Nurses must be competent and confident in assessing patients’ needs. Marie Curie Cancer Care designed and evaluated an online course to improve practice.
Sally Smith, MSc, Lettol, PGCE, RN is practice educator; Gill Arnold, RN, Adult teaching certificate, was practice educator; Shaun Kinghorn, MSc, BA, ITOL, Lettol, Cert Ed, HEA, RN is online learning developments lead; Amanda Poppleton, BSc, RN, is A1 assessor and verifier for health care assistant development programme/communication skills manager; all at Marie Curie Cancer Care.
Smith S et al (2010) Using e-learning to develop communication skills when assessing patients’ end of life needs. Nursing Times, 106:41, early online publication.
Marie Curie Cancer Care developed and delivered an online end of life care assessment course. The outcomes of the pilot indicate that e-learning using facilitated discussion forums may help nurses develop effective assessment skills.
Keywords End of life care, E-learning, Online discussion forums
- This article has been double blind peer reviewed
- E-learning can help nurses to develop skills for end of life care assessment.
- Online discussion forums can support nurses’ learning share good practice.
- E-learning can be used to develop skills that are often taught in face to face settings.
Effective assessment is crucial in identifying the end of life care needs of patients and their families. NICE (2004) guidance on supportive and palliative care for adults with cancer notes that one of the reasons why patients’ needs are not always met is that professionals do not identify their problems or concerns. The development of assessment skills in the end of life care nursing workforce is central to recent guidance on the commoncore competences and principles for health and social care staff working with adults at the end of life (NHS, 2009).
Marie Curie Cancer Care is committed to developing the competence and confidence of nursing staff involved in assessing patient and family needs. This article reports on the delivery of a six week online programme developed by Marie Curie, Communication Skills for Effective Patient and Carer Assessment, and its impact on the practice of the 30 practitioners who participated in the pilot. It also reports on the extent to which online learning was acceptable to staff involved in the pilot.
E-learning is one of several approaches to support the development of nurses’ skills and knowledge. Key strategic documents over the last decade have focused attention to the learning and development needs of staff, including the use of e-learning (Department of Health 2008a, 2008b, 2006).
The DH (2008c) has emphasised the need for high quality care for all adults at the end of life and the significant role of e-learning in developing the end of life care workforce. This strategy has led to the development of a suite of programmes under the umbrella of End of Life Care for All (e-ELCA), which was launched in January 2010.
Like many other end of life care providers, Marie Curie is faced with the challenge of developing the assessment skills of large numbers of staff spread across the UK. In 2006 Marie Curie embarked on several projects to introduce e-learning to staff via its online classroom learnanddevelop.mariecurie.org.uk. It was clear at an early point that feedback was encouraging. This provided the impetus for developing more e-learning programmes, which were either fully online or were combined with workshops, skills labs and study days.
Design of the programme
“Communication skills for effective patient and carer assessment” is fully online and one of a number of programmes that make up Marie Curie’s communication skills training. Over a period of six weeks participants spend approximately 90 minutes per week working through online learning activities.
The course was designed to meet the needs of a disparate group of nurses spread throughout the UK. One particular target group are nurses who work at night in patients’ homes, which can limit their ability to attend courses during the day. In some cases nurses had to travel long distances to access face to face learning opportunities. The programme was therefore designed to be delivered completely online, without attendance at a traditional study day. Many of the learners were new to the experience of studying online.
The programme covers a range of activities which not only develop required communication and assessment skills but also enhance the participants’ online study skills. It was decided to run the course over a period of six weeks, as this time period would enable participants to engage with the material while at the same time not requiring an overly long time commitment.
Each week covers an aspect of the assessment process. The programme uses a variety of resources and learning activities facilitated by an online moderator. Key features include:
- Getting to know each other online via online discussions;
- Access to and review of useful literature;
- Review and online discussion of case studies delivered by audio or video;
- Personal reflection on practice and the development of a personal action plan;
- Course evaluation online.
Participants were expected to contribute to weekly discussion forums to share experiences of the activities and to participate in online conversation with other members of the group. The audio and video resources were scripted and developed in house by members of the design group team.
Online moderator involvement was designed to encourage and motivate the participants to complete the course by moderating the discussions, and to offer advice and support. Technical help was provided by Marie Curie’s online learning developments team and IT helpdesk.
At the end of the course participants were expected to develop an action plan to take back into the work environment and share with their manager. This was designed to encourage the transfer of learning into practice.
Preparation of online moderators
Given that the programme is highly dependent on the support of online moderators, it is essential that moderators are trained and supported. In 2007/08 the Marie Curie online learning developments team designed and started delivering an inhouse training programme for moderators. Participants in this fully online programme were required to undertake two to three hours of study per week for the eight weeks.
Nurses who registered for the first wave of the communication skills programme were recruited from across the Marie Curie workforce. Participants included registered nurses and healthcare assistants from the Marie Curie nursing and hospice services.
A total of 30 staff participated in the first two pilots. Of the three staff who withdrew, two cited personal reasons and one had intermittent IT problems.
The prerequisites for enrolling on the programme included:
- A minimum of six months’ employment with Marie Curie Cancer Care; this was to ensure a level of experience to refer and relate to practice;
- Access to a computer and basic computer skills;
- Flexibility to commit up to two hours per week to complete weekly activities and participate in discussion forums.
It was agreed initially that the optimum group size for this pilot was between 12 and 15. This ensured that an appropriate number of nurses were able to share their thoughts and insights online, accommodating the potential for attrition due to personal or technical reasons. The recruitment process involved nursing and hospice service managers across the organisation, as they were best placed to identify and nominate members of nursing staff who met the selection criteria and were willing to take part in the pilot.
Evaluation of the programme
The evaluation methods used were:
- Online self assessment questionnaire of confidence before and after the course;
- Online post course candidate evaluation;
- Online post course moderator evaluation.
Assessing confidence before and after the course
The self assessment questionnaire before the start of the course required participants to reflect on their confidence in relation to managing the assessment process. This questionnaire was a modification of the questionnaire devised by Wilkinson et al (2003, 2008) to assess nurses’ confidence as part of Marie Curie’s advanced communication skills training. Nurses were asked to score their level of confidence in seven aspects of the patient/carer assessment process on a scale from one to 10 (with one being least confident and 10 being very confident). This activity had to be completed during the first week of the programme. The participants were asked to complete the same questionnaire at the end of the six week course.
Comparison was then made between the group average before and after the course (Fig 1). Although no statistical analysis has been conducted on these scores, it was evident that the participants’ confidence increased in all areas. The increase in confidence was greatest in two aspects:
- Explaining the assessment process to the patient/carer: an increase from 6.1 to 8.47
- Summarising the assessment interview and discussing an action plan with the patient/carer: an increase from 6.35 to 8.5.
Course evaluation – the learners’ perspective
At the end of the course participants were asked to complete a series of questions online, based on an internally developed semi structured questionnaire. Overall, 57% of participants evaluated the course as excellent; 43% rated the course as good. In relation to online discussion with other learners, 60% strongly agreed and 37% agreed that this had helped them to develop new insights about this topic. Interestingly, 100% of the participants stated they would take part in online learning again.
It is beyond the scope of this paper to offer an exhaustive review of nurses’ evaluation comments, but the following quotes highlight some benefits of this approach:
- “Reading other nurses’ views and experiences in the online discussions is helpful. The course makes you reflect on your own practice, highlighting things you maybe didn’t think about before.”
- “Communicating with colleagues around the country and getting views from different perspectives [was very useful].”
- “I am much more aware of my communication and assessment skills and have already started to put [them] into practice … reading other people’s experiences has been very beneficial.”
Online learning was a new venture for most staff enrolled on the programme. Traditionally assessment skills were taught face to face, and some nurses were sceptical whether they could be delivered in this way. They were also uncertain about whether or not they had the requisite IT skills to be able to participate, the available time in their busy work schedules, or the written skills to be able to express themselves fully online.
On completion of the programme staff recognised the positive elements of learning online. All staff felt they had benefited from focusing and reflecting on the subject, as they had to have clear thoughts before sharing them online. Reading what others had written and then having the time to consider this before responding had enhanced their uptake of knowledge. However, some participants found it difficult to get across online what they truly meant, and some thought they had not always done this. In the face to face setting, observing a nurse’s body language would have enabled meaning to be clarified. Despite this, participants agreed that the interaction and sharing with others was helpful and that their confidence increased as the course progressed.
Although learners expected to have some sort of face to face experience, they did concede that the online delivery method enabled them to learn at times convenient to them. Gaining perspectives from around the country was also appreciated, as practice varies in different areas.
Learners gave constructive comments on how they thought the course could be improved.
Online moderators’ experience
The two course moderators had no previous experience of designing and facilitating an online learning programme. However, following the preparatory eight week moderators’ programme, delivering the course wasa positive experience which enabled us to develop and refine our online facilitation skills.
The benefit of co-facilitating became apparent from the outset as the course was a new programme and subject area. However, the advantages of continuing to run this course with two moderators became clearer as the weeks progressed.
This programme was developed around weekly activities, Monday to Sunday. From the first week the majority of participants accessed and completed the activities over the weekend. As we had expected group participation to be spread throughout the week, this required us to review and adjust our scheduling. Future scheduling of programmes will take into account this pattern of activity.
Traditionally communication skills are taught in a face to face setting. As moderators for this new online communication skills course we were aware that our sole method of interacting with the participants was through discussion forums. Our challenge was to provide feedback without the benefit of face to face interaction. Relying on asynchronous discussion forums to promote debate and provide support and guidance to participants, required use of clear and concise language. We also needed to be clear about what we expected from participants in order to try to prevent or avoid misunderstandings. It was interesting to observe participants in the discussion forum develop as the course progressed. We feel this was due to the increasing confidence of the participants, greater understanding of the principles of e-learning and the development of group cohesiveness.
A key part of the moderators’ role was to identify when it was appropriate for us to be an active presence in the forum and when to step back while the discussion flowed freely amongst the participants.
This article has evaluated a small scale pilot of a fully online e-learning programme to develop practitioners’ communication skills for patient/carer assessment in end of life care. The pilot highlighted this approach can be an effective means of learning as an alternative to a traditional face to face approach. Further evaluation of this programme is ongoing. The positive feedback received can be attributed to a number of features. The programme design encouraged the learner to engage in learning activities for short, intensive periods of time but over a longer timeframe. This gave participants the opportunity to read and reflect prior to contributing their thoughts in the discussion forums. Judging by the very low drop out rate, it can be inferred that this mode of learning was both relevant and convenient.
It was evident that online facilitation added to the positive online experience. The moderators were proactively and consistently involved throughout the course by contributing to discussions and providing timely feedback. They were pivotal in steering the group through the programme and achieving the positive evaluation.
Many of the nurses involved in this pilot have gone on to register for other Marie Curie online learning programmes. The enthusiasm of the learners and their willingness to participate in future online courses has encouraged the development team to continue using e-learning as a delivery method for further communication skills courses and other opportunities for continuing professional development.
Although the pilot has not provided a definitive picture of the impact of the programme on nurses’ assessment skills in practice, it was clear from the learners’ evaluations that they were focused on reviewing their practice. This was demonstrated in the peer reviewed action plans participants developed. This action plan would form the agenda for each practitioner to develop their practice, with the support of their manager. In the words of one of the participants: “The greatest benefit was being made to examine my own practice. It was very good and healthy to question whether I use the principles of assessment.”
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Department of Health (2008a) High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health.
Department of Health (2008b) High Quality Workforce: NHS Next Stage Review. London: Department of Health.
Department of Health (2008c) End of Life Care Strategy:Promoting High Quality Care for All Adults at the Endof Life. London: Department of Health.
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