Online training: coming soon to a computer near you; This might be more time-saving and effective than you thought.

The Internet can be a powerful training tool. With a few clicks of your mouse, you can use it to:

* (virtually) invite nationally acclaimed geriatrics experts into your facility to lecture your staff on a wide variety of topics (check out, for example, the recorded Web seminars available free from the American Society on Aging [ASA] at www.asaging.org/webseminars);

* access cutting-edge research on nursing home care from peer-reviewed journals such as the Journal of the American Geriatrics Society (www.blackwell-synergy.com/rd.asp?code=JGS&goto=journal); or

* browse through Web-based training modules developed specifically to help nursing homes improve their care (visit Gero T.I.P.S. Online Learning at www.nursing.upenn.edu/centers/hcgne/gero_tips to scroll through its free module on restraint-free care).

Sounds promising, doesn't it? But all this and more from the World Wide Web may be nearly useless to your staff. Ultimately, much depends on your ability to harness the power of Web-based training tools within a learning system that includes nursing home staff as students and your facility's technology resources.

Let's use a hypothetical example to see how the different elements, or variables, in this system might interact, whether successfully or unsuccessfully. Suppose, for example, that you want to access Web-based resources that will teach nurse aides how to provide prompted voiding as a means of improving continence among residents. Where do you start?

Start with the first variable in our learning system: the Internet itself. At last count, there were an estimated 49 million unique Internet Web sites, (1) yet it's possible that not one of them offers the type of online training you seek or anything close to it. Indeed, we came up short after considerable searching, using not only widely recommended search engines such as Google (www.goole.com) and Yahoo! (www.yahoo.com), but also within Web sites that specifically target long-term care providers, such as the American Medical Directors Association (AMDA) (www.amda.com) and state Quality Improvement Organizations (QIOs). To be sure, we found excellent written materials on the topic, including journal articles and clinical practice guidelines on managing incontinence through prompted voiding. But while these materials might be useful in a training seminar, none of them constituted one.

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In general, there is a scarcity of Web-based seminars and tutorials for nursing home staff on any topic of possible interest. One reason for this has been lack of demand. Let's face it: Nursing homes have been slow to embrace the Internet, and the Internet has returned the favor. But demand is rising, fueled largely by the Nursing Home Quality Initiative (www.cms.hhs.gov/quality/nhqi), which has created public pressure for nursing homes to enhance their care and has charged QIOs with helping facilities to make these improvements. In this era of reform, more providers are looking to the World Wide Web to help them offer ongoing, flexible, cost-effective training to a workforce characterized by rapid turnover.

On the supply side, long-term care educators (and we count ourselves among them) have shied away from the Internet as an untested teaching tool. As it is, there is plenty we don't know about using traditional education methods to improve nursing home care. While some training programs have led to increased knowledge among staff, few have been shown to produce sustained improvements in nursing behavior. (2) For years, that inability to effect change in practice has served as a brake on using more innovative but less familiar strategies to deliver continuing education to nursing home staff. Now, however slowly, long-term care educators are turning to Web-based programs in hopes that these can achieve what traditional training programs have not.

Current, pioneering programs for the Web and computers signal future directions for online training. Among these programs, three teaching models are discernible:

1. The online tutorial, as exemplified by the Gero T.I.P.S. training module on restraint-free care, offered by the Penn Nursing Hartford Center of Geriatric Nursing Excellence (www.nursing.upenn.edu/centers/hcgne/gero_tips), and the online Gerontological Nursing Certification Review Course offered by the John A. Hartford Foundation Institute for Geriatric Nursing (www.nyu.edu/education/nursing/hartford.institute/course/home.html). In essence, online tutorials are online training manuals. Although they may include a few multimedia features, they are largely word-based, so you have to read to learn.

2. The Web-based seminar, as exemplified by those offered by the ASA. These are audio-visual presentations featuring online lectures with PowerPoint presentations delivered by experts in the field. On the computer screen, you see the presentation, not the expert, but you hear this person lecturing.

3. The computer-based interactive video training module (not yet available on the Web). Highly visual and featuring few written words, these modules look like documentary films and may ask nursing home staff to think about and evaluate care routines that are demonstrated on the video.

These three basic models fall along a continuum that ranges from very wordy to very visual. Choosing among them means taking into consideration the second variable in our learning system: the students. As more online education programs become available, you'll want to select those best suited to the educational levels and learning styles of the staff to be trained.

Let's return to our hypothetical example: the search for Web-based training on prompted voiding, geared toward nurse aides. We at the Borun Center are developing a Web-based tutorial on this very topic. But will it appeal to nurse aides? In all honesty, probably not. As a tutorial, it entails a lot of reading. In addition, like most online tutorials, it requires a fair amount of self-motivation and discipline on the part of students to complete all sections of the training module. For best results, the students also should be comfortable using online discussion boards and e-mail services. In most nursing homes today, this student profile fits advanced practice nurses better than nurse aides, most of whom have a high school education or less. (3)

Such were the findings when Gero T.I.P.S. analyzed feedback from users of its online training module. (4) To be sure, few users (n = 18) completed the voluntary feedback form. But of those who did, 78% were either advanced practice nurses or nurse educators. Another 17% were administrators or managers. Only 5% were licensed practical nurses. None were nurse aides. (In a sign of the times, however, all the respondents said they were interested in other Web-based training.)

Web-based seminars or lectures may be more appealing to nurse aides, especially those sessions featuring dynamic, entertaining speakers. You can often preview recorded (as opposed to live) online seminars to assess whether they might be of interest to your staff.

Perhaps the programs most likely to draw and hold the attention of nurse aides are interactive video training programs that require minimal reading and writing skills to complete. Researchers at the University of Pittsburgh developed and tested such a training model on mental health education with aides in three nursing homes, comparing it to lectures on the same topics. (5) Results showed greater compliance and satisfaction with the training among nurse aides who used the computer-based interactive videos. Knowledge of core concepts was also higher among these students, compared to those exposed to the lectures.

The bad news is that training models of this sort are difficult to impossible to find on the Internet; in fact, in our own search we struck out completely. Part of the problem may be that these online programs are more difficult and expensive to produce and update than Web-based tutorials and seminars. As a result, their availability may depend on first strengthening the market for other online nursing home training programs. A more serious impediment to their availability, however, is that most Internet connections, even high-speed ones, are simply too slow to support the transfer of lengthy video programs to your computer. It's the same reason there is almost no market at present for online movies.

This brings us to the third variable in our learning system: your facility's resources, starting with its computer technology. Do you believe that you need to lower the thermostat in your conference room and line it with computer cubicles to effectively offer online training to your staff? The short answer is you shouldn't. What you need are:

* one or a few capable computers--these days you can buy a fast one, more than adequate for the task, for about $500 at most computer or business supply stores;

* the fastest Internet connection your facility can afford--cable is best, telephone landlines are worst;

* a quiet location for the computer or computers, where staff can gather to interact among themselves and with the online program; and

* sufficient time set aside for staff training (although computers are quick, computer-based training programs take about as much time to complete as traditional training programs).

A common misassumption is that your facility will need a bank of computers so that staff can train online all at the same time. Not only is this impractical in most nursing homes, it may also be undesirable. Most online training programs currently available--Web-based tutorials and recorded seminars--are self-paced and asynchronous, meaning the student can access them at any time on any day. These features enable nursing homes to offer ongoing training to staff on all shifts with minimal disruption to daily work schedules. Why not take advantage of this flexibility? Yes, you can gather everyone around one or two computer screens for a Web-based seminar, but you don't have to, and you may prefer not to. You could instead ask a few nurse aides to view an hour-long Web-based seminar on each of five consecutive days and then bring them together on the sixth day for a 45-minute discussion of what they learned. This format may be just as effective as traditional in-service training sessions, yet less disruptive to everyone's work schedules.

Online tutorials are probably best completed with one person to a computer (unless you like that feeling of someone constantly reading over your shoulder). Again, there is no need for all staff members to complete a tutorial at one time. Consider work schedules and the number of computers available for training in your facility to devise a realistic training schedule.

Keep in mind that staff members with little or no previous computer experience will need extra time to learn how to use a mouse or directional keys on the keyboard. To start, you may want to pair these workers with more computer-savvy staff members.

The Outlook

Online training for nursing home staff is in its infancy. But Internet offerings will likely grow quickly in the coming months and years, spurred by new demands to improve quality of care and new hopes that online flexibility and ease of dissemination will lead to more effective teaching. For now, nursing homes can take advantage of Web-based offerings for long-term care providers by mixing, matching, and blending them with their traditional in-service training programs.

Let's return once more to our hypothetical training session on prompted voiding for managing urinary incontinence. After considerable searching, we didn't come up with a stand-alone online course appropriate for nurse aides. But we didn't come up empty-handed either. You could, for example, download clinical practice guidelines on incontinence care from the AMDA Web site and distribute copies for discussion at your next in-service training on prompted voiding. You could set the stage for resident assessment by gathering small groups of staff in shifts for a Web-based ASA seminar on comprehensive geriatric assessment (go to www.asaging.org/webseminars/ondemand.cfm). It would take some searching, but you might find an appropriate PowerPoint presentation on one of the state QIO sites (for a directory of QIOs, visit the American Health Quality Associations' Web site [www.ahqa.org]). When our site goes online later this year (www.medsch.ucla.edu/boruncenter), a comprehensive tutorial that goes beyond clinical guidelines to tell you exactly how to target, provide, and manage prompted voiding care will be available. If the tutorial is too much reading for nurse aides, you can opt instead to download the single page that features step-by-step instructions for providing prompted voiding, while the other sections can help train your trainer.

The point is that there is a lot out there--with more to come--that will enable you to tailor training to your staff's and residents' needs. Part of the allure of Web-based training is the creative power it imparts to users. Developers know that once their educational materials are accessed online, control over them is relinquished to the user. It's up to you to pick, choose, and use what will work best in your facility.

Through your selections, you can also influence the development of new online offerings. E-mail a few lines to the developers to let them know what you liked and didn't like about their materials. Virtually all Web sites welcome feedback from visitors. And, because good Web sites are regularly updated, your comments and those of others may rapidly translate into new materials, information, and resources that better meet the continuing education needs of long-term care providers.

References

1. Netcraft. Search Web by Domain. Accessed April 20, 2004, at www.netcraft.com/?host.

2. Aylward S, Stolee P, Keat N, Johncox V. Effectiveness of continuing education in long-term care: A literature review. The Gerontologist 2003; 43:259-71 (http://gerontologist.gerontologyjournals.org/cgi/content/abstract/43/2/259).

3. Yamada Y. Profile of home care aides, nursing home aides, and hospital aides. The Gerontologist 2002;42:199-206 (http://gerontologist.gerontologyjournals.org/cgi/content/abstract/42/2/199).

4. Cotter VT. University of Pennsylvania, School of Nursing. Personal communication with author, April 16, 2004.

5. Rosen J. Mulsant BH, Kollar M, et al. Mental health training for nursing home staff using computer-based interactive video: A6-month randomized trial. Journal of the American Medical Directors Association 2002;3:291-6 (www.jamda.com).

BY ANNA RAHMAN, MSW; JOHN F. SCHNELLE, PHD; AND SANDRA F. SIMMONS, PHD

Anna Rahman, MSW; John F. Schnelle, PhD; and Sandra F. Simmons, PhD, are on the staff of the Borun Center for Gerontological Research, University of California at Los Angeles, and the Jewish Home of the Aging of Greater Los Angeles. For further information, call the Borun Center at [phone] or e-mail Rahman at [e-mail]. To comment on this article, please send e-mail to [e-mail]. For reprints in quantities of 100 or more, call [phone].