18.3 Staff Training, Competency and Remediation

Identify the Task and the Gap

Training begins with what staff must know and do. Dialysis roles include assessment, cannulation, catheter care, setup, alarms, medication tasks, water testing, termination, disinfection, documentation and emergency response. Different roles need different depth and legal authorization. A generic annual lecture cannot establish competence in every task for every employee.

Use orientation requirements, direct observation, incidents, near misses, audits and staff feedback to identify gaps. A cluster of contaminated hub technique calls for a different intervention from errors in conductivity interpretation. Define the behavior precisely. 'Needs more education' is not a useful training plan unless it states what must change and how that change will be evaluated.

Write Measurable Objectives

An objective includes the action, conditions and success standard. For example, the staff member will perform catheter connection using the approved aseptic procedure without contaminating the prepared hub, or will identify a final chlorine failure and implement the stop/escalation protocol during simulation. The standard should identify critical steps, not reward completion speed over safety.

Separate knowledge, psychomotor skill and judgment. A written test can assess calculation or recognition. Return demonstration assesses handling. Simulation assesses decisions under unusual conditions. Competence in one dimension does not establish the others. A person who calculates UF correctly may still fail to recognize symptomatic instability requiring immediate action.

Teach and Practice

Explain the purpose and sequence, demonstrate correctly, provide supervised practice and give specific feedback. Use the actual device, supplies and approved procedure. Training on a different machine can create misleading assumptions about clamps, alarm behavior or rinseback. Teach staff to consult the instructions and escalate uncertainty rather than memorize one universal procedure.

Avoid teaching solely through slides for skills that require physical performance. Repeat practice when errors occur and explain the mechanism. A learner who touches a cleaned hub needs feedback about contamination, not only a lower checklist score.

Assess Competency

Use a standardized checklist with observable steps and explicit critical failures. The evaluator should be qualified and familiar with the current procedure. Document the device, task, date, evaluator, results and any conditions or limits. A signed form without evidence of observed performance is not a reliable competency record.

CDC recommends access-care competency evaluation on hire and every six to twelve months. Other tasks follow applicable requirements and facility policy; do not present one schedule as a universal law for every skill. Product changes, long absence, repeated errors or new responsibilities can trigger additional assessment. A current certificate does not eliminate the need to verify a task-specific skill.

Remediation and Supervision

When a gap appears, determine whether it reflects knowledge, technique, judgment, fatigue, workflow or equipment design. Give targeted teaching and practice, then reassess. Restrict independent performance of a safety-critical task until competence is established. The supervisor should arrange safe assignments while the employee learns; assigning the same task unsupervised as a test can expose patients to avoidable harm.

A staff member who repeatedly misses a water-test failure may need both knowledge instruction and review of test-strip handling, lighting, documentation and escalation access. Training alone will not correct an expired reagent supply or a procedure that hides the final sample point. Address system contributors while retaining accountability for safe performance.

Emergency Team Training

Practice roles in bleeding, cardiac arrest, air, hemolysis, anaphylaxis, fire and utility failure. Staff need to know who stops the pump, who calls help, who brings equipment and who communicates the patient history. Simulations reveal delays and conflicting instructions without exposing a real patient. Debrief constructively, identify concrete changes and repeat the scenario after correction.

Record readiness checks and drills according to policy. A successful drill is not merely one that ends without criticism; it should show timely appropriate decisions. Do not claim that positioning an air-embolism patient is more important than stopping air entry, oxygenation and resuscitation. Emergency teaching must use the current approved protocol.

Evaluate the Training Program

Measure more than attendance. Look at observed performance, process adherence, treatment errors and relevant patient outcomes over time. Avoid attributing a change to training without considering other factors. If behavior improves but infection does not, examine exposure, surveillance and remaining system barriers. If performance remains unsafe, revise the teaching method or resources.

Scenario

A new employee passes a written catheter-care test but contaminates the connection during return demonstration. The evaluator stops the task, explains the error, provides supervised practice and repeats assessment. Independent connection is deferred until safe performance is consistent. This response protects patients and gives the learner a clear route to competence rather than treating a quiz score as sufficient proof.

Sources: CDC dialysis competency recommendations, NCSBN delegation responsibilities.