hospital Epidemiology 30 (5), 415-419.

Erasmus V., Daha T.J., Bruh H., Richardus J.H., Behrendt M.D., Vos M.C. & Van Beeck E.F. (2010) Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology 31(3), 283-294.

Haider E. (2007) Applied leadership: Nurse leaders as teachers. Nursing Management UK 14(4), 30-33.

Harden R.M., Downie W.W., Stevenson M. & Wilson G.M. (1975) Assessment of clinical competence using objective structured examination. British Medical Journal 22 (1), 447-451.

Health Services Executive (2013) Hand Hygiene and Skincare. (Internet) Available at:www.hse.ie/../list/3/hospitals/sligo/depts/Hand_Hygiene_and_Skincare_a_ Guide_to_Best_Practice, (Accessed 25th October 2013).

11 Helder O.K., Brug J., Looman C.W., Van Goudoever J.B. & Kornelisse R.F. (2010). The impact of an education programme on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: An intervention study with before and after comparison. International Journal of Nursing Studies 47 (10), 1245-52.

Hunter J.L. & Krantz S. (2010) Constructivism in cultural competence education. Journal of Nursing Education 49(4), 207-214.

Irish Times (2013) HIQA Inspections find poor hygiene in four hospitals. (Internet) Available at: http://www.irishtimes.com/news/health/hiqa-inspections-find- poor-hygiene-in-four-hospitals-1.1564219, (Accessed 24th October 2013).

Jackson P. & Londell D. (2009) Revisiting adult learning theory through the lens of an adult learner. Adult Learning 20 (3), 22-22.

Knowles M. (1984) Andragogy in Action: Applying modern principles of adult education. 1st edn. Jossey Bass, San Francisco.

Malim T. & Birch A. (1998) Introductory Psychology 1st edn. Palgrave, Houndmills.

Martensson G. & Lafmark A. (2013) Implementation and student evaluation of clinical final examination in nursing education. Nurse Education Today 33(12), 1563-1568.

McWilliam P. & Botwinski C. (2010) Developing a successful nursing objective structured clinical examination. Journal of Nursing Education 49(1), 36-41.

Linton W. & Wei-Fen M. (2013) The philosophical foundations of evidence-based nursing. Journal of Nursing 60(5), 5-10.

Oranye N., Ositadimma A., Che’an A., Bakar N. & Rosnida A. (2012) Assessing nursing clinical skills competence through objective structured clinical examination (OSCE) for open distance learning students in Open University in Malaysia. Contemporary Nurse: A Journal of the Australian Nursing Profession 41(2), 233-241.

12 Ozkan N.F. & Ulutas B. (2012) Evaluating the effect of teaching strategies and learning styles to students’ success. New World Sciences Academy 7(2), 613- 620.

Ramani S. & Orlander J.D. (2013) Human dimensions in bedside teaching: Focus group discussions of teachers and learners. Teaching & Learning in Medicine 25(4), 312-318.

Ramezani M. & Kermanshahi S. (2011) A survey of the quality of clinical education in nursing. Journal of Jahrom University of Medical Sciences 9(2), 21-22.

Rutherford-Hemming T. (2012) Simulation methodology in nursing education and adult learning theory. Adult Learning 23(3), 129-137.

Song X., Stockwell D.C., Floyd T., Short B.L. & Singh N. (2013) Improving hand hygiene compliance in health care workers: Strategies and impact on patient outcomes. American Journal of Infection Control 41(10), 101-105.

Sreiner S.H., Hewett B.J., Floyd E., Lewis N.C. & Walker E.H. (2010) Creating a learner-centred environment in nursing education: An immersion experience. Journal of Adult Education 39(1), 11-17.

Stevens S.C. & Scott C.L.M. (2012) Hand hygiene: a way out of the deadlock. Australian Health Review 36 (4), 13-464.

Kedge S. & Appleby B. (2009) Promoting a culture of curiosity within nursing practice. British Journal of Nursing 18(10), 635-637.

Liou Y.M., Chen M., Chiang L., Chien L., Chang P. & Hung Y. (2013) Experiences of a nation-wide integrated program for healthy body weight among students. Journal of Nursing 54(5), 30-36.

Ronsen A. & Hanssen I (2009) Communication in palliative care: philosophy, teaching approaches and evaluation of an educational program for nurses. Nurse Education Today 29 (7), 791-795.

13 Scheckel M. & Hedrick-Erickson J. (2009) Decentring resources: A phenomenological study of interpretive pedagogies in patient education. Journal of Professional Nursing 25(1), 57-64.

Simpson E. & Courtney M. (2008) Implementation and evaluation of critical thinking strategies to enhance critical thinking skills in Middle Eastern Nurses. International Journal of Nursing Practice 14(6), 449-454.

Williams B., Brown T. & Etherington J. (2012) Learning styles of undergraduate nutrition and dietetics students. Journal of Allied Health 41(4), 170-176.

Yu-Chih C., Lee-Chun T. & Shin-Shang C. (2013) Strategy for promoting evidence based nursing practice in hospital. Journal of Nursing 60(5), 25-30.

14 Appendix 1 – Assessment of target group

Q1: What are nosocomial infections?

______

Q2: What are the reasons that nosocomial infections are so prevalent in our hospitals?

______

Q3: List the ways in which a nurse can contaminate their hands

______

Q4: What is the aim of appropriate hand washing techniques?

______

Q5: What is the rationale for effective hand washing technique?

______

Q6: Are you aware of the Strategy for the control of Antimicrobial Resistance in Ireland (SARI) guidelines for effective hand washing?

______

Q7: Are you aware of the steps listed by SARI to promote effective hand washing?

______

15 Appendix 2 – Lesson Plan

Date Time: Duration: 10/12/2013 15.15 40 Mins

Group: Registered nurses from Millview residential unit Enniscorthy

Group Size: 5 Nurses

Subject: Appropriate hand hygiene technique for practicing nurses

Venue: Staff room & Clinic room of Millview

Session Lecture, Group Discussion, Demonstration & Skill Style: Assessment

Previous Relevant Knowledge: Nurses had some knowledge as regards hand hygiene, however all agreed that more current and evidence based knowledge was required.

Aim of Session: To reinforce practicing nurse's knowledge and skills around appropriate hand hygiene

Learning Outcomes:

1: To be aware of the possibility of cross contamination 2: To have a renewed understanding of appropriate hand washing techniques 3: To discuss the SARI (2005) guidelines for hand washing and importance of these guidelines 4: The ability to demonstrate effective hand washing technique

Equipment: Laptop, Screen, Projector, Handouts, Hand washing facilities, Flipchart, Learner Duration Stage Method Resources/Rationale Activity 5 mins Introduction to Lecture Use PowerPoint Listen, group topic. Identify slides 1-3 and discussion, aims and brainstorm with questions and objectives of nurses to establish answers lesson prior knowledge

16 5 mins Define cross Lecture and Use PowerPoint Listen, group contamination learner slides 4-6. Using participation and nosocomial participation flipchart document infection. Ask incidents. Helps learners to give highlight how incidents of contamination can contamination, happen assess prior knowledge

3 mins Introduction of Lecture Listen, note- rationale for taking, appropriate hand Use PowerPoint questions and washing slides 7-9. This will answers technique highlight importance of effective hand washing 3 mins Reinforcement Lecture Use PowerPoint Listen, note- of SARI slides 10-11. This taking, (2005)guideline reinforces the SARI questions and s and guidelines and answers importance of highlights the these guidelines importance of same to practice

1 min Transfer to N/A N/A N/A clinic room for skills demonstration 4 mins Demonstration Motor skill Hand washing Listen, of effective hand demonstration facilities in clinic observation, washing room of unit questions and techniques in answers line with SARI guidelines X 2

6 mins Opportunity to Learner Hand washing Practice practice participation facilities in clinic effective hand effective hand and room of unit washing washing skills in opportunity to technique. line with SARI practice skill Clarifies any (2005) uncertainty guidelines

17 8 mins Assessment of Assessment Hand washing Assessment of hand washing facilities in clinic effective hand using an room of unit. This is washing Objective to assess that technique Structured effective techniques using SARI Clinical have been learned guidelines Examination OSCE (1975) based assessment.

1 min Transfer to staff N/A N/A N/A room finish presentation 3 mins Recap on the Lecture Use PowerPoint Listen, main points and slides 12-15. This questions and importance of would recap on main answers hand hygiene. points and reinforce Recap of SARI learning outcomes (2005) guidelines and importance of same.

1 min Feedback from Questionnaire Pre prepared Questionnaire learners on the questionnaire. This to be filled in lesson delivery gives teacher and content feedback on lesson delivery and content which can be used for future lesson plans

18 Appendix 3 – Evaluation of Target Group

Wexford Mental Health Services

Objective Structured Clinical Examination (OSCE)

Nurses Name:______Examiner's Name:______

Skill: Hand Washing

Performance Criteria Performed Not fully Not competently competent performed or incompetent Remove hand and wrist jewellery

Using elbow, obtain liquid soap from dispenser Forms lather

Rubs lather palm to palm 5 times

Rub right palm over back of left hand up to wrist, repeat with other hand Rub right palm over left hand, rub interlaced fingers 5 times and repeat with other hand Rub palm to palm with fingers interlaced

Wash thumbs separately

Rub the tips of fingers in opposite palm in circular motion Rinse thoroughly

Turn off taps using elbows

Dry hands with paper towel

19 Discard paper using pedal bin.

Appendix 4 – Evaluation of Lesson

Q1: On a scale of 1 – 10, 1 being not informative, 10 being very informative, how informative did you find the lesson?

______

Q2: Did you find the lesson beneficial, if yes, in what way?

______

Q3: In what way did the lesson help highlight issues that can arise from ineffective hand hygiene?

______

Q4: Did the lesson assist you to reinforce your prior knowledge of effective hand hygiene?

______

Q5: Did the content delivered assist you sufficiently to achieve the learning outcomes of the lesson?

______

Q6: Do you think the variety of teaching styles maintained your interest in the lesson?

20 ______

Q7: Is there anything that you would have changed to improve the lesson?

______

Q8: Any further comments.

______