Online learning in palliative care: Where are we up to?

Sean Hughes, Nancy J Preston, Sheila A Payne

Introduction

In this journal, Bob Becker (2009)1 discussed the availability of online education in palliative care for nurses. He concluded that online learning (OL) in this context would expand in the future– as has proved to be the case across the health and social care sector.2There are now many examples of palliative care education being delivered through online modalities and at all levels. These range from stand alone, un-moderated, one off courses aimed at general level education through to blended learning programmes leading to higher degrees. As in all educational interventions, it is important to know not only how students’ evaluate a course but what impact it has in practice by improving the care of patients and families. Education seeks to add to knowledge and – especially in professional contexts – to develop skills and improve attitudes, all of which can be difficult to assess remotely. Little is known about the utility and efficacy of distance learning in palliative and end of life care contexts, nor about its sustainable impact on practice. The international reach of online learning adds complexity to these tasks. This paper aims to briefly examine the current literature in the field and to consider the evidence for impact on professional practice, posing some challenges for moving forward, given that online education in the health and social care fields is evidently here to stay.3,4

Method

A scoping of the literature in OL in palliative care was conducted from 2009 to 2014. This date range was chosen to capture literature published since Becker’s1 earlier work. The following databases were searched: Medline, AMED, Cinahl and ERIC (2008-2014) by SH. Search strategies were modified to different database requirements. The main search term: online learning, was used in combination with evaluat*, research, palliative, and end of life as free text terms.

Findings and discussion

Overall we identified seven papers that were relevant to the aims of the paper.

Does online education in palliative care work?

All the programmes described in the seven papers used some form of evaluation of the impact of the course on participants. A variety of instruments were used to assess gains in knowledge, confidence in dealing with palliative and end of life care issues and skills in symptom management.

Most of the studies evaluated the student experience of the online aspects of the course itself including their confidence with the technology or OL platform and satisfaction level with the learning experience. MacDonald et al., attempted to evaluate the impact on professional practice some 1-2 months after the learning tasks had been completed.5They used instruments that examined inter-professional collaborative practice and the application of learning to practice. The study found that whilst 80% of participants agreed that they had applied new knowledge and/or skills in the workplace – other data gathered in the study contradicted this. Indeed, firm evidence of improving outcomes for palliative care patients that can be attributed to OL is apparently lacking in the studies we reviewed, which is also the case for many, if not most, conventional educational approaches. Students may report increased confidence and that the learning they received has improved their practice, but we were unable to identify muchexplicitevidence for this.

An exception is to be found in a more recently published paper that reported a pilot study on the impact of an OL learning module in specialist palliative care pain management.6 In addition to assessing the knowledge gained by students, this study sought objective data on the patient pain experience following the educational intervention. The study used Qstream, described as ‘a real time learning analytics platform that promotes active learning’(op citp523). Of note in this approach is that the delivery of content is repeated and linked to clinically case-based scenarios partly relying on the ‘...finding that education encounters which are ‘spaced’ and ‘repeated over time’ result in more efficient learning and improved retention’ (op citp523). The authors concluded that using OL can have a demonstrable effect on patient-reported outcomes in some aspects of pain relief. It is difficult to assess the veracity of these positive claims, but this paper provided an example of an attempt to measure impact and how this might be achieved.

Which modes of OL delivery work best?

The evidence for the positive impact of OL in health care education, in general, was equivocal. For example, Cook et al (2008) in a review of internet based learning in health professional education, found that OL is an effective educative tool when compared with no intervention, but of similar efficacy when compared to traditional teaching approaches – so neither better nor worse, conclusively.7The studies in palliative and end of life care education noted above mostly deployed some aspect of interactivity in programme delivery. Activities included: live and virtual face to face contact with tutors and/or peers,8 online discussion boards and/or tutorial opportunities.5,9,10,11 One study reported on a CD ROM based course which was entirely un-moderated.12 This latter model is used extensively in a range of currently available training programmes in health and social care. For example, the e-ELCA end of life care module – a strand of the British NHS learning for healthcare provision.

Pulsford and colleagues conducted a systematic review examining distance and classroom based palliative care courses for health and social care staff.2The authors suggest that successful programmes are those that deploy a combination of participative and interactive learning techniques. This chimes with Becker who views OL as a rapidly developing educational methodology that compliments more conventional teaching methods. He emphasises the utility of good quality OL packages in enabling access to quality palliative care education from those in resource poor countries or who are unable to access more traditional educational routes.1

A further study found that students in online environments performed somewhat better than those taught in purely face to face conditions.13 The authors, however, acknowledged that confounding issues such as the fact that most blended approaches (in which OL is mixed with more conventional teaching) include additional features such as online student interaction such as that between the students themselves and with course tutor. In addition, they observed that the additional time available for the completion of learning tasksmight have accounted for the positive effects they found.13

Where next for OL in palliative care?

Noting the likelihood that OL is a burgeoning field, Cook et al suggest that research effort should not be wasted on questions of if to use OL in health professional education, but rather on how and when it should be used. This, alongside calls for improved conceptual clarity and for educators and other stakeholders to reach consensus on definitions, and outcome measures.14Acknowledging limitations in their review, particularly in the heterogeneity of their sample – Cook and colleagues concluded that there is no strong evidence in the current literature to make conclusive recommendations for practice which suggests that more research is required. 14

Means et al (2013) in their meta-analysis of OL learning in the wider educative context predictthat research in this area will increase but go on to point out that the time taken in design, implementation and publication of such studies fails to keep pace with the rapidity of practice and technological developments, which can limit their usefulness.13 This points to a need for a research programme that keeps pace with these developments and for the inclusion of methods for evaluating effectiveness of programmes at the design stage. However, this is likely continue to be a challenge in un-moderated modules and courses or on platforms that rely on quizzes and self-completion of which there are many current examples extant in the palliative and end of life care arena. The recent arrival and increasing popularity of MOOCs (massive online open courses) are an example of the rapid development and deployment of new ventures in this field which seems never to stand still. Improvements in the technology that facilitate more interactive opportunities – webinars, synchronous discussion groups and the like – also hold potential in the provision of palliative and end of life education.

Conclusion

Whilst the evidence base for OL may be compromised by a plethora of variables such as programme design, system requirements, degree of interactivity, educational styles, topic– to name but a few, the OL approach is well established and growing in all sectors of educational endeavour. As such, it may appear evident that advantages of reach and accessibility could be considered to offset any current evidence deficits. The challenge to address this issue is made in the frequent call for more research and greater conceptual clarity.14

It remains important for those of us involved in research and in the dissemination of best practice in palliative and end of life care education to ensure that professionals developing services and delivering care do so in line with optimum standards based on robust research and quality, on-going educational input. A current EU funded study: Person-centred integrated palliative care pathways in advanced cancer and chronic disease (InSup-C),15 is currently developing an OL module on best practice in integrated palliative care based on the results of this four year project. The module will be freely available to professionals, patient and carers – individuals and other interested groups in April 2016. The module will be supported by the provision of a MOOC in the autumn next year. Both platforms will be available through the project webpages: This work exemplifies how internet based education platforms can be utilised to disseminate research results to as wide an international audience as possible.

OL learning programmes and platforms in palliative and end of life are plentiful. The conundrum of how to ensure that these make a positive and sustainable impact on practice development remains if we are to improve the provision of care to all those who require it in a more standardised and consistent manner.

Total words: 1632

References

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