So my husband has a brain tumor. Since his diagnosis and surgery last year I’ve spent a lot of time interacting with performers in the healthcare system. Many of us in the eLearning business are called on to produce programs around administrative content (electronic records, HIPAA) or even clinical skills (handling sharps). (Editor’s Note: “Sharps” is medical terminology for devices designed to puncture or lacerate the skin. For readers outside the US, “HIPAA” is the federal Health Insurance Portability and Accountability Act of 1996.)

Figure 1: Kent, post-op (Photo used by permission)

But every interaction reminded me: “Job performance” goes beyond a particular task in a particular moment.

Old-school training still matters

I’ve spent much of my career in proximity to training projects with questionable efficacy, mostly related to policy awareness or concepts like diversity or ethics. It’s made me often question the usefulness of training in general and face-to-face training in particular. But when you’re confronted with helping someone who’s just emerged from brain surgery with balance and vision problems, who is about to be sent home to navigate stairs and showers, the effectiveness of hands-on training is no longer a question.

Figure 2: Training matters (Photo used by permission)

A fabulous occupational therapist assessed Kent’s needs and designed interventions that she then implemented. Then he was evaluated by means of a scheduled “independence day”: successfully showering, grooming, and dressing himself with minimal help meant he could go home. By the way: She knew he was ready before he did. She knew he would be successful due to her ongoing formative assessments during the training phase rather than waiting until some final terminal assessment to determine that.

Know what else? There were no slides. Or lecture. Or presentation of “content.” There was practicing letting go of a walker, palming the walls of a shower stall for balance, and getting situated in a shower chair. And then back out. At least half a dozen times. First with help, then with coaching, then alone.

What else mattered? Things that surprised me. And they’re all things that L&D can support.

Affect matters

When someone is explaining how they are going to cut into your skull and mess with your brain stem you really really need that person to be strong and confident. Not tentative. Not hesitant. Eye contact. Clear language. One day on a clinic visit we encountered a pinch-hitting nurse from another unit who exuded no confidence at all. She kept asking me what she should do about removing his sutures. Kent didn’t want her to touch him and on our way out we just sought out someone else to confirm everything she’d said. It was wasted time for us and for them. Funny, the nurse we went to—someone we knew—said the tentative one we encountered was “a very good clinical nurse.” But you sure couldn’t tell it. Patients need to feel they’re in good hands, and the demeanor of the caregiver is important. Confidence comes partly from skill and experience, yes, but it’s also partly how one comes across.

So: knowledge, experience, confidence, assertiveness, clear language, eye contact? Hire for it. Train for it.

[Caveat: You also must learn to not take all that confidence at face value, to separate the factual from the snake oil. It’s up to the patients and their advocates to verify and research and curate and be sure the confidence is justified. ]

Community matters; open-mindedness matters

Things Kent and I learned early on: the world makes it easy to become an invalid, and the process ages you in ways you don’t anticipate. One of the most heart-wrenching memories I have is of watching my youngish husband struggling with an aluminum-frame walker on the sidewalk in front of our house. He looked 85 years old, head down, with that familiar slow lift/shuffle/set/repeat you see at eldercare facilities. Then a friend whose husband had balance trouble after back surgery sent the most wonderful gift: a pair of hiking sticks. These offered Kent enough stability to get rid of the loathed walker and made the world more accessible to him. (As ever, it frustrates me that so often these things are so serendipitous: I happened to post a picture of him with the walker on Facebook, and a friend whose husband had had back surgery happened to see it.)

Figure 3: Kent walking the dog for the first time post-op (Photo used by permission)

The sticks were just what he needed for his balance and—this matters more than I can explain—they made him look much less … impaired. Instead of an elderly, struggling patient with a medical device, he looked more like an eccentric middle-aged guy wandering around the grocery store with hiking sticks, training for his Kilimanjaro climb. It mattered. He loved the sticks and took them to his occupational therapist for her OK. The OT, in a room full of “approved” walkers and canes, admitted they were a new solution for her and one she’d keep in mind for other patients.

So: Hire people who are open minded. Put them in systems that allow some flexibility about the rules. Train for creative problem solving and finding new solutions and in flexing approved methods against patient comfort.  

Culture matters

We had many trips back to the hospital, and the minute staff saw my husband with walker or cane or hiking stick, or even just reaching to steady himself on a table or door frame, they slapped a bright yellow all-caps “FALL RISK” bracelet on him.

Figure 4: Fall Risk bracelet—part of the culture

He had never once fallen, and he hated the bracelet, but one of the biggest risks to a patient—especially someone post-craniotomy—is falling. The hospital knows this and has managed to create awareness in every corner, every nook, and every shadow of the huge medical complex. I heard world-famous neurosurgeons mention it. And food service workers. And the people in the insurance office. And the radiation oncology reception staff. You saw notices about fall prevention everywhere. There were posters with warnings about falls. There were posters with pictures of the bracelets. And you could spot those yellow bracelets at 50 paces. One day, headed back to a clinic for a checkup, a neuro nurse with a PhD saw that some water had dripped from a cooler. She did not call housekeeping. She did not put up a “wet floor” sign. She did not ask some lesser mortal to take care of it. She asked us to stand there and watch it while she went for paper towels and cleaned it up. It’s not someone else’s job. It’s not up for debate. It is part of the culture.

When I mentioned this to a training acquaintance at the hospital she said the fall prevention program is only a part of a much larger focus on patient safety, and is perhaps one of the things more visible to visitors like me. “It’s wonderful to hear that it’s being noticed,” she said. “We’ve been working on it since 2007.”

So: remember that culture change can happen, but it takes patience and persistence and energy and time, and it won’t come from a hit-and-run initiative launch with an implementation deadline six months away.

Street smarts matter

Even for patients with not-so-serious issues the American medical system is a puzzling, complex organism with many moving parts. A great ally to the patient is the staff member who has a system view of the environment and sees how the different parts fit together. She understands how the typical schedule for radiation treatments connects with appointment availability in the MRI unit. He knows you can’t walk from the surgeon’s office to the imaging center in under 10 minutes. A friend currently undergoing treatment for breast cancer says: “The difference between someone who knows what to do and how to deal, and someone who does not, is night and day.”

So: work to make training encompass a broader world view than just working in a specific role or in a specific area. Encourage partnering and shadowing and communities. Encourage everyone to show their work. Find ways to help cross streams and connect silos.

So what?

Again, many of my readers have likely worked on healthcare-related administrative or technical skill training. I have. But it’s important to remember that “job performance” goes beyond a particular task in a particular moment. People are actors in a system. And the stakeholders referenced in so many of our conversations might include people who aren’t management or employees or governing bodies but customers—and their wives. I was disheartened when, not long after the surgery, I encountered a self-proclaimed “L&D thought leader” who insisted that the patient’s perspective of nursing competencies was irrelevant. Because her 85-year old former-nurse aunt said so. I’m glad we were never at her mercy.


Kent went back to work last month, one year and two days after the eight-hour surgery. He gave up the hiking sticks last fall. He’ll likely always struggle with the tumor’s damage to his vision, which affects his balance a bit as well. But he’s alive and walking, talking, and working.

Note: Thanks to Jason Willensky, healthcare-related eLearning developer extraordinaire, for his editorial help.