Ever since the Institute of Medicine released its unsettling report in 1999 that between 44,000 and 98,000 Americans die each year from medical errors, hospitals have been reviewing all aspects of care delivery to ensure patient safety. The Joint Commission Patient Safety Goals reiterate the importance of establishing protocols and policies that address practices such as identifying patients using two identifiers, preventing medication errors, eliminating the use of misleading abbreviations, enhancing "handoff" communication, and reducing the incidence of nosocomial infections. In addition, every health organization has some mechanism for assessing the competency of its staff. Still, the question remains, "How do we, as educators, really know what staff know?" The question has even greater significance for preceptors because these nurses are the individuals responsible for enculturating new staff and assisting them to prioritize care and make decisions based upon salient data. Preceptor preparation courses concentrate on preparing staff nurses to use a myriad of educational strategies that foster learning and assist in evaluating performance. However, what is truly known of the preceptor candidate's rationale for decision making besides "this is the way we do it on this unit" or "this is how I was taught"? What is in place in your organization that is used to assess the accuracy of preceptor's knowledge regarding the care of the patient with stroke, heart failure, cancer, or diabetes?

Determining the degree of learning that results from participation in an educational session has always provided a challenge to educators. Course evaluations often concentrate on measuring, using a rank-ordering system, the degree to which the participant believes that an objective has been met. Other course evaluations request that the participant enumerate ways that clinical practice will change as a result of attending the individual program. Some educators combine a variety of strategies to assess learning, such as pretests/posttests, return demonstrations, or games. Unfortunately, these methods often fall short in identifying serious gaps of critical concepts. This month's column will explore the concept of behavioral rehearsal.

Behavioral rehearsal is an engaging approach. It uncovers the discrepancies in surface knowledge from that of mastery. It is an easy and time-effective diagnostic tool that learners can use for self-assessment. In addition, it provides immediate feedback about the rationale for decision making. Nurses have said that this technique is "unsettling" but tremendously valuable in identifying their gaps in knowledge.

Behavioral rehearsal has its origins in the psychology literature, most notably in the area of social skill deficits. Marlene Kramer also used the term in her work with "reality shock" and new graduate nurses. Kramer's supposition was that new graduates would learn from the mistakes of others by listening to the stories of their peers in support groups. By critiquing situations, which resulted in an error or conflict, new nurses were able to socially "practice the correct action." Given the fast-paced work environment, nurses must learn subtle nuances of decision making through behavioral rehearsal in the "classroom." The intent of behavioral rehearsal is to challenge the learner to a deeper understanding of key concepts. At the conclusion of an inservice class or orientation program, the educator requires the participant to decide upon a course of action to a perplexing situation. Verbal responses are solicited, debated, and discussed. This methodology allows participants to grasp new concepts in a meaningful way. Behavioral rehearsal differs from case studies in that little background information is presented. The intent of behavioral rehearsal is immediate application of learning to real-life situations that have confused others or have resulted in errors.

We will use diabetes management to illustrate this concept. The session on diabetes management has just been concluded. Target glucose levels and rationale for targets have been discussed; medications and, specifically, insulins have been presented in depth; and strategies to prevent hypoglycemia have been offered. Three basic tenets have been emphasized in the session: (1) It is estimated that 30% of all patients admitted to hospitals in the United States have diabetes, (2) insulin errors represent 50% of all medication errors within the hospital, and (3) diabetes care has become more complex in recent years with the introduction of three new insulins and several new glucose-lowering agents.

Behavioral Rehearsal 1

The resident writes the following order:

"Humalog N 10 units at hs."

Patient's blood glucose is 82 mg/dl

What is your course of action?

Most participants state that they would give this medication. When challenged to defend their decision with "Exactly what insulin are you going to administer?" the nurses respond with "I'm not sure." When further pushed to correct the order, the nurses remain puzzled.

The correct response should be "That insulin does not exist. The resident confused the rapid-acting insulin Humalog with NPH. The correct order should read 'Humulin N 10 units at hs." Humulin N should be given for a blood glucose of 82 mg/dL at hs because this insulin will cover the patient's basal needs so her glucose will not be high in the morning.

Behavioral Rehearsal 2

The patient has the following insulin orders:

Lantus 22 units every AM

Apidra 15 units before each meal

Supplemental insulin (Sliding Scale), regular insulin, 2 units for blood glucose 150200 mg/dl

Patient's blood glucose at 0800 is 178 mg/dl

What is your course of action?

Most respondents state that they would give all these insulins for this blood glucose level. When asked how many insulin injections they would need to give this patient, there is a heightened awareness in the room when the response is "three" injections. A participant or two will verbalize that the correct course of action is an order change in the supplemental insulin. This requires a consultation with the physician so that the supplemental insulin is changed from regular insulin to Apidra. This change will result in the patient receiving only two injections.

Behavioral Rehearsal 3

The patient receives 15 units of 70/30 insulin before breakfast and dinner. The patient is NPO for a cardiac catheterization in the morning. The following insulin order is written, "Replace the 70/30 insulin with NPH and give 1/2 of the 70/30 dose as NPH."

What is your course of action?

Most nurses automatically report that they would administer half of the 15 units, resulting in the incorrect dose of 7.5 units. The correct answer is 5 units. This is calculated by multiplying 15 by 0.7, which equals 10.5. Half of 10.5, rounding down, is 5; giving 2 extra units of insulin could result in an additional reduction of blood glucose by 50 mg/dl. Most nurses make no mention that this order is incomplete and confusing and that the physician should be consulted for clarification.

We all know that time has become the most precious commodity in health care. No longer can we overload learners with content. Educational activities must be structured to allow time for validation of learning. This will permit the learner to assimilate the content in a safe environment. In his book Complications: A Surgeon's Notes on an Imperfect Science, Gawande (2004) lamented, "We want perfection without practice" (p. 24). Behavioral rehearsal allows for the old adage "Practice makes perfect."

If you have behavioral rehearsal examples that you have used with preceptors, please e-mail us and we would be happy to share.

Mary Beth and Mary

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