Measles, Mumps and Missing the Moment

By Marilyn Hanchett, RN, MA, CIC

From the front of the hospital classroom I saw the indifferent stares of 30 nurse residents. These first year nurses were participating in an employer sponsored program to facilitate their transition into clinical role as well as to support retention which is often unfortunately poor during this critical period in a professional RN career. However well-intended the residency program was, the lack of enthusiasm for my upcoming infection prevention update was unmistakable. As a long-time infection preventionist (IP), this was not particularly surprising, as few trainees seek out prevention content unless there is an imminent threat or some other infectious crisis. Overcoming such learner apathy – including the anticipated “we’ve heard this all before” attitude – is endemic to the infection prevention educational environment.

Overcoming this indifference is always challenging but on this particular day I felt especially prepared. I’d developed several small case stud-ies not only to include group participation but also to offer a few less frequently encountered scenarios. The residents did well with the first two. The third situation completely stumped them; there wasn’t even a guess as what might be wrong with the sick nine year old presenting at the pediatrician’s office. I had described a classic presentation of measles.

The group was curious, and I began to briefly expand on the topic as well as the changes brought about by widespread immunization. When I mentioned that I had first-hand experience, every face lifted. 'You mean you have actually seen a case of measles?' they asked. When I informed them that not only had I seen it, as a child I’d actually had it – mumps too- there was an audible gasp in the room.

My initial reaction was, frankly, embarrassment. I had unwittingly exposed the significant gap in age and clinical experience that existed between me and this group. For a second I feared that the residents were seeing me as some sort of dinosaur rather than a nurse colleague. Shrugging off that momentary self-consciousness, I understood that I suddenly had the full attention of every person in the room. Postures had changed, eye contact was directed at me rather than marginally hidden electronics, and the energy level in the room was almost palpable.

This was what educators in the mid-20th century described as the teachable moment. It is that time, impossible to predict but equally impossible to deny, when learners are, for a variety of reasons, most receptive to new information. While this may sound ideal, it is actually far more complex. In most situations it will present a dilemma, as it did for me on that day. The dilemma, at its most basic level, compels an immediate and unexpected choice. The trainer can be capture the moment and incorporate it into his/her content, striving for maximum impact. It can also be marginally acknowledged, lessening its potential impact and possibly less satisfying for both the instructor and the learners. The trainer may also choose to ignore it and move on.

I had to make an instant decision. I could leverage the teachable moment to talk about the challenges surrounding emerging and re-emerging infectious disease and immunization controversies, both very timely and important topics. Alternately I could acknowledge the group’s interest but return to my lecture plan and meet the learning objectives specified for the one hour session. There was not enough time for both. And the content that still needed to be addressed was important, too. My lecture would be evaluated based largely on meeting the session objectives, and I was acutely aware that poorly rated sessions are vulnerable to elimination the next time the nurse residency educational plan is under administrative review.

But the dilemma is actually more than balancing content with allotted training time. Given the scope of infection prevention and the evolving needs of acute care, it is likely that the dynamic tension between content and available time will continue to plague all healthcare educators. But looking beyond this obvious issue, is the ability of the trainer to effectively address the teachable moment when it does occur. On that day I realized that none of my academic degrees or continuing education had addressed this issue. What are the best techniques to capitalize on a teachable moment without hijacking the overall lecture? How exactly does an educator direct or redirect an intensified level of learner interest and still achieve the overall training goal? Is conformity to pre stated objectives the best approach or possibly a rigidity that can, at least some-times, undermine the desired outcome? How does the IP educator know what to do and how to do it?

Perhaps an overlooked aspect of overcoming apathy toward infection prevention training is more effective preparation of its educators. IPs are introduced to the basic principles of adult education. They eventually develop skills at lectures and most become adept with question and answer sessions. Beyond that, the skill set becomes much harder to define, let alone assess. One common characteristic of IP lead training is pragmatism. This approach is summarized according to three components: doing the best that you can  with whatever resources are available in whatever situation you must teach. That approach is by no means wrong. But it does raise concerns if it is sufficient to drive learning that will support behavioral changes required to improve patient care and make healthcare safer.

As the IP profession continues to change, it is time to make a much more serious and detailed analysis of the tools and techniques offered to IPs to help them become proficient in teaching.  While this is not a simple task, it is essential to future and long term success of prevention programs.  This is underscored by the consistent emphasis placed by institutions on the educator role when recruiting IPs. If providing education is essential to the IP role, how can IPs be best prepared to provide it? And are the approaches commonly used today, including the pragmatic do the best you can approach, enough to meet future challenges?

What did I do about the measles issue in my lecture? Of course I took a pragmatic approach. But at the end of my hour with the nurse residents, I wondered how much anyone would remember about the various topics we’d covered. But I was sure of one thing: they would remember they’d met someone who’d actually had childhood measles. Prepared or not, like it or not, on that day I became the teachable moment.

Marilyn Hanchett, RN, MA, CIC, is an infection preventionist and author. She lives in Westminster, Md. and can be reached at han-chett14@comcast.net.