The HITECH Act promises to offer RTs an opportunity to expand their knowledge base by becoming experts in health information technology, but what is the best way to teach the skills needed?

By Julianne S. Perretta, MSEd, RRT-NPS

I often wonder: Why don’t people remember what they are taught? Why is there so much we have to relearn? What happens when we need to know something right now? If managers and educators assume that their staffs care about their patients and intend to do the right thing whenever they provide respiratory care, then we have a responsibility to discover why wrong things happen, and why clinicians do not realize what they did was wrong before they did it. Patient safety results tell us that clinicians do not always do the right thing. Discovering which patient safety issues are learning deficits and then fixing the learning problems will improve patient safety, increase job performance (and thus job satisfaction), and improve competency of respiratory staff.

Sometimes the answers are easy. If 75% of the staff cannot troubleshoot a high pressure alarm on a ventilator, it is safe to say it was not taught well. It also could be that no one assesses whether staff can troubleshoot this alarm before they complete orientation. Other times, there could have been a lengthy time frame between when an RT learned a skill and when they used it, allowing the skill to decay. All of these require us to address our respiratory therapy education.

Many other factors impact RT continuing education: Joint Commission, licensing boards, and the National Board for Respiratory Care (NBRC), among them. RT professionals have an intrinsic desire to learn, but it is hard to make learning activities meaningful in the limited time available. If we cannot substantially increase the quantity of education time, we have to maximize the quality of education. To do this, we must understand the factors influencing each educational endeavor we take.

What Affects What RT’s Learn?

There is no shortage of guidelines for hospital-based continuing education. For hospital accreditation, The Joint Commission requires that competence to perform job responsibilities is assessed, demonstrated, and maintained for all clinicians. It has worked in collaboration with the Health Care Education Association (HCEA) to build the Guide to Staff Education, because it says staff education is “perhaps the most important tool to help ensure safe, efficient, and appropriate care and treatment.”1 Most states require at least 6 hours of continuing education per year to maintain respiratory care licensure, with some requiring as many as 12. The NBRC has the Continuing Competency Program, which maintains that all credentials awarded after July 2002 are valid for a 5-year period. One way to renew your credentials is to prove 30 hours of continuing education within the 5-year period.2

The American Association for Respiratory Care (AARC) defines continuing education as “learning experiences designed to strengthen and expand the knowledge and skills of respiratory therapists involved in … practice, education, administration, and research,”3 and has published guidelines for what it will approve as continuing education. The US Congress is even getting involved. In Title XIII of the American Recovery and Reinvestment Act of 2009, Congress proposes an electronic health record (EHR) for each person in the United States by 2014. It will soon be looking for institutions to “integrate certified EHR technology into clinical education of health professionals to reduce medical errors, increase access to prevention, reduce chronic diseases, and enhance healthcare quality.”4

Most hospital administrations mandate annual goals packaged as education, but usually are no more than review material. Fire safety, service excellence, age-specific criteria, medical device errors, and even TB tests and N95 fit tests get lumped with education. A good rule of thumb to maintain: If you cover the same topics year after year, it is not education; it is review. Staff are not learning it—you are re-covering it.

Why Do Adults Participate in Education Activities?

In 1974, Morstain and Smart5 sought to answer that question, because they believed that why adults participate in education may affect whether they learn. They came up with six motivations for learning:

  1. Social relationships—involved to make new friends (or in the case of many RT meetings, meet up with old friends);
  2. External expectations—involved to comply with the directives of someone with authority (“my boss is making me go”);
  3. Social welfare—involved because they want to serve others or the community;
  4. Professional advancement—becoming the health information technology maven, for instance;
  5. Escape/stimulation—involved to alleviate boredom; and
  6. Cognitive interest—involved for the sake of learning itself.

What Do I Need to Understand About My Staff as Learners?

Most people who have spent time studying adult learning know Malcolm Knowles’ 1970s work on andragogy. Knowles’ research has given us some characteristics of adult learners that set them apart from children. Adult learners:

  1. Are more independent and self-directed;
  2. Want to feel accepted, respected, and supported when learning;
  3. Want to feel a partnership with their instructor;
  4. Have a wealth of experience to draw from when learning;
  5. Are problem-centered, so they want to feel they can immediately use what they are learning.5

Both adults and children also have preferred ways to approach learning tasks, called learning styles. There are several learning-style classifications, such as Multiple Intelligences, Learning Styles Inventory, and VARK. Using VARK (visual, aural, read/write, and kinesthetic),6 individuals can understand how they learn most effectively. Visual learners like to use charts, graphs, and algorithms to learn new concepts. Aural learners have a preference for information that is heard or spoken, which in today’s society includes lectures, tutorials, group discussions, e-mail, and Web chats. Read/write learners prefer information displayed as words, so they make lists, read instruction manuals, and desire hand-outs during educational activities. Kinesthetic learners prefer using experience and practice to learn. Kinesthetic learners are better in clinical rotations than in the classroom, and take apart new equipment to understand how it works, even if they are not sure how to put it back together.

How Do We Make It Meaningful?

There are lots of things that make it problematic for respiratory therapists to have meaningful learning experiences. We frequently do not teach staff what they want to learn, but what we think they should learn. We do not reliably create opportunities for struggling learners to remediate or give them extra time to work through new concepts. And, of course, we are busy! There is more work to do in the same amount of time. Job vacancies mean RTs are taking busier workloads or working extra shifts. Continuing education usually means coming in an extra day for education, or taxing clinical areas with less staff so some can learn during their shift.

So, how do we do the most good in the least amount of time? Lots of good planning and a healthy dose of effective adult learning principles. First, anything that is not education should not take up education time. Many hospitals now hire online learning technology companies to assist them in teaching core concepts to the entire hospital online. This allows staff to complete review materials during downtime, without pulling them away from patients. A good rule of thumb is that if it does not require discussion, it should not be face-to-face. There could also be topics that staff might find helpful to have both online and as face-to-face formats. Infrequently used therapies and new ventilator modes are items that can be introduced online first and in group sessions later.

Moving topics to a self-paced format allows time for interactive learning activities. Designing education to be learner-centered means RTs are actively involved in the learning process, continually assessing the progress of learning and making adjustments to improve their learning. One of the best ways to get RTs actively involved is having them complete a needs assessment. This is “a process to acquire an accurate, thorough picture of the strengths and weaknesses of a [learning program] that can be used … for improving student achievement.”7 Needs assessments allow staff to give input on what works well in current educational activities, what needs work, what content they think they have mastered, and what additional content they would like to learn. Having staff suggest content gives them ownership and keeps them involved in the learning process. Also, consider including vendors in your needs assessment. They often have precreated learning activities based on their equipment that meet your department’s identified needs.

Actively involved learning activities include simulation, skills labs, discussion groups, and interactive case studies. A good question to ask when choosing which activity to use is: Do RTs need to know something (knowledge), or do they need to be able to do something (skills)? If RTs are supposed to do something, then most of the learning activity should involve them doing it. Sounds simple, right? But often we talk with our staff about what they should do without giving them opportunities to practice. How many of us would feel competent at CPR if we were only given an opportunity to hear a lecture on it, or watch a video, or talk through the skills, or take a test? It is by doing CPR in skills labs and simulations that we get good at CPR. Instructors can also create authentic discussions about time management, critical decision-making, patient assessment and diagnosis, and treatment recommendations to allow RTs to communicate with their peers, reflect on bedside management, debate patient care techniques, and reinforce hospital guidelines and protocols. Building interactive case studies based on real patients and critical or difficult events allows staff to make similar group reflections while using real experiences to teach. Both techniques should be facilitated by an instructor familiar with the cases and hospital standards, and can ensure group members maintain decorum during emotionally charged discussions. Offering the same topics in multiple formats (discussion, simulation, readings, and online materials) will meet the various learning styles of the staff and also provide “just in time” material they can use clinically when they have to implement new knowledge and skills.

Duration of learning activities is often hard to determine. Although we are given state and national guidelines about this, I stress that mastery learning theory should always be considered. The theory was originated by educational psychologist Benjamin Bloom and presumes all students can learn if they are provided with the appropriate learning conditions.8 Some RTs may be able to take a pretest and prove they have already mastered the knowledge or skills, while others may need to participate in multiple learning activities and skills labs several hours long before being competent. When determining time of a learning activity, you can also consider the Mini-skirt Test: it should be long enough to cover the important parts, but short enough to be interesting.

As managers and educators build continuing education, making it meaningful for RTs will keep them engaged and can help improve knowledge and skills retention. Moving review material to an asynchronous and self-directed format (like online modules or self-learning packets) allows more time for interactive learning activities. Using a needs assessment to identify education topics will make learning problem-centered and relevant for staff. Increasing effective learning will improve patient safety, job performance, and RT competency and satisfaction.


Julianne S. Perretta, MSEd, RRT-NPS, is simulation educator, The Johns Hopkins Hospital, Baltimore. For further information, contact [email protected].


  1. The Joint Commission. (nd) Guide to Staff Education. Accessed May 1, 2009.
  2. National Board for Respiratory Care. (nd) Continuing Competency Program. Accessed May 1, 2009.
  3. American Association for Respiratory Care. (nd) Continuing Education Program Application. Accessed August 1, 2007.
  4. One Hundred Eleventh Congress of the United States of America. (2009, January 6). American Recovery and Reinvestment Act of 2009. Available at: Accessed May 1, 2009.
  5. Merriam SB, Caffarell RS. Learning in Adulthood. San Francisco: Jossey Bass; 1999.
  6. VARK-A Guide to Learning Styles. VARK Categories. (2001-2009). Accessed August 10, 2007.
  7. North Dakota Department of Public Instruction. (nd) Needs Assessment. Accessed May 15, 2009.
  8. Notes from a Benjamin Bloom Lecture. [ACSA April 1987]. Accessed May 15, 2009.