The Journal of Continuing Education in Nursing

Teaching Tips 

Outside-the-Box Skills Validation of Competency

Doris V. Bennett, MSN, RN-BC, CCRN


The potential for harm to patients related to initiation and maintenance of continuous dialysis therapy by the bedside nurse led to the development of a novel method to educate nurses new to the skill of continuous renal replacement therapy. [J Contin Educ Nurs. 2019;50(2):59–60.]


The potential for harm to patients related to initiation and maintenance of continuous dialysis therapy by the bedside nurse led to the development of a novel method to educate nurses new to the skill of continuous renal replacement therapy. [J Contin Educ Nurs. 2019;50(2):59–60.]

Nurses caring for acutely ill patients with complex care needs is a challenge facing health care organizations. Ensuring competency, capability, and quality care of these critically ill patients is a high priority. Development and use of a method to address this challenge was implemented to teach precise processes that would resonate with multigenerational learners, permitting practice and development of clinical reasoning for high-risk skill safely. Quality audits indicated this educational modality influenced patient safety. Pre- and postevaluation comparisons revealed positive learner knowledge, competency, and satisfaction.


The challenge of ensuring patient safety for acutely ill patients with complex care needs pushes educators to think creatively. Staffing and patient needs dictate that nurses may only have a 6-month experience when attending a continuous renal replacement therapy (CRRT) class. Ensuring competency, capability, and quality care of these critically ill patients has been identified as a high priority.

Acute kidney injury occurs in 25% to 65% of critically ill patients. Of these patients, 5% to 8% will require specialized therapy, such as CRRT, in the intensive care unit (Richardson & Whatmore, 2015). CRRT is a continuous slow dialysis for patients who are hemodynamically unstable and cannot tolerate intermittent hemodialysis. CRRT is a high-risk therapy requiring critical thinking and skillful task responses by nurses. Practice varies between facilities in how the nurses receive the CRRT machine. In this facility, the direct care clinical nurses receive the “cycler” or CRRT machine with the cartridge in place and an initial prime completed. The nurses must reprime the cartridge, purge the system of air, make connections to additional primed tubing, connect the machine to the patient, and manage it safely. It is crucial for nurses to adhere to the strict sequential process of the setup for patient safety and to successfully initiate therapy. Ongoing management of CRRT necessitates advanced critical reasoning to manage the combination of the cycler and the intense patient needs.

Educators needed a method that would resonate with the nurse learners, allowing each to “do” the CRRT process in a manner mimicking reality. According to Lapkin, Levett-Jones, Bellchambers, and Fernandez (2010), developing clinical reasoning skills are related to nurses' ability to build on previous experiences to address new or unfamiliar situations. The method used builds the foundation on which these nurses can further expand their clinical reasoning skills when facing similar situations in the unit.

Requirements for passing the 4-hour course are:

  • Complete four Web-based modules.
  • Observe expert nurses providing real-time CRRT patient care.
  • Attend class and demonstrate the setup and management skills.
  • Complete knowledge assessment with 85% accuracy.
  • Submit documentation of competency validation of skills at the bedside.

The Web-based modules were created by system educators, related to the system process, for in-house use. The content covers basic principles of CRRT, nutritional aspects, pharmacy interaction, and calculations for fluid maintenance.

Prior to attendance, it is beneficial for nurses to observe expert providers in their unit who provide care to CRRT patients in real time. Seeing therapy in “real life” makes a distinct difference in the understanding of the flow of the therapy.

A major potential area for errors is in the setup of the system after repriming. In an effort to mitigate these errors, teaching the reprime was accomplished by using cardboard boxes as mock cyclers. Boxes were fitted with old training cartridges, and a laminated color picture of the cycler face was secured to the front. Empty therapy fluid bags were suspended from intravenous poles. Instructors identified various parts of the tubing while discussing the blood flow through the cartridge and pressures created in the process. Learning nurses demonstrated the part identification, with the instructor providing support and validation.

The second phase involved the actual repriming process. Instructors demonstrated the proper technique. The learning nurses first demonstrated priming of the prescription fluid lines and the heater fluid bag with prescription fluid, and then manipulated all of the various lines without contamination or prematurely connecting anything. Instructors again were at the nurses' side coaching critical thinking. This was followed with the instructors demonstrating air removal from the various ports practice, and the learning nurses then practicing air removal. Once all of the air was removed, it was time for the nurses to make all the appropriate connections and verbalize how to connect the patient to the cycler.

Continuing with the hands-on learning method, nurses then were required to manage an actual cycler providing therapy on a low-fidelity manikin with a dialysis catheter. The nurses programmed volumes and rates from simulated scenarios requiring therapy fluid calculations, followed by placing the cycler in recirculation mode as if the patient necessitated traveling and then resuming therapy after the travel was completed. Scenarios were provided to encourage problem solving and critical reasoning.

Following the class, the nurses completed a hands-on proficiency demonstration by caring for an actual patient under the supervision of a CRRT expert nurse. This competency verification was mandatory on two separate occasions before the nurses were deemed qualified to care independently for patients requiring CRRT.

Program outcomes to be tracked included patient harm events and nurses' knowledge, skill, and satisfaction. This process was ongoing.


The CRRT program has been in place for more than 25 years, with the same machine used for the majority of those years. This specific training method has been used for 2 years.

Patient Harm Events

Prior to this method of education, several incident reports had been received for incorrect connections, incorrect repriming of the system, and failure to remove all of the air from the system, resulting in a clogged filter. After implementing this change in education, no incidents have occurred involving newly trained nurses in the care of CRRT patients.

Learner Outcomes

Nurses completed a written test as well as pre- and posteducation evaluations. The evaluations specifically looked at the percent change from pre- to posteducation on six parameters. Learner feedback revealed a positive percent change in all six areas. Free text comments indicated great satisfaction regarding the repriming practice.


Implementing an outside-of-the-box teaching strategy for CRRT training has been an effective education method with encouraging outcomes for 2 years. This author continuously monitors pre- and postevaluations of class, as well as the facility for any reports of problematic prime or setup issues. It is believed that this training method facilitates and supports new CRRT nurses to critically think through the complex care needs, allowing new nurses to provide safe, competent, and confident CRRT care. The use of something as simple as a cardboard box to mimic something complex can be applied to many situations–think beyond the box!


  • Lapkin, S., Levett-Jones, T., Bellchambers, H. & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6, e207–e222. doi:10.1016/j.ecns.2010.05.005 [CrossRef]
  • Richardson, A. & Whatmore, J. (2015). Nursing essential principles: Continuous renal replacement therapy. Nursing in Critical Care, 20, 8–15. doi:10.1111/nicc.12120 [CrossRef]

Ms. Bennett is Clinical Educator, Indiana University Health, University Hospital, Indianapolis, Indiana.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Doris V. Bennett, MSN, RN-BC, CCRN, Clinical Educator, Indiana University Health, University Hospital, 550 N. University Blvd. #6301, Indianapolis, IN 46202; e-mail:


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