My main job at work, now that I am a nuclear maintenance technical instructor, is to teach new hires all of the knowledge, skills, and attitudes they'll need to be successful in their nuclear craft. Calvert Cliffs Nuclear Power Plant, part of Constellation Energy Nuclear Group (CENG) which also includes two other reactor sites in New York, hires between 10 and 40 new maintenance technicians each year. My training group's responsibilities, therefore, really center around the constant process of Instructional System Design known as ADDIE so that the new learners are always getting the most current and relevant technical instruction possible. ADDIE is a constant loop cycle of training creation and refinement which stands for Analysis, Design, Development, Implementation, and Evaluation. Since most of the group's training materials have long since been created, most of my out-of-classroom work consists of using student and management feedback to improve training material from year to year.
I think there are a few ways we can significantly improve our training program to dramatically help our learner's ability to use their training to improve their job performance, improving their chances of success and promotion, and simultaneously boosting the line's ability to meet maintenance schedules which drives down costs, increases plant up-time, and maximizes profits for the company.
One thing I have noticed that concerns me about our program is how linearly our training events are delivered. What I mean is we teach a series of discrete topics, starting with administrative material and moving along into complex technical learning, including laboratory demonstrations and evaluations. Each topic is taught in its own predetermined time block, which may range from one day to as many as eight. When each class's instruction is complete and a review is done, an examination is given to check for learning. Students are given their grade, an upgrade is done via an exam review, and they leave. The next day, a whole new topic is taught, with little to no thought about the previous day's instruction, and little linkage to the big picture of their professional technical development.
What I'd like to suggest we do differently involves a sea change in our thinking and process. What I hope to do with this new blog string is refine my thinking and perhaps attract some constructive comments from other interested learning professionals.
One of the biggest challenges in making a training program effective is to ensure knowledge transfer. This, of course, is Donald Kirkpatrick's third step of evaluation, meaning how well can the learner apply the new knowledge, skills, and attitudes back at their job. How did the training make them better while doing their work? Many new ideas about this important stage of learning are being discussed in the training world. The work of Jim and Wendy Kirkpatrick continues to improve Don's original framework. Andy Jefferson and Roy Pollock at the The 6Ds Company have an integrated approach to training system development that focuses on transfer and followup. And there are many others concerned with the importance of ensuring training has a sound business case justifying its costs by firmly demonstrating how learners are better at their job after attending the training.
First, I propose we build into the beginning of each successive training event a short review period of a few of the topics that had preceded it. This reinforcement of past learning can't help but improve learner's long-term memory of the material, but will also serve as a way to discuss how the learning improved their work experience. Some possible discussion questions include: Was a new skill successfully put to use since the training event? Did the learners feel more confident in their work with the new knowledge they could now draw from? How did their new attitudes improve the performance of their teams? This discussion will help learners understand how their training fits into the grand scheme of things.
Next, I propose we stop using the schedule to strictly dictate the length of the learning experience. Now I fully understand how business training cannot just run indefinitely. CENG is a business with an existential profit motive, after all. What I mean is that we are excessively regimented by the schedule. We can find ourselves driven to complete a lesson plan quickly in order to get an exam administered and reviewed before the end of the day. Student feedback always suffers for it as they realize what's happening. We shortchange their learning so that we can meet the time schedule. The schedule is tightly packed with the new class commencing the day after the previous one ends, so there's little flexibility to make real-time adjustments to the plan if needed. There need to be gaps in the training schedule, days left unfilled to allow for schedule creep as classes run long based on the natural pace of instruction. The point of training, after all, is to deliver learning. We should not feel satisfied by just getting the lesson taught and tests passed on time. And those extra days, if not needed for instruction, allow the learners to get some work time with the shop and the instructors to be better prepared for the next event.
Finally, I propose that we follow a simple concept I most recently read about in Jenn Labin's terrific book, Real World Training Design, that states "Knowledge First, Skills During, Application After." This incredibly powerful idea so wonderfully summarizes my critical thinking about our instructional implementation method. We do not currently require our learners to read the course materials, including any relevant procedures, drawings, or diagrams, before they arrive for the training. They therefore need to spend the majority of the training time developing their knowledge of the material, Bloom's lowest level of cognitive learning. Most of our training objectives reinforce this low target with their defining language. What choice do we have when the learners arrive to the class with little to no previous knowledge of the topic? I want to improve our overall learning and transfer of training with a requirement for pre-learning, which can be as simple as sending learners email links to the lesson plan and other documents or as sophisticated as pre-loading materials on the learner's tablet or laptop. This new pre-learning requirement also supports the Leader-Leader and Certify concepts increasingly driving management thinking at CENG. When the learners arrive with a decent knowledge component already under the belts, we as instructors can spend the training time developing the learner's skills through practice, group activities, plant walk-throughs, observations, and discussions. Wouldn't this make our training much more effective? And then, after the training is over, we should provide some followup materials a few weeks down the line to help learners recall the training, again reinforcing long-term memory and use. If we coordinate this followup with the learner's supervisors, we can truly integrate training with the line's needs helping make sure training and performance improvement continues to be viewed as a valuable strategic business partner.
When we really regard training as a way to improve performance, realizing that training is not a means unto itself but a means to an end, we recognize the need to move in the direction I suggest here. Training managers will have to fully embrace this plan and then actively manage the change, first bringing instructors on board with more dynamic training methods, spending less class time on knowledge material and going deeper into understanding and application. Next, the line must understand how they will need to give learner's the time to complete the pre-learning, how training isn't just about being in a classroom or lab somewhere, but is an all-the-time process. The line also must partner more with training, aligning expectations, ensuring post-training evaluations are meaningfully performed, and agreeing on appropriate opportunities for the followup material I discussed earlier. Lastly, learner expectations must be set early, so that the pre-learning is part of their daily routine. Arriving to training on time, well rested, and fully prepared with knowledge, learners will experience a deeply involving training event with lots of interactive practice, skill refinement, and practical application of their new learning. That is a true win-win-win for all involved.
Sunday, August 4, 2013
Wednesday, October 10, 2012
After
After some questioning and reassurance that my steroid shots wouldn't be sourced from New England Compounding Pharmacy, I accepted the procedure as scheduled. The nurse at the pain management doctor was very kind and informative, and the doctor was too. The procedure was uncomfortable but well worth it if it helps.
My neurosurgeon's thinking is twofold concerning the cervical facet block injections. First, maybe it would help relieve some of the pain resulting from my neck popping and cracking. Second, it would be diagnostic, such that if it does help, then we can talk about further, more permanent solutions including surgery. The popping and cracking haven't gone away, but the pain seems a little less so far.
My pain doctor has me keeping a pain diary for the next two weeks so we can see how well the shots helped. I'm supposed to rate my pain three times a day on a scale from one to ten. So far, I'm hanging out in the six to seven range, but hopefully the steroids kick in over the next week and bring that number way down.
One unexpected side affect of the steroid shots was the horrible waves of nausea I felt this morning. I didn't expect that at all. The pain doctor told me to call if I developed a fever or chills, or if I started getting severe headaches that went away when I laid down. I don't know what the nausea was all about, but it wasn't any fun and it lasted well past noontime.
I did get in to see my primary care physician today so we could synchronize her record of my activities and so she could see how I looked herself. She updated my company's FMLA and disability documents for the additional missed days from work and she checked out the injection sites to make sure they looked okay. Finally, she wrote me a referral for some physical therapy. Even though the muscle relaxer is working well, she still detected how stiff my neck muscles are and suggested that PT could help loosen me up and increase my strength. I'll call to set an appointment for that after my three week wait to see my pain doctor is over and I see what he says.
There is one very pleasant development to add. The pain nurse took my blood pressure three times yesterday, once before the shots and twice afterwards. Each time, my bp was perfectly normal, which is great because it's been running high for the last several years. My primary care doctor also took it today and it was also perfect. She confirmed what I thought, which is that stopping the ibuprofen and adding the muscle relaxer was helping my heart and kidneys work better, thus lowering my blood pressure. We'll see if this keeps up, but it's good news.
I'm scheduled to meet the company nurse practitioner tomorrow at work after the shop's morning meeting. Hopefully I feel well enough to go and hopefully she clears me to get back to work. That would be nice.
Sunday, October 7, 2012
Fear
So I'm all set to see the pain management doctor on Tuesday for a cortisone shot in my neck to relieve my facet bone pain. The neurosurgeon and the pain doc think that all the popping in my neck is from the little bones between the vertebrae, called facets, possibly rubbing or being too close to each other. That's why I need to crack my neck constantly, why it keeps locking up and hurting.
I am happy that the new muscle relaxer seems to be working well. Despite my worry, it isn't putting me right to sleep like the past two prescriptions and it does loosen my neck muscles up. I have been able to turn my head more comfortably this weekend, definitely far better than the past week when the pain and stiffness kept me in a recliner with a heating pad most of the time.
No sooner do I make the decision to have the shot than I happen to catch a news story about tainted steroids used for spinal injections causing fungal meningitis, sickening over 90 people and killing seven so far. Apparently, a compounding pharmacy in New England starting shipping poorly prepared steroids all over the country to pain doctors wanting to save some costs. The compounded medicine isn't well regulated by the FDA, so their standards can be lower and their costs can be less. Doctors trying to maximize profits or trying to charge less for their services in a competitive pain relief market found this attractive, and it worked until the pharmacy didn't keep their product clean.
Meningitis is an inflammatory condition of the brain and nervous system. It can be viral, bacterial, or fungal, with fungal being the most difficult to diagnose with several non-specific symptoms. The fungus in the cases that are occurring now are the same as can be commonly found in the air and soil and which don't generally hurt us. But contaminate a medicine injected directly into the spine and the fungus has an express path to the central nervous system. Meningitis wasn't something I was worried about last week when I casually made the appointment for the seemingly routine procedure.
Needless to say, I have several important questions to ask the pain doctor tomorrow morning. If I don't like what I hear, I obviously won't be getting the facet shot on Tuesday. I am so tired of my neck locking up but I doubt fooling with meningitis is worth the risk, do you?
I am happy that the new muscle relaxer seems to be working well. Despite my worry, it isn't putting me right to sleep like the past two prescriptions and it does loosen my neck muscles up. I have been able to turn my head more comfortably this weekend, definitely far better than the past week when the pain and stiffness kept me in a recliner with a heating pad most of the time.
No sooner do I make the decision to have the shot than I happen to catch a news story about tainted steroids used for spinal injections causing fungal meningitis, sickening over 90 people and killing seven so far. Apparently, a compounding pharmacy in New England starting shipping poorly prepared steroids all over the country to pain doctors wanting to save some costs. The compounded medicine isn't well regulated by the FDA, so their standards can be lower and their costs can be less. Doctors trying to maximize profits or trying to charge less for their services in a competitive pain relief market found this attractive, and it worked until the pharmacy didn't keep their product clean.
Meningitis is an inflammatory condition of the brain and nervous system. It can be viral, bacterial, or fungal, with fungal being the most difficult to diagnose with several non-specific symptoms. The fungus in the cases that are occurring now are the same as can be commonly found in the air and soil and which don't generally hurt us. But contaminate a medicine injected directly into the spine and the fungus has an express path to the central nervous system. Meningitis wasn't something I was worried about last week when I casually made the appointment for the seemingly routine procedure.
Needless to say, I have several important questions to ask the pain doctor tomorrow morning. If I don't like what I hear, I obviously won't be getting the facet shot on Tuesday. I am so tired of my neck locking up but I doubt fooling with meningitis is worth the risk, do you?
Friday, October 5, 2012
Pain
I don't know what started it. Lately, I'd been feeling well enough to join my shop's softball team. We weren't very good, but it was fun and it was exercise. I had been doing more bicycling with my sons and I had really started to get more serious with my photography. Work was satisfying and home was good. We had finally sold the other house so the dual mortgage baggage had been thrown to the curb. Why did my neck have to start hurting again?
Four years ago, I was still in the Navy and living in Virginia. My ship had completed a shipyard refit and we were getting ready to go underway in preparation for deployment. It started as a mysterious weakness in my left arm. I had trouble lifting my towel in the morning. I could force myself to do it but it took an effort of concentration. Not normal for me, that's for sure. I had been riding the exercise bike in the ship's gym for a few months at that point and I was getting fit. I don't like the recumbant style of cycle, so I rode the upright with my body in a roadbike tuck, watching the TV and trying to keep my cadence up. My neck must have complained, but I never noticed.
Some time passed and the weakness morphed into pain, radiating down my left arm through the tricep, across the hollow of the elbow and down to my index and middle fingers. I sought help at ship's medical, and the good doctor tried to help. After a few experiments with some mild pain reliever and nerve blocker, he decided I needed to seek some specialized help at the naval hospital. I had only been to Portsmouth Naval Hospital a couple times previously, once for some stitches and the other to visit a Sailor of mine. The increasingly debilitating pain in my arm and the path of numbness into my fingers told the neurologist what he needed to know. It appeared I had a pinched nerve from a collapsing disc in my neck.
Some x-rays and an MRI later, we had some confirmation of the diagnosis. Told I had degenerative disc disease, I decided to not rush into surgery despite what my ship's doctor wanted, and I began several rounds of traction and physical therapy to try and relieve the pain in my arm. The neurologist also tried steroid injections into my disc twice. I also was on a high dosage of nerve blocker and narcotic pain reliever. None of this made my arm hurt less but by then I had transferred off the ship for medical reasons and my mom had come to help me with transportation and company since my wife and sons had their lives in Maryland. This extended time with my mom as an adult is one of the treasures of my lifetime.
The neurosurgeon, arrogant and confident as surgeons usually are, seemed confident that surgery would eliminate the pain in my arm by lifting the disc pinching the nerve. The choice was between disc fusion and installing an artificial replacement disc. Fusion was tried and true, but also would reduce my range of motion. The Pretige disc was fairly new at the time but seemed promising and would allow my neck to turn and flex fully. I was not yet forty so the choice was easy. In April of 2009, with my wife at my side, I had the first surgery of my life and gained a stainless steel body part.
The artificial disc did its job. After the normal healing and wound care, the pain in my arm did go away, leaving only the finger numbness from which I stiff suffer. A byproduct of the extended time the nerve was pinched, it may never fully recover. My neck muscles were tight but I assumed that would subside over time. I was able to slowly start living my life again, exercising more, sleeping in a bed instead of a chair, playing with my kids. I retired from the Navy, moved to Maryland with my family, and looked for work. I eventually started doing some business development work for a small defense contractor and I took some college classes at the local community college. My neck was doing okay but the stiffness and tightness in my neck never went away. I weaned myself off all the pain killers and nerve blockers, but I still needed 2400 mg a day of ibuprofen to keep the stiffness tolerable so I could work.
Time went on, my mom passed away, and I had to empty out her house to settle the estate. I spent weeks unloading stuff from her house into dumpsters or into a truck to take to the scrap yard. My neck worked fine during all of that heavy labor, but the painful stiffness continued to be a bother. I needed the ibuprofen like clockwork or I would end up fatigued and drained like I had the flu. My neck would get tender and tight and the pain would get worse. I rarely felt any pain in my arm again, but my neck was a constant issue. At one point, my neck was so stiff my doctor tried giving me a muscle relaxer that ended up affecting my vision. He then prescribed twelve weeks of physical therapy, which did improve my range of motion and probably reduced the stiffness temporarily, but even continuing the exercises didn't let me eliminate the kidney-damaging daily overdose of ibuprofen.
In 2011, we moved to Calvert County, MD, where I started my new job at Calvert Cliffs Nuclear Power Plant. Things went well at work, especially for the first year when I was in training most of the time. My neck grew stiff from the sedentary nature of classroom study, but nothing I wasn't used to by then. Unfortunately, training ended, which put me in the field (where I wanted to be) but my neck didn't like it. I felt well enough to bike and play first base, but it couldn't last. The stress of high heat and poor lighting combined with abnormal body positioning to put my neck under terrific strain, which I tolerated well some days and suffered in great pain on others. I also developed a new condition in my neck whereby I felt the need to pop my neck constantly. I could feel the vertebrae locking together and I seemed to need to pop them loose. This sometimes resulted in a strong tug down my spine. It also caused a metallic pinging sound inside my neck and head, which only I could hear but which was very real.
My new family doctor again tried a new muscle relaxer which might have helped but also put me to sleep so it wasn't a viable solution. Heat also relieved some of the stiffness but only while it was applied. I missed enough work to need a Family Medical Leave Act and Disability case assignment. I had x-rays and another MRI done so I could see a neurosurgeon in Annapolis to make sure my artificial disc was still properly in place. He confirmed that it was and that I could see a chiropractor if I desired to, but he thought it might be a good idea to get a couple flexion x-rays to verify the disc flexibility, which I did, and to see a pain management doctor about a cortisone shot into the disc above the artificial one. I consulted with the pain doctor who prescribed yet another muscle relaxer, which seems to actually lessen the stiffness without knocking me out. The locking sensation didn't go away, so I agreed to return to the pain doctor for the spinal cortisone injection. I have been missing more work because of this again so I hope the injection and the muscle relaxer does the job long term.
We'll see how it goes on Tuesday.
Four years ago, I was still in the Navy and living in Virginia. My ship had completed a shipyard refit and we were getting ready to go underway in preparation for deployment. It started as a mysterious weakness in my left arm. I had trouble lifting my towel in the morning. I could force myself to do it but it took an effort of concentration. Not normal for me, that's for sure. I had been riding the exercise bike in the ship's gym for a few months at that point and I was getting fit. I don't like the recumbant style of cycle, so I rode the upright with my body in a roadbike tuck, watching the TV and trying to keep my cadence up. My neck must have complained, but I never noticed.
Some time passed and the weakness morphed into pain, radiating down my left arm through the tricep, across the hollow of the elbow and down to my index and middle fingers. I sought help at ship's medical, and the good doctor tried to help. After a few experiments with some mild pain reliever and nerve blocker, he decided I needed to seek some specialized help at the naval hospital. I had only been to Portsmouth Naval Hospital a couple times previously, once for some stitches and the other to visit a Sailor of mine. The increasingly debilitating pain in my arm and the path of numbness into my fingers told the neurologist what he needed to know. It appeared I had a pinched nerve from a collapsing disc in my neck.
Some x-rays and an MRI later, we had some confirmation of the diagnosis. Told I had degenerative disc disease, I decided to not rush into surgery despite what my ship's doctor wanted, and I began several rounds of traction and physical therapy to try and relieve the pain in my arm. The neurologist also tried steroid injections into my disc twice. I also was on a high dosage of nerve blocker and narcotic pain reliever. None of this made my arm hurt less but by then I had transferred off the ship for medical reasons and my mom had come to help me with transportation and company since my wife and sons had their lives in Maryland. This extended time with my mom as an adult is one of the treasures of my lifetime.
The neurosurgeon, arrogant and confident as surgeons usually are, seemed confident that surgery would eliminate the pain in my arm by lifting the disc pinching the nerve. The choice was between disc fusion and installing an artificial replacement disc. Fusion was tried and true, but also would reduce my range of motion. The Pretige disc was fairly new at the time but seemed promising and would allow my neck to turn and flex fully. I was not yet forty so the choice was easy. In April of 2009, with my wife at my side, I had the first surgery of my life and gained a stainless steel body part.
The artificial disc did its job. After the normal healing and wound care, the pain in my arm did go away, leaving only the finger numbness from which I stiff suffer. A byproduct of the extended time the nerve was pinched, it may never fully recover. My neck muscles were tight but I assumed that would subside over time. I was able to slowly start living my life again, exercising more, sleeping in a bed instead of a chair, playing with my kids. I retired from the Navy, moved to Maryland with my family, and looked for work. I eventually started doing some business development work for a small defense contractor and I took some college classes at the local community college. My neck was doing okay but the stiffness and tightness in my neck never went away. I weaned myself off all the pain killers and nerve blockers, but I still needed 2400 mg a day of ibuprofen to keep the stiffness tolerable so I could work.
Time went on, my mom passed away, and I had to empty out her house to settle the estate. I spent weeks unloading stuff from her house into dumpsters or into a truck to take to the scrap yard. My neck worked fine during all of that heavy labor, but the painful stiffness continued to be a bother. I needed the ibuprofen like clockwork or I would end up fatigued and drained like I had the flu. My neck would get tender and tight and the pain would get worse. I rarely felt any pain in my arm again, but my neck was a constant issue. At one point, my neck was so stiff my doctor tried giving me a muscle relaxer that ended up affecting my vision. He then prescribed twelve weeks of physical therapy, which did improve my range of motion and probably reduced the stiffness temporarily, but even continuing the exercises didn't let me eliminate the kidney-damaging daily overdose of ibuprofen.
In 2011, we moved to Calvert County, MD, where I started my new job at Calvert Cliffs Nuclear Power Plant. Things went well at work, especially for the first year when I was in training most of the time. My neck grew stiff from the sedentary nature of classroom study, but nothing I wasn't used to by then. Unfortunately, training ended, which put me in the field (where I wanted to be) but my neck didn't like it. I felt well enough to bike and play first base, but it couldn't last. The stress of high heat and poor lighting combined with abnormal body positioning to put my neck under terrific strain, which I tolerated well some days and suffered in great pain on others. I also developed a new condition in my neck whereby I felt the need to pop my neck constantly. I could feel the vertebrae locking together and I seemed to need to pop them loose. This sometimes resulted in a strong tug down my spine. It also caused a metallic pinging sound inside my neck and head, which only I could hear but which was very real.
My new family doctor again tried a new muscle relaxer which might have helped but also put me to sleep so it wasn't a viable solution. Heat also relieved some of the stiffness but only while it was applied. I missed enough work to need a Family Medical Leave Act and Disability case assignment. I had x-rays and another MRI done so I could see a neurosurgeon in Annapolis to make sure my artificial disc was still properly in place. He confirmed that it was and that I could see a chiropractor if I desired to, but he thought it might be a good idea to get a couple flexion x-rays to verify the disc flexibility, which I did, and to see a pain management doctor about a cortisone shot into the disc above the artificial one. I consulted with the pain doctor who prescribed yet another muscle relaxer, which seems to actually lessen the stiffness without knocking me out. The locking sensation didn't go away, so I agreed to return to the pain doctor for the spinal cortisone injection. I have been missing more work because of this again so I hope the injection and the muscle relaxer does the job long term.
We'll see how it goes on Tuesday.
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