Introduction to e-learning as a medium for communication skills training
Advanced communication skills training is inherent in the development of a health and social care workforce capable of delivering high-quality palliative care. Traditionally this training has focused on specialist healthcare professionals working in the field of oncology. However, in the Department of Health (DoH) document The End of Life Care Strategy (DoH 2008) it was recognized that most people died at the end of a progressive chronic illness. Included as some of the major contributors to this mortality, were cardiorespiratory disease, stroke, dementia, and neurological conditions. The follow on document from the DoH (2009) identified quality markers and measures for end-of-life care and reiterated the need for the appropriate training of both health and social care professionals in order to ensure good quality care.
Education for Health is a charity, dedicated to providing education and training to health professionals working in primary care, with the aim of improving the lives of people living with long-term conditions. In 2002 the charity first gained accreditation from the Open University for its diploma and degree level distance learning modules. Each 30 credit module is designed to be studied over a six-month period. The delivery of the modules was originally a blended learning format incorporating face-to-face contact (usually two study days per 30 credit module) with a distance learning pack. Since 2010 the module learning materials have been converted from the distance learning pack to an e-learning format and students are still able to attend the two study days if they wish. In 2012, the cardiorespiratory palliative care degree level module underwent this process. Prior to conversion of the module, the educational needs of the future healthcare workforce in relation to end-of-life care was considered. It was decided to broaden the curriculum to make it more applicable to the management of people living with and dying from a range of non-malignant conditions.
The module is aimed at any non-palliative care specialist healthcare professionals. In other words—any healthcare professional who participates in the delivery or management of healthcare provided to people with the advanced stages of common life-limiting long-term conditions (respiratory disease, heart failure, long-term neurological conditions, and dementia) who does not work as part of the specialist palliative care team. It focuses on the management of symptoms, when treatments are limited, and a proactive, palliative care approach is required, particularly at the end of life.
Communication skills are a key part of good palliative care and the module explores the effective use of advanced communication skills and consultation skills in order to facilitate holistic patient-centred care. This chapter will elaborate on the process of developing the communication and consultation skills unit into an e-learning format, looking at the advantages and disadvantages, and suggesting solutions in order to maximize the student’s learning.
Communication issues in non-malignant life-limiting conditions
Unlike a diagnosis of cancer, a diagnosis of many of the life-limiting long-term conditions (chronic obstructive airways disease (COPD), chronic heart failure (CHF), multiple sclerosis (MS)) do not carry the same perception of poor prognosis with patients, their carers, and society at large (Murray et al. 2002; Gardiner et al. 2009; Golla et al. 2014). Often they are considered long-term conditions to be ‘lived with’ rather than ‘died from’, and there is not a realization that they have a prognosis worse than many cancers (Stewart et al. 2001).
However, unlike many cancers, the course of the condition is unpredictable, with periods of exacerbation followed by sudden deterioration of symptoms and quality of life, interspersed with more stable symptom control. Though it is known that the conditions (COPD, CHF, many neurological conditions) are likely to result in an early death, there tends to be uncertainty around distinguishing between an exacerbation of the condition and end-stage disease. This leads to problems in prognostication and it is cited by healthcare professionals as a barrier to initiating conversations about prognosis and end-of-life care in this patient group (Barclay et al. 2011; De Vleminck et al. 2014). It is felt that conversations about end-of-life care during an exacerbation might foster the perception of loss of hope in the person and their carers. However, there is also some evidence that even during periods of symptom stability, a significant minority of patients and carers prefer not to focus on discussions around death and dying (Momen et al. 2012). Patients with conditions that have an impact on cognitive function (long-term neurological conditions, dementia, hypoxic conditions) need to be managed with this potential in mind as discussions need to be timed to enable patients to have an influence on their future care even if they lose mental capacity.
The particular communication issues that arise for healthcare professionals are facilitating opportunities for discussion around prognosis with patients and carers, together with the timing of discussions around advance care planning and end-of-life care (Barclay et al. 2011; De Vleminck et al. 2014).
Technology enhanced learning for healthcare professionals
The Department of Health document, A Framework for Technology Enhanced Learning (DoH 2011), emphasizes the need for educators to recognize the place of technology in the provision of education and training in the healthcare sector. There has been a cultural shift in the way society works and interacts, with an increasing reliance on technology both as a means of communication and a source of knowledge. Improvement in areas such as bandwidth, storage, processing speed, and software have enabled the development of ever more responsive, flexible online learning facilities to be made available to a potentially increasing number of healthcare professionals. The NHS England Five Year Forward View (2014) recognizes the role technology will have in the future organization of healthcare, and learning and development should focus on supporting staff to adopt innovation, harnessing technology, and embracing change.
E-learning includes a variety of technical applications and educational approaches and can be defined as any learning taking place on a computer, usually attached to a network, either locally or via the internet (DoH 2011). It should not be used as an end in itself, but appropriately integrated into a blended approach to learning, implemented to address specific learning and clinical needs.
With the development of e-learning has come a reconsideration of the theories of learning and the recognition of the need for a new theory to fully recognize the impact and opportunities this new learning environment affords. Connectivism has been described as the ‘theory for the digital age’ (Siemens 2005). It looks at learning from the perspective that all learners have prior knowledge and future learning evolves from making connections with new information, people, and devices. It also recognizes that knowledge can be housed in appliances and learning can be around knowing when and how to access that information (Siemens 2005). The mix of human and non-human tools for learning is felt to be unique. Connectivism has been criticized for encouraging overreliance on continuous access to information, negating the importance of the learner to learn (Duke et al. 2013) or to apply critical thinking (Harper 2006) and the possibility of technological applications giving only the impression of engaging students in more active forms of learning, without necessarily being used to its full potential, has been raised (Greitzer 2002). For most however, connectivism reflects the increasingly student centred approaches being used in education (Kop and Hill 2008). ‘Blended learning combines different approaches and technologies, in particular a combination of traditional (e.g. face-to-face instruction) and online teaching approaches and media’ (Littlejohn and Pegler 2007). This approach was one Education for Health was keen to adopt, as student feedback indicated they valued the opportunity to attend study days and engage in interactive interprofessional learning with a clinical expert facilitating the day. However, the use of technology also offers learners flexibility with a choice of where, when, and how to engage in learning, affording busy healthcare professionals the opportunity to balance working and personal lives with a commitment to continuing professional development.
The e-learning modules developed by Education for Health provide the learner with a scaffolded approach to learning, with structured online learning materials providing the knowledge base and online activities encouraging learners to explore other resources and construct their knowledge linked to their own practice. This approach to learning is in alignment with how adults learn; that is, they are self-directed, internally motivated, problem centred, use their life experiences to contextualize new information, and need practical application of information gathered (Fidishun 2005).
Education for Health provides academically accredited courses and the approach taken to teaching and learning is based on Chickering and Gamson’s (1987) Seven Principles of Good Practice in Undergraduate Education. Features of the virtual learning environment (VLE) that reflect this approach include:
◆ The use of a reflective diary to encourage active learning. Space is provided on each page of the e-learning resource to allow students to make notes. As well as allowing students to bookmark sections for further consideration, it encourages them to think about what they have learnt in that section, relate it to past experiences and record for future reference.
◆ The availability of prompt feedback in various activities including assessment tool, drag and drop, and the provision of expert answers in formative exercises.
◆ Time on task is maximized by providing tools such as external links to further information and evidence.
◆ Online messaging board that facilitates communication between the clinical lead and administrative team and the students.
◆ Support materials for students carrying out summative assessment and additional information in the form of an online student guide.
◆ The provision of a flexible environment where diverse ways of learning are respected meaning that students can learn at a time and pace in a way to suit a variety of learning styles-student centred learning, flexible, own pace, variable timescale, location independent, variable workspace, variety of learning modes and preferences are catered for.
Feedback from students has influenced the continued development of the VLE predominantly around the ease of access and navigation around the site. From the perspective of the e-learning materials, students have identified many of the features described above as advantages of the learning format and have appreciated the flexibility and interactivity of the modules (Box 31.1).
Reproduced with kind permission of Education for Health.
Design of consultation and communication skills unit for delivery via e-learning
When designing the unit on consultation and communication skills within the Non-malignant Palliative Care Module, consideration was given to the aims and objectives of the training (Box 31.1). Students are required to consider the importance of communicating well, develop appropriate attitudes and beliefs, and change their communication behaviours as a consequence of the unit (Fallowfield et al. 2003). The five learning outcomes relating to communication skills that the unit aimed to address were: understanding the importance of good communication; identifying the different facilitators and barriers to communication; identifying when these facilitators and barriers are being used/having an impact on a consultation; demonstrate ability to use facilitators and avoid/address barriers to communications; change own clinical practice to incorporate skills into consultations.
It was considered that the e-learning materials would be particularly useful in contributing to the knowledge content of the unit. The benefits of an e-learning environment enabled this information to be presented in a variety of forms that appeal to different learning styles. In addition, certain content lends itself to delivery in particular formats available within the VLE. The communication content of the e-learning unit (Box 31.2) covers a variety of topics that were felt to be key to the appropriate development of skills for the communication challenges for healthcare professionals dealing with people with life-limiting long-term conditions.
Reproduced with kind permission of Education for Health.
Facilitators and barriers to good communication were represented in written form, with a click and reveal format. This enabled the students firstly to assess their knowledge (suggest their own definition of each skill) then, by clicking on each icon, to build on their learning by contextualizing the skills through an audio soundtrack demonstrating the use of each skill (Fig 31.1). This page can be returned to and repeated by the student, enabling consolidation of learning.
Having enabled the students to describe and give examples of the communications skills the training is aiming to enhance, the content moves on to exploring the student’s ability to recognize when these skills are being used in practice. Within a three-day advanced communication skills programme (Wilkinson 2008), this is initially done by asking students to identify the skills used in a teaching video simulation. These are expensive to produce but are an invaluable learning tool as, in contrast to ‘real time scenarios’ they can be revisited and rechecked by the student to facilitate deeper learning. The e-learning environment is an ideal medium for students to review simulated scenarios, and the unit not only has access to videos imbedded into the material (Wilkinson 2007), but also has external links to a variety of web-based scenarios freely available online. Students are asked to view and review the simulated scenarios and identify how the facilitators and barriers to communication impact on the consultation being observed. Again this contextualizes their learning and deepens their understanding of the particular role of communication skills in palliative and end-of-life care.
Another feature of the VLE which is effectively used in this unit is the reflective diary facility, which enables the student to make online notes attached to each learning page. These can comprise explanatory notes and can link the student’s personal experiences with the content of the units, further contextualizing the information, and facilitating deeper learning.
With the plethora of information and papers written on communication within the healthcare context, students find it useful to be guided to some initial publications to help them direct their learning. This is particularly important in assisting the student in differentiating between the different quality of the evidence available. The use of online links to publications facilitates the easy access to papers which have been chosen to enhance the students’ depth of learning. These include research papers, but also pivotal government publications and NICE guidelines. Activities are included around some of the articles referred to in order to help students consider their implications on their practice (e.g. McKillop and Petrini 2011). Links can also be used to websites such as Gold Standards Framework and The National Council for Palliative Care. It is anticipated that students use these documents as a springboard for further learning and exploration of the topic.
Student activities are interspersed throughout the unit content. These address the student learning need at several levels. Some are specifically based on consolidating knowledge (e.g. reviewing videos); however, there are also activities for the student to apply in clinical practice, encouraging them to use some of the skills that they have explored within the unit (Box 31.3).
Reproduced with kind permission of Education for Health.
Working through the content of this unit, in the student’s own time, is designed to equip them with the knowledge and recognition of the skills for communication with patients with life-limiting long-term conditions.
Currently the timing of access to the learning materials and the start of the module means that the students are unlikely to have accessed the information prior to the first study day, which is based around communication skills. The study day supports the e-learning in terms of content. It also gives the opportunity for detailed discussion of the skills being acquired and the immediate response of the trainer to student queries. Simulated scenarios are used to help the students recognize communication skills and barriers (see Box 31.4). The face-to-face contact with the trainer and other students facilitates the use of role play to enhance skill acquisition. Contact and discussion with other students is considered an important part of learning communication skills. This contact is currently restricted to the face-to-face sessions, but other methods of incorporating student interaction within the VLE will be discussed in the section on future development of the unit.
Reproduced with kind permission of Education for Health.
It is recognized that students require support for a variety of different aspects of their course. A VLE guide has been produced to facilitate the students’ initiation into the e-learning environment. Frequently asked questions are addressed and a step-by-step guide on how to get started has been developed. A session on using the VLE has also been included in the first study day to ensure all students get the most out of the available learning materials. A team of administrators is also provided who can help guide the student through technical issues around the VLE, as well as administrative issues around the running of the course.
As a blended/primarily distance learning course, there is a limit to the face-to-face contact the student has with both their peers and the trainer. However, Education for Health has put in place strategies to improve the student experience and reduce the sense of isolation and lack of motivation that can occur when students undertake a distance learning course (Abrami and Bures 1996). The module has a designated clinical lead and the contact details are given to the students at the start of the course and during the study days. The clinical lead can also be contacted through the online environment, as well as via more conventional methods (email and telephone). The support provided is usually in relation to the development and writing of the summative assignments, but may also be around study skills and the course materials.
There is currently no structured peer-to-peer support, but students within cohorts are often employed by the same healthcare provider and are geographically close to each other. Informal links are fostered in the study days and students often keep in contact with each other via email.
As adult learners working within a healthcare environment, they are also guided to seek out suitable clinical experience to support their learning of advanced communication and consultation skills. This includes recommendations to work with or shadow local clinicians with the appropriate skills and experience. However, in order to be as inclusive as possible, and recognizing that this support is not always available to students, this is neither a structured mentorship nor a compulsory aspect of the course.
Assessment of students
The key aim of the unit on consultation and communication skills training is to improve the skills of the students so that they can be more effective in their clinical practice, and so facilitate better patient outcomes.
In the Cochrane review that investigated the effectiveness of communication skills courses in training healthcare professionals working with people with cancer, the outcome measures were around the students demonstrating that they had used the skills they had learnt from the course and measures of how that impacted on patient satisfaction and anxiety (Moore et al. 2013). When designing the summative assignment for the unit, various methods were considered to incorporate the assessment of the students’ communication skills, together with ensuring that the assessment was at the appropriate academic level. There is no formal mentorship of the student within their clinical practice, which excludes the use of a form of work based clinical assessment of skills. It was considered whether the assessment could be based around the critical review of a simulated scenario that could be viewed online by the students. However, this would only demonstrate that the student could recognize the skills being used and would not assess whether they had taken the further step to use the skills in practice.
Consequently, a reflective assignment has been developed which asks the student to analyse their personal experience of a patient consultation with someone who has a life-limiting long-term condition. In the assignment they are asked to be specific about the skills they used, and use quotes from the consultation to demonstrate those skills. They are also asked to explore the evidence base around the techniques used and look for alternative communication solutions if the consultation was not effective. This goes some way to establishing the assessment of the students’ use of the skills they have developed from studying the unit.
A downside of distance learning can be a sense of isolation, which can be perpetuated within the online environment (Wilkinson et al. 2004). The importance of human contact cannot be overestimated and the blended approach has proved to be of benefit in providing the opportunity for learners to meet face-to-face to share their learning and practice experience. A future development will be to provide additional opportunities for students to come together; mindful of the difficulties healthcare professionals face in finding time to attend face-to-face days, online communication tools will be used to connect and motivate students (Westbrook 2012). These communication tools will be embedded in the VLE alongside the online learning materials.
Asynchronous online discussion forums afford text-based communication and collaboration, which students can contribute to at any time that suits them rather than needing to be available at an allocated time (synchronous). The asynchronous characteristic of the activity has the added benefit of providing students and tutors with the time and space for reflection before contributing.
The forums can be used to support some of the same types of activity that occur at the face-to-face study days. Online formative activities designed to encourage reflection on practice can be re-designed to encourage students to share these reflections with one another in the forum and to provide peer feedback on others’ reflections. However, it is also recognized that the use of forums requires careful introduction. Consideration should be given to the skills required of the tutor to facilitate the online discussion, as well as the support and time required for students to familiarize themselves with this online environment before they are comfortable contributing (Westbrook 2012).
Another development will be to provide students with scheduled synchronous online tutorials. Using a webinar or virtual classroom tool, this will provide students with an opportunity to come together online at the same time. This will enable some of the formative activities to be re-designed to encourage group work. One example would be the streaming of one of the simulated scenario videos, followed by a structured feedback session facilitated by the tutor to encourage critical reflection on the video.
Both of these developments will enhance the student experience by moving beyond the online learner-content interaction and providing the opportunity for increased learner-learner and learner-tutor interaction, the value of which is increasingly being recognized.
Communication skills training is an important part of the education of healthcare professionals who care for people with long-term life-limiting conditions. Training has traditionally been provided by three-day interactive workshops. However, this method of training has disadvantages associated with the release of staff to attend courses and the labour intensive nature of the workshops.
Much of the learning that is required to develop the necessary communication skills lends itself to being delivered in an e-learning format. This facilitates the ability to address students’ differing learning styles, as well as allowing flexibility of how, when, and where to engage in learning. Despite this, the importance of face-to-face contact is also recognized. Therefore, a blended approach to learning via a mixture of study days and e-learning is probably the most effective method to adopt. With the continued development of technology, peer-to-peer contact and peer-to-tutor contact will increasingly be feasible within the e-learning environment, which will further enhance the learning experience.
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