E-learning for cancer nurse education

Irving, M.J. et al (2007) E-learning for cancer nurse education. www.nursingtimes.net

Educating cancer nurses requires innovative approaches as the difficulties in both providing, and accessing, face-to-face training become increasingly apparent. The power and scope of the internet now offer real possibilities to address some of the challenges faced by educators. The charity Nurse Learning has developed a standalone online learning environment (www.cancernursing.org) that now gives cancer nurses around the world access to high-quality educational material that might otherwise not be available to them. This article describes the development of the website and the benefits of this type of learning to both nurses and organisations everywhere.

Educating cancer nurses presents significant challenges. There are increasing demands on nurses that prevent them from accessing opportunities to increase their knowledge and skills. This is a matter of considerable concern as the relationship between the education of care provider and the standard of patient care is well established (Finlay et al, 2006; Love, 2005; Hogston, 1995).

While face-to-face learning remains the gold standard for delivering education, developments in web-based technology have created opportunities that were previously unavailable. It is now possible to reach out to nurses across the world with high-quality educational material that otherwise may not be available to them.

The rapid developments in cancer treatment and patient management mean that nurses involved in cancer care are increasingly facing a situation where they must continually update their skills and knowledge. This, combined with a recognised desire of nurses to increase professional knowledge (Ryan, 2003), means that opportunities for continuous development are constantly being sought. However, at the same time, nurses may also be working in an environment of staff shortages and time constraints. This can mean that the ability to attend traditional face-to-face training events becomes severely restricted. In addition, in larger countries such as Canada, Australia and New Zealand, for example, geographical isolation can further restrict training opportunities.

There is evidence to suggest that some of these problems can be addressed by online learning (Blair, 2004; Atack et al, 2005; Atack and Rankin, 2002), as this can promote flexibility of learning while, at the same time, still lead to improvements in practice and patient care. E-learning has also been described as 'essential' if nurses are to continue to meet the rapidly increasing expectations of future patients (Blair, 2002).

This article describes an e-learning innovation designed to address many of these challenges in the area of cancer care. The innovation is CancerNursing.org (www.cancernursing.org), a website developed by Nurse Learning, a UK-based registered charity. Nurse Learning develops and provides free online courses for nurses and cancer carers around the world. This article outlines the development of the CancerNursing.org website, from its initial very humble beginnings to a globally-accessed learning resource.

E-learning

E-learning has been defined as encompassing all forms of electronic supported learning and teaching that contribute towards the learning process (Tavangarian et al, 2004). These electronic resources range from the provision of straightforward text via web pages to fully integrated learning management systems that use a variety of multimedia components. The selection and utilisation of technological resources both very much depend on the model of e-learning selected. These models can be expressed on a continuum (Fig 1). At one end of the continuum lies collaborative e-learning, where learners work in tutor-facilitated teams, sharing their knowledge and experiences and learning together. Learners may collaborate with each other using online discussion areas (or even video conferencing) on some courses and focus on achieving a particular task with the support of an online tutor. At the other end of the continuum is standalone e-learning, which is based on an individual person, and usually involves learners being provided with a core body of knowledge in either text or multimedia format.

This form of learning provides greater flexibility for learners but this is at the cost of the interaction that is available with collaborative e-learning. In between the two extremes there is 'hybrid', or as it is sometimes termed, 'blended e-learning', which utilises both approaches.

The CancerNursing.org model

The model of e-learning selected and used at the CancerNursing.org website is a standalone model and was selected for a number of reasons. First and foremost, it provides learners with the most flexibility; they can start and stop learning at a time of their choosing, avoiding the timetables and deadlines of a collaborative approach. This flexible learning is becoming more appropriate as the demands on nurses increase. A standalone e-learning environment is also scalable and can just as easily provide learning to 100,000 learners as it can to 100. Active tutor support is not required for learners in this model as all identified learning outcomes can be met using the material provided.

The standalone model, therefore, met with one of the original aims of the project, which was to reach out to a global audience of cancer nurses. The main drawback of the standalone model is the reduced interaction between learners that a collaborative model would offer, thereby reducing the opportunity to learn from others. In an attempt to address this deficiency, online discussion forums are to be integrated into the website within a new design planned for launch in the spring of 2007.

Course development

Quality control is an essential aspect of the course-development process. Nursing and medicine is rapidly changing and systems need to be in place to ensure that the accuracy and reliability of the presented material is maintained. Presenting material on the internet does have the advantage that it can be altered immediately if any change in practice is identified, although this does require constant surveillance of the relevant literature.

Each CancerNursing.org course is written by experts in the relevant subject area. These experts are either identified and contacted by the website team or they initiate contact themselves using a form from the website. The material submitted by the writing team is then extensively reviewed by an international panel of experts identified from the nursing press or contacts obtained through the website. For example, the most recent course on prostate cancer was written by a nurse consultant from the UK. The course was then reviewed by the Prostate Cancer Charity UK and specialist nurses/lecturer practitioners from the UK, USA and Australia before publishing. Following publication, all courses are formally reviewed on an annual basis, although any changes in practice that are identified by learners or the website team within that time are investigated and integrated immediately, if appropriate.

The range of CancerNursing.org courses is currently being evaluated by a UK university so that those learners who want to obtain an accredited certificate and credit accumulation and transfer (CATS) points will have the opportunity to do so. This will involve an additional written assessment and a small fee. It is interesting to note that less than 1% of all learners have requested accreditation for these courses and in fact many more than this have expressed appreciation that they do not need to submit a written assessment. It would appear that there are a large percentage of nurses who simply want access to high-quality meaningful content that can be directly applied to practice without having to complete academic assessment.

Website statistics

At the end of 2006, there were eight courses available on the CancerNursing.org website (Box 1). Many more courses are in various stages of development (Box 2). There are now over 11,000 learners registered on the website who have provided over 20,000 individual course registrations. Since the first course was launched in 2003, a sustained and, more recently, progressive increase in learners has been experienced (Fig 2). It is forecasted that these numbers will reach 20,000 by the end of 2007 due to increased publicity and the launch of a large number of additional courses.

Box 1. CancerNursing.org courses

Box 2. Courses in development

Features of the online learning environment

A huge amount of time and effort went into the original website design so that learners would be continually engaged and stimulated in what was going to be, predominantly, textual information. The CancerNursing.org online learning environment offers nurses the following resources and features:

• Authoritative textual content and graphics - This is material developed by experienced nurses in the particular subject areas. Images are used whenever possible to illustrate aspects of care bearing in mind that over-use of images may affect browsing for those with slower connection speeds;
• Self-assessment tests - These provide learners with an immediate and enjoyable way of testing their knowledge and understanding;
• Glossary - In places, the courses do need to use precise medical terminology. To enhance understanding and avoid any possible confusion a glossary of such key terms is provided. Learners are also offered a facility to request that a term be considered for inclusion;
• 'Ask the expert' facility - When nurses do not understand an area of course content, they can fill in a form to contact the course authors/ reviewers for further clarification;
• Frequently-asked questions - A series of questions that are commonly asked about the course subject area are given, together with authoritative answers. These offer another method of summarising core course concepts;
• Personal learning log - Nurses can make notes about key learning points in an online learning log. This private, personal record remains online permanently so that nurses can view and add to it each time they log in to the course, and can print out the log to include in a learning portfolio. The learning log is not formally assessed but is an excellent tool for reflection on learning. The log is password protected and can only be accessed by the individual learner;
• Record of achievement - Learners that undertake all of the self-assessment tests in a course gain access to a printable certificate. This record of achievement can be used as proof of course completion within a ward or unit, and can be included in a learning portfolio alongside other forms of learning.

Benefits of e-learning

There are many benefits for nurses who decide to pursue this form of e-learning:

• Critically, nurses are offered choice and flexibility. The nurse decides when to learn, where to learn, how long to learn and what to learn. Compared with face-to-face training methods this choice, or flexibility, is extremely attractive in the modern working environment. Access to financial resources is also unnecessary;
• Nurses can learn independently and are in complete control of their learning. There is no-one looking over their shoulder or establishing how they should progress through the course. For example, self-assessments can be retaken as many times as wished until nurses are satisfied with their result. This form of learning environment offers nurses the opportunity to make non-harmful mistakes. For example, setting the rate of the Graseby syringe driver incorrectly on an online course is harmless and can be rectified, unlike when the mistake occurs in a real-life situation;

• Nurses can check pre- and post-course knowledge via online self-assessments. They can test whether or not they actually do need to take parts of the course beforehand, saving them the time to focus on areas of which they have little knowledge;
• Nurses can undertake as much or as little of the course as they need, depending upon their existing knowledge. The modular structure of the CancerNursing.org courses means that nurses can work through manageable chunks of learning. For example, in the cancer of the oesophagus course, the individual modules cover diagnosis and screening, surgery, palliative aspects and nutrition;
• Nurses can gain a record of achievement if they complete the whole course by taking all of the self-assessment tests. This certificate provides them with concrete proof that they have completed the course;
• Nurses can ask an expert for help if they do not understand a concept. E-learning need not mean isolation from human contact - each course has an online course expert whom learners can contact with queries;
• Nurses can keep an ongoing record of personal reflections and learning points. The CancerNursing.org e-learning model promotes reflection and context-specific learning. Optional activities invite nurses to look at their own hospital or unit and keep notes on their findings.

Organisational benefits

In addition to the benefits enjoyed by nurses with this type of learning, individual organisations are also now using these courses to develop their own staff members' knowledge by integrating them into training plans (Bye, 2006). A number of paediatric oncology wards, for example, are making it a requirement for all new nurses to complete the course on cancer in children and young people, as this provides an excellent introduction to paediatric oncology and was written by the paediatric oncology nurse education (PONE) group of the RCN.

There is more to it than simply asking nurses to go away and do the courses, however. As there are no timetables or deadlines within the learning environment it requires motivation of the learner, although it is still possible for deadlines to be set by the particular ward or unit if desired. It also requires that staff members possess the ability to use the internet, and it is important that educators are aware and available to facilitate this. Blair (2004) suggests that teaching on the use of the internet is generally ad hoc and should be built into both pre- and post-registration courses. This should go some way to reducing the divide between those who can and those who cannot access the wide range of online resources available.

Perhaps the key benefit to organisations is that, as all the courses are free and can be done in the nurses' own time, it actually costs them nothing at all. As trusts face an ever-increasing battle to reduce costs, online training is likely to become increasingly attractive. But this does raise two important questions. First, will nurses be prepared to take responsibility for their own continuing development and learn in their own time? And second, is this learning effective in improving standards of care? The learner feedback described in the following section provides some insight into these issues.

Learner feedback

Every time that a learner completes a CancerNursing.org course, they are asked to provide feedback before printing out their record of achievement. This feedback is then used to both improve and adapt the courses and provide future learners with information as to how their peers have used the material. Learners provide the feedback through the website using Likert scales and optional free text.

Of the 11,000 learners registered on the website, 98% of those who completed one of the courses found the content valuable and useful to them. Some 85% felt that the courses had improved their knowledge and understanding of that particular cancer subject and 83% felt that the care they provided would improve significantly as a result. Although this data is subjective, it provides some evidence to suggest that undertaking standalone e-learning courses can lead to improvements in quality of care. Further scientific investigation is needed to determine the true value to patients.

A number of different issues have emerged from the free-text feedback obtained from learners over the last three years. The most frequently occurring comment has been in relation to the flexibility of the online learning environment. The ability to start and stop learning at a time of the learner's choosing is very important and fits in well with those who have busy lives. Learners suggest that this flexibility makes learning in their own time both attractive and convenient and they enjoy being able to learn in the comfort of their own homes. This is most apparent for those learners who have commitments that prevent them from easily accessing traditional face-to-face training, such as those working night shifts, community nurses and those having problems with child care.

Another issue that has been mentioned frequently by learners is that the online courses provide them with increased confidence to practise. This has been referred to by learners completing all of the courses and most frequently by those completing practical courses such as that on using the Graseby syringe drivers in palliative care. Many learners explain that they had received minimal formal training and the online course in this situation reinforced learning and provided an excellent revision tool.

Finally, learners have indicated that they have found online learning a fun way to learn. They enjoy being responsible for their own learning, provided that suitable structured resources exist to facilitate this.

Although the feedback has been overwhelmingly positive, it is important to remember that all of the data presented here should be interpreted with caution. This is not only due to its subjective nature, but also, more importantly, because this may well be a self-selecting group of motivated nurses whose comments cannot be applied to the wider nursing population. Again, further investigation is necessary to determine how appropriate and effective this type of learning might be to all nurses.

Lessons learnt

Since the launch of the CancerNursing.org site in the spring of 2003, a number of lessons have been learnt about providing this form of online learning for nurses:

• Nurses are keen for opportunities to expand their knowledge and skills, and are increasingly finding that they cannot attend traditional training or educational events;
• Nurses like to be able to test their existing knowledge of a subject area before they invest time in further study;
• Modular courses, divided into manageable chunks of content, that can be studied as part of a whole course or individually, offer a popular, and sometimes essential, form of flexibility;
• Self-assessment tests are a convenient way to assess knowledge and understanding, and they provide nurses with the motivation to increase their score if they do not achieve a high mark first time;
• E-learning can bring training and education to nurses whose geographical location can prevent them from accessing learning easily;
• Simple technologies work best. Internet connection speeds and the technological ability of learners must be considered when selecting a model of e-learning. CancerNursing.org uses the simplest of technologies (web pages) while at the same time engaging the learner via self-paced tasks and tests.

Conclusion

The fast-evolving nature of the nursing role and the requirements of registration bodies mean that CPD and lifelong learning are critical within the nursing profession. For a number of reasons - most notably staff shortages and geographical isolation - the ability for nurses to undertake traditional face-to-face training has been dramatically impaired. Non-traditional methods for ensuring that nurses can continually develop their knowledge and skills are being sought. E-learning offers many positive possibilities and advantages as it can provide the necessary flexibility in times of massive workplace change.

It is envisaged that, at some point in the near future, all nurses will come into contact with internet-based learning, whether through third-party sites such as CancerNursing.org, or via national government initiatives. Whatever the origins of the learning environment, it is vital that strict quality-control mechanisms are in place that promote evidence-based practice and provide learners with confidence that the material they access is of the highest standard. This type of learning will require nurses to have ready access to the technology as well as the skills to use it. In turn, individual nurses will have access to an enormous range of online learning opportunities that can be integrated into their careers and lifestyles. Such a wealth of opportunities does increase the requirement that nurses proactively manage their own learning portfolio and plan for their future in terms of learning and career development. These are key skills in themselves.

The feedback obtained from learners completing CancerNursing.org courses has been overwhelmingly positive and indicates that this standalone model of learning is both appropriate and acceptable to them. Organisations also benefit from this style of online learning as the cost is negligible and there is evidence to suggest that it does lead to improvements in patient care. However, further research is necessary to determine the true value to learners, organisations and patients.

The challenge to meet the educational needs of the future cancer nurse is a significant one. The CancerNursing.org standalone model may not answer all of the questions faced by educators, but in providing flexible, free access to high-quality educational material on a variety of cancer topics, it answers some of them.

References

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Blair, J. (2002) E-learning: a virtual challenge for educators. Nursing Times; 98: 31, 34-35.

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Finlay, N. et al (2006) Nursing education changes and reduced standards of quality care. British Journal of Nursing; 15: 13, 700-702.

Hogston, R. (1995) Nurses' perceptions of the impact of continuing professional education on the quality of nursing care. Journal of Advanced Nursing; 22: 3, 586-593.

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